Barriers to adult vaccination in Canada: A qualitative systematic review.

Background: In recent years, Canadian health care professionals have observed an increase in vaccine refusal. The objective of this study is to review published literature and identify the main themes related to vaccine hesitancy and barriers to vaccination in Canadian adults and recent immigrants. Methods: A qualitative systematic review was performed. A comprehensive search of MEDLINE (1946 to January 2021) and EMBASE (1974 to January 2021) was conducted to identify existing literature that addressed the primary research question. Studies were eligible for inclusion if the study population involved 1) the general population, 2) Indigenous populations, 3) recent immigrants to Canada or 4) Canadian health care professionals. Results: Thirty-four studies were included with a focus on the general population (n = 22), health care professionals (n = 10) and recent immigrant populations (n = 2). The most frequently reported barriers were lack of vaccine information (41%), lack of access to vaccination (38%), fear of adverse reactions (38%), financial reasons (29%), lack of awareness of vaccine existence (29%), antivaccine sentiments (24%), notion that older adults do not need vaccination (18%), misconceptions on vaccine effectiveness (12%), potential sexual health promotion stigma (6%) and fear of needles (3%). Interpretation: Barriers to vaccination among Canadians and recent immigrants continue to be a challenge in the health care system. Conclusions: The greatest yield in improving vaccination rates is likely to come from supporting vaccine-hesitant individuals in shifting their thinking to greater vaccine acceptance. Pharmacists are well positioned to address vaccine hesitancy and involvement through education, facilitation and administration of vaccines. Can Pharm J (Ott) 2022;155:xx-xx.

Prehospital Analgesia With Intranasal Ketamine (PAIN-K): A Randomized Double-Blind Trial in Adults.

STUDY OBJECTIVE: We compare intranasal ketamine with intranasal placebo in providing pain reduction at 30 minutes when added to usual paramedic care with nitrous oxide. METHODS: This was a randomized double-blind study of out-of-hospital patients with acute pain who reported a verbal numeric rating scale (VNRS) pain score greater than or equal to 5. Exclusion criteria were younger than 18 years, known ketamine intolerance, nontraumatic chest pain, altered mental status, pregnancy, and nasal occlusion. Patients received usual paramedic care and were randomized to receive either intranasal ketamine or intranasal saline solution at 0.75 mg/kg. The primary outcome was the proportion of patients with VNRS score reduction greater than or equal to 2 at 30 minutes. Secondary outcomes were pain reduction at 15 minutes, patient-reported comfort, satisfaction scores, nitrous oxide consumption, and incidence of adverse events. RESULTS: One hundred twenty subjects were enrolled. Seventy-six percent of intranasal ketamine patients versus 41% of placebo patients reported a greater than or equal to 2-point VNRS reduction at 30 minutes (difference 35%; 95% confidence interval 17% to 51%). Median VNRS reduction at 15 minutes was 2.0 and 1.0 and at 30 minutes was 3.0 and 1.0 for ketamine and placebo, respectively. Improved comfort at 15 and 30 minutes was reported for 75% versus 57% and 61% versus 46% of ketamine and placebo patients, respectively. Sixty-two percent of patients (95% confidence interval 49% to 73%) versus 20% (95% confidence interval 12% to 32%) reported adverse events with ketamine and placebo, respectively. Adverse events were minor, with no patients requiring physical or medical intervention. CONCLUSION: Added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events.

Cardiovascular Risk Reduction in the Workplace With CAMMPUS (Cardiovascular Assessment and Medication Management by Pharmacists at the UBC Site).

BACKGROUND: Cardiovascular (CV) disease is a leading cause of death despite being largely preventable. Employers increasingly offer preventive health programs in the workplace, and pharmacists are well suited to provide these programs. OBJECTIVE: To evaluate the impact of a pharmacist-led service on CV risk in University of British Columbia (UBC) employees. METHODS: This was a prospective observational pre-and-post design study, with participants as their own controls. Employees >18 years of age in the UBC health plan with a Framingham Risk Score (FRS) ≥10% or ≥1 medication-modifiable CV risk factor were included. Participants received a baseline assessment, individualized consultation for 12 months, and a final assessment by a pharmacist at the UBC Pharmacists Clinic. The primary end point was FRS reduction. RESULTS: Baseline assessment of 512 participants between September 2015 and October 2016 yielded 207 (40%) participants, of whom 178 (86%) completed the 12-month intervention. Participants were 54% female and 55% Caucasian, with an average age of 51 (SD = 9.1) years. FRS at baseline was <10 in 45.8%, 10 to 19.9 in 37.9%, and ≥20 in 16.4% of participants. Over 12 months, significant reductions in average FRS (from 11.7 [SD = 7.7] to 10.7 [SD = 7.3]; P = 0.0017) and other parameters were observed. Significant improvements in quality of life (EQ5D change of 0.031 [95% CI = 0.001, 0.062] P = 0.023) and medication adherence (MMAS-8 change of 0.42 [ P = 0.019]) were also noted. CONCLUSIONS AND RELEVANCE: UBC employees had improvements in health markers, self-reported quality of life, and medication adherence after receiving a 12-month pharmacist-led intervention. Pharmacists are encouraged to provide CV risk reduction services in workplaces.

Intravenous cefazolin plus oral probenecid versus oral cephalexin for the treatment of skin and soft tissue infections: a double-blind, non-inferiority, randomised controlled trial.

OBJECTIVE: The purpose of our study was to determine if cephalexin 500 mg orally four times daily was non-inferior to cefazolin 2 g intravenously daily plus probenecid 1 g orally daily in the management of patients with uncomplicated mild-moderate skin and soft tissue infection (SSTI) presenting to the ED. METHODS: This was a prospective, multicentre, double dummy-blind, randomised controlled non-inferiority trial conducted at two tertiary care teaching hospitals in Canada. Patients were enrolled if they presented to the ED with an uncomplicated SSTI, and randomly assigned in a 1:1 fashion to oral cephalexin or intravenous cefazolin plus oral probenecid for up to 7 days. The primary outcome was failure of therapy at 72 hours. Clinical cure at 7 days, intravenous to oral medication transition admission to hospital and adverse events were also evaluated. RESULTS: 206 patients were randomised with 104 patients in the cephalexin group and 102 in the cefazolin and probenecid group. The proportion of patients failing therapy at 72 hours was similar between the treatment groups (4.2% and 6.1%, risk difference 1.9%, 95% CI -3.7% to 7.6%). Clinical cure at 7 days was not significantly different (100% and 97.7%, risk difference -2.3%, 95% CI -6.7% to 0.8%). CONCLUSION: Cephalexin at appropriate doses appears to be a safe and effective alternative to outpatient parenteral cefazolin in the treatment of uncomplicated mild-moderate SSTIs who present to the ED. TRIAL REGISTRATION NUMBER: NCT01029782; Results.

Capnography versus standard monitoring for emergency department procedural sedation and analgesia.

BACKGROUND: Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting. OBJECTIVES: To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015. SELECTION CRITERIA: We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA. DATA COLLECTION AND ANALYSIS: Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models. MAIN RESULTS: We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time. AUTHORS' CONCLUSIONS: There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.

Opioid Pharmacokinetics-Pharmacodynamics: Clinical Implications in Acute Pain Management in Trauma.

OBJECTIVE: To evaluate acute traumatic pain protocols and to suggest optimization by characterizing opioid pharmacokinetics and pharmacodynamics (PK-PD). DATA SOURCES: MEDLINE (1946 to November 2015), EMBASE (1974 to November 2015), International Pharmaceutical Abstracts (1970 to December 2014), and Cochrane Database of Systematic Reviews (2005 to November 2015). KEYWORDS: morphine, hydromorphone, fentanyl, trauma, acute pain, intravenous, opioid, pharmacokinetics, and pharmacodynamics. STUDY SELECTION AND DATA EXTRACTION: Literature characterizing opioid PK-PD was included. Additionally, studies evaluatingoutcomes of opioids for acute severe pain in adult trauma patients were selected. DATA SYNTHESIS: PK-PD literature suggests that morphine exhibits an effect delay of 1.6 to 4.8 hours; however, clinical significance is doubtful. The relative onset of morphine is approximately 6 minutes, and duration, 96 minutes. Morphine 0.1 mg/kg IV then 0.05 mg/kg every 5 minutes achieved pain control in 40% of patients at 10 minutes and 76% at 60 minutes. The effect delay of hydromorphone (orally) is 18 to 38 minutes; its relative onset (IV), 5 minutes; and duration, 120 minutes. Hydromorphone every 15 minutes achieved variable success in clinical trials. The effect delay of fentanyl IV is 16.4 minutes; relative onset, 2 minutes; and duration, 7 minutes. One randomized controlled trial used fentanyl 0.1 µg/kg IV every 5 minutes. CONCLUSIONS: Further integration of opioid PK-PD into acutepain protocols is possible. One opioid should not be deemed more effective but rather titrated to effect. Morphine and hydromorphone can be titrated IV every 5 minutes until adequate pain control. Fentanyl can be titrated every 3 minutes.

A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management.

OBJECTIVE: To comparatively evaluate hypertonic sodium (HTS) and mannitol in patients following acute traumatic brain injury (TBI) on the outcomes of all-cause mortality, neurological disability, intracranial pressure (ICP) change from baseline, ICP treatment failure, and serious adverse events. DATA SOURCES: PubMed, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and WHO ICTRP (World Health Organization International Clinical Trials Registry Platform) were searched (inception to November 2015) using hypertonic saline solutions, sodium chloride, mannitol, osmotic diuretic, traumatic brain injury, brain injuries, and head injury. Searches were limited to humans. Clinical practice guidelines and bibliographies were reviewed. STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized trials comparing HTS and mannitol in adults (≥16 years) with severe TBI (Glasgow Coma Scale score ≤8) and elevated ICP were included. ICP elevation, ICP reduction, and treatment failure were defined using study definitions. DATA SYNTHESIS: Of 326 articles screened, 7 trials enrolling a total of 191 patients met inclusion criteria. Studies were underpowered to detect a significant difference in mortality or neurological outcomes. Due to significant heterogeneity and differences in reporting ICP change from baseline, this outcome was not meta-analyzed. No difference between HTS and mannitol was observed for mean ICP reduction; however, risk of ICP treatment failure favored HTS (risk ratio [RR] = 0.39; 95% CI = 0.18-0.81). Serious adverse events were not reported. CONCLUSIONS: Based on limited data, clinically important differences in mortality, neurological outcomes, and ICP reduction were not observed between HTS or mannitol in the management of severe TBI. HTS appears to lead to fewer ICP treatment failures.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach.

BACKGROUND: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). OBJECTIVE: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. METHODS: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. RESULTS: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. CONCLUSIONS: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Emergency Procedural Sedation With Propofol in Older Teenagers: Any Cause for Concern?

INTRODUCTION: Propofol is a standard for adult emergency department procedural sedation (EDPS). Use in pediatric patients remains controversial. Our primary objective was to investigate whether adverse events occurred more frequently in teenage pediatric patients receiving propofol for EDPS. METHODS: This retrospective study examines records from the Halifax Procedural Sedation Registry, collected between January 1, 2006 and May 31, 2013. Patients undergoing EDPS using propofol were divided into those aged 16 to 19 years (teenagers), 20 to 65 years (adults), and older than 65 years (seniors). The primary outcomes were the incidences of hypotension and hypoxia. RESULTS: Four thousand sixty-three EDPSs were included in the analysis, of which 230 involved teenagers, 2853 adults (mean age, 43.0 years), and 980 seniors (mean age, 77.1). The teenage group was significantly less likely to develop hypotension or hypoxia. These differences were confirmed on multivariate analysis. Patients in the teenage group received higher doses of propofol per kilogram/minute than the other groups. No other differences met statistical significance. CONCLUSIONS: Teenage patients receiving EDPS with propofol had a lower incidence of adverse events, and both received and tolerated larger adjusted doses of medication than older patients. Satisfaction and duration of EDPS were similar. Concerns about propofol use in younger patients have not been supported by this study. We believe that these findings support the use of propofol for EDPS in older teenagers.

Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review.

OBJECTIVE: To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN: A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS: We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION: Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Propofol for procedural sedation in the emergency department: a qualitative systematic review.

OBJECTIVE: To evaluate the efficacy and safety of propofol compared to other agents for procedural sedation of adults in the emergency department (ED) and to review the use of opioids in conjunction with propofol for procedural sedation in the ED. DATA SOURCES: PubMed (1949-December 2012) and EMBASE (1980-December 2012) were searched using combinations of the following search terms: (procedural sedation or conscious sedation [MESH]) and propofol. A manual search of references was also performed. STUDY SELECTION AND DATA EXTRACTION: English-language, full reports of randomized controlled trials (RCTs) and observational studies evaluating propofol use in adults undergoing procedural sedation in the ED were included if they reported efficacy or safety outcomes. Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. DATA SYNTHESIS: Thirteen RCTs and 20 observational studies meeting our inclusion criteria were retrieved. Regardless of the agent used for sedation, pro ce du ral success was greater than 80% and most trials demonstrated no statistically significant difference in the incidence of respiratory depression with propofol compared to alternatives. One RCT showed a significantly greater percent decrease in systolic blood pressure from baseline in those who received propofol compared to ketamine. Where reported, no significant difference was found in patient recall, pain, and satisfaction when opioids were added to propofol com pared to propofol alone; the addition of opioids may have resulted in a higher incidence of respiratory adverse events. CONCLUSIONS: Propofol for procedural sedation is a reasonable alternative for use in the ED, with comparative efficacy and safety to other alternatives. Use of opioids in addition to propofol may not provide added benefit but does contribute to increased rates of adverse events.

Setting Goals to Reduce Cardiovascular Risk: A Retrospective Chart Review of a Pharmacist-Led Initiative in the Workplace.

Background: Cardiovascular diseases (CVD) are the second leading cause of death in Canada with many modifiable risk factors. Pharmacists at a Canadian university delivered a novel CVD risk management program, which included goal-setting and medication management. Aim: This study aimed to describe what CVD prevention goals are composed of in a workplace CVD risk reduction program, and how might these goals change over time. Methods: A longitudinal, descriptive qualitative study using a retrospective chart review of clinical care plans for 15 patients enrolled in a CVD prevention program. Data across 6 visits were extracted from charts (n = 5413 words) recorded from May 2019-November 2020 and analyzed using quantitative content analysis and descriptive statistics. Results: Behavioural goals were most popular among patients and were more likely to change over the 12-month follow-up period, compared to health measure goals. Behavioural goals included goals around diet, physical activity (PA), smoking, medication, sleep and alcohol; health measure goals centered on weight measures, blood pressure (BP) and blood lipid levels. The most common behavioural goals set by patients were for diet (n = 11) and PA (n = 9). Over time, goals around PA, medication, alcohol and weight were adapted while others were added (e.g. diet) and some only continued. Patients experienced a number of barriers to their goal(s) which informed how they adapted their goal(s). These included environmental limitations (including COVID-19) and work-related time constraints. Conclusions: This study found CVD goal-setting in the pharmacist-led workplace wellness program was complex and evolved over time, with goals added and/or adapted. More detailed qualitative research could provide further insights into the patient-provider goal-setting experience in workplace CVD prevention.

Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial.

STUDY OBJECTIVE: We determine whether a 1:1 mixture of ketamine and propofol (ketofol) for emergency department (ED) procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared with propofol alone. METHODS: Participants were randomized to receive either ketofol or propofol in a double-blind fashion. Inclusion criteria were aged 14 years or older and American Society of Anesthesiology class 1 to 3 status. The primary outcome was the number and proportion of patients experiencing an adverse respiratory event as defined by the Quebec Criteria. Secondary outcomes were sedation consistency, efficacy, and time; induction time; and adverse events. RESULTS: A total of 284 patients were enrolled, 142 per group. Forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared with 46 (32%) in the propofol group (difference 2%; 95% confidence interval -9% to 13%; P=.80). Three ketofol patients and 1 propofol patient received bag-valve-mask ventilation. Sixty-five (46%) patients receiving ketofol and 93 (65%) patients receiving propofol required repeated medication dosing or progressed to a Ramsay Sedation Score of 4 or less during their procedure (difference 19%; 95% confidence interval 8% to 31%; P=.001). Six patients receiving ketofol were treated for recovery agitation. Other secondary outcomes were similar between the groups. Patients and staff were highly satisfied with both agents. CONCLUSION: Ketofol for ED procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol.

Perspectives and experiences with telepharmacy among pharmacists in Canada: A cross-sectional survey.

Objective: This study aims to understand Canadian pharmacists' use, experiences, and perspectives of telepharmacy. Methods: We conducted a cross-sectional online survey. Individuals were eligible to participate if they were currently a registered, licensed pharmacist practicing in Canada. We collected perspectives of both telepharmacy users and non-users by creating a survey logic that asked specific and shared questions between the two groups. Data was analyzed using descriptive statistics including means and standard deviations (SD) for continuous variables and proportions for categorical variables. Results: Between October and December 2020, 136 pharmacists completed the survey, including 61 (52.6%) telepharmacy users and 55 (47.4%) non-users. Among those who use telepharmacy, the majority of participants (39, 72.2%) expressed that telepharmacy augmented their clinical practice and feel comfortable managing minor ailments using telepharmacy (41, 80.4%). Among non-users, 45 (84.9%) indicated that telepharmacy will augment their clinical practice and 48 (90.6%) would feel comfortable managing minor ailments using telepharmacy. Important considerations for successful implementation of telepharmacy for those who use telepharmacy included easier system implementation (29, 19.3%), better privacy & data protection (28, 18.7%) and simple to learn technology (23, 15.3%). Conclusion: Despite the growing recognition of benefits of telepharmacy, our findings suggest that utilization among pharmacists in Canada is still quite low. Nonetheless, our study identified areas of consideration for better integration of telepharmacy in pharmacy practice including optimizing workflow, addressing barriers, and providing training to pharmacy students.

Outcomes of emergency department patients presenting with adverse drug events.

STUDY OBJECTIVE: Our objectives are to describe the outcomes of patients presenting to the emergency department (ED) because of an adverse drug event and to compare them with outcomes of patients presenting for other reasons. METHODS: This prospective observational study was conducted at Vancouver General Hospital, a 955-bed tertiary care hospital. We prospectively enrolled adults presenting to the ED between March and June 2006, using a systematic sampling algorithm. Pharmacists and physicians independently evaluated patients for adverse drug events. An independent committee reviewed and adjudicated cases in which assessments were discordant or uncertain. Data from the index visit were linked to vital statistics, administrative health services utilization, and cost of care data. RESULTS: Of 1,000 patients, 122 (12.2%; 95% confidence interval [CI] 10.3% to 14.4%) presented to the ED because of an adverse drug event. Of these, 48 presented because of an adverse drug reaction (one type of adverse drug event defined as an unintended response that occurred despite use of an appropriate drug dosage). We found no difference in mortality among patients presenting with and without adverse drug reactions (14.6% versus 5.9%; hazard ratio 1.57; 95% CI 0.70 to 3.52). After adjustment, patients with adverse drug events had a higher risk of spending additional days in the hospital per month (6.3% versus 3.4%; odds ratio 1.52; 95% CI 1.43 to 1.62) and higher rate of outpatient health care encounters (1.73 versus 1.22; rate ratio 1.20; 95% CI 1.03 to 1.40). The adjusted median monthly cost of care was 1.90 times higher (Can $325 versus $96; 95% CI 1.18 to 3.08). CONCLUSION: ED patients presenting with an adverse drug event incurred greater health services utilization and costs during a 6-month follow-up period compared with patients presenting for other reasons.

Ketamine in adult emergency medicine: controversies and recent advances.

OBJECTIVE: To review the evidence for the use of ketamine in adult emergency medicine for procedural sedation and analgesia (PSA) and rapid sequence intubation (RSI), as well as to focus on the issues of recovery agitation, combination with propofol for PSA, and the use of ketamine as an induction agent in patients with acute head injury in need of definitive airway management. DATA SOURCES: PubMed (1949-July 2011), EMBASE (1980-July 2011), Google Scholar (to July 2011), International Pharmaceutical Abstracts (1964-July 2011), and Cochrane databases were searched independently. A manual search of references was also performed. STUDY SELECTION: English-language, full reports of experimental and observational studies evaluating ketamine in adults undergoing PSA and RSI in the emergency department (ED) were included if they reported efficacy or safety outcomes. DATA EXTRACTION: Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. DATA SYNTHESIS: Six studies that used ketamine for PSA were included. The majority reported adequate sedation with high patient satisfaction and lack of pain and procedural recall. There is no evidence to support the superiority of a combination of ketamine and propofol compared to propofol alone for PSA in adults. Recovery agitation is common but can be minimized with premedication with midazolam (number needed to treat 6). Two studies were identified that evaluated the role of ketamine for induction during RSI in the ED. Although ketamine is not a first-line agent for RSI, it is an alternative and may be used as an induction agent in patients requiring endotracheal intubation. CONCLUSIONS: Ketamine is an effective agent in adults undergoing PSA and RSI in the ED. The best available evidence provides sufficient confidence to consider use of this agent in the ED.

Intensity of anticoagulation with warfarin and risk of adverse events in patients presenting to the emergency department.

BACKGROUND: The ability of patients receiving warfarin to maintain an international normalized ratio (INR) within the desired therapeutic range is important for both efficacy and risk of adverse events. It is unclear whether the desired INR is maintained in patients receiving warfarin who present to the emergency department (ED) and whether they have a higher rate of adverse events. OBJECTIVE: To evaluate the intensity of anticoagulation with warfarin and the risk of bleeding and thromboembolic complications in patients in the ED. METHODS: A prospective observational study was performed using a convenience sample of patients receiving warfarin and presenting to the ED over an 18-week period. Data were collected using a standardized form that included chief complaint, history of present illness, past medical history, medication history, and allergy status. Information from the physical examination, laboratory results, and other diagnostic tests obtained as part of routine assessment in the ED, was used as necessary. The primary outcome was the proportion of patients whose INR was within, above, or below the desired therapeutic range. Bleeding complications and thromboembolic events were recorded in an attempt to determine the relationship between the intensity of anticoagulation and adverse outcomes. RESULTS: Two hundred one patients were included, with a mean (SD) age of 74.0 (13.2) years; 53.7% were female. Primary indications for warfarin were atrial fibrillation (75.6%) and venous thromboembolic disease (14.9%). A therapeutic INR was observed in 88 patients (43.8%; 95% CI 37.1 to 50.7), while 45 patients (22.4%; 95% CI 17.2 to 28.7) and 68 patients (33.8%; 95% CI 27.6 to 40.6) had subtherapeutic and supratherapeutic INRs, respectively. Overall, there were 28 (18 major and 10 minor) bleeding complications (13.9%; 95% CI 9.8 to 19.4) and 4 thromboembolic events (2.0%; 95% CI 0.6 to 5.2). Among patients with a bleeding complication, 14 (50.0%) had a supratherapeutic INR, while 2 patients who experienced a thromboembolic event (50.0%) had a subtherapeutic INR. CONCLUSIONS: The majority of patients receiving warfarin on presentation to the ED had INRs outside the desired therapeutic range. By establishing the impact of warfarin-related adverse events in this population, focused interventions can be established in this setting to address factors that can be targeted to reduce these events.