Risk of Acute Kidney Injury Associated With Medication Administration in the Emergency Department.

BACKGROUND: Patients who develop acute kidney injury (AKI) have a 2-fold increased risk for major adverse events within 1 year. An estimated 19-26% of all cases of hospital-acquired AKI may be attributable to drug-induced kidney disease (DIKD). Patients evaluated in the emergency department (ED) are often prescribed potentially nephrotoxic drugs, yet the role of ED prescribing in DIKD is unknown. OBJECTIVE: We sought to measure the association between ED medication administration and development of AKI. METHODS: This was a retrospective 5-year cohort analysis at a single center. Patients with a serum creatinine measurement at presentation in the ED and 24-168 h later were included. Outcome was incidence of AKI as defined by Kidney Disease Improving Global Outcomes criteria in the 7 days after ED evaluation. Medication administration risk was estimated using Cox proportional hazards model. RESULTS: There were 46,965 ED encounters by 30,407 patients included in the study, of which 6461 (13.8%) patients met the criteria for AKI. For hospitalized patients, administration of a potentially nephrotoxic medication was associated with increased risk of AKI (hazard ratio [HR] 1.30 [95% confidence interval {CI} 1.20-1.41]). Diuretics were associated with the largest risk of AKI (HR 1.64 [95% CI 1.52-1.78]), followed by angiotensin-converting enzyme inhibitors (HR 1.39 [95% CI 1.26-1.54]) and antibiotics (HR 1.13 [95% CI 1.05-1.22]). For discharged patients, administration of antibiotics was strongly associated with increased risk of AKI (HR 3.19 [95% CI 1.08-9.43]). CONCLUSION: ED administration of potentially nephrotoxic medications was associated with an increased risk of AKI in the following 7 days. Diuretics, angiotensin-converting enzyme inhibitors, and antibiotics were independently associated with increased risk of AKI. Nephroprotective practices in the ED may mitigate kidney injury and long-term adverse outcomes.

The validity of self-reported primary adherence among Medicaid patients discharged from the emergency department with a prescription medication.

STUDY OBJECTIVE: We determine the validity of self-reported prescription filling among emergency department (ED) patients. METHODS: We analyzed a subgroup of 1,026 patients enrolled in a randomized controlled trial who were prescribed at least 1 medication at ED discharge, were covered by Medicaid insurance, and completed a telephone interview 1 week after the index ED visit. We extracted all pharmacy and health care use claims information from a state Medicaid database for all subjects within 30 days of their index ED visit. We used the pharmacy claims as the criterion standard and evaluated the accuracy of self-reported prescription filling obtained during the follow-up interview by estimating its sensitivity, specificity, positive likelihood ratio and negative likelihood ratio tests. We also examined whether the accuracy of self-reported prescription filling varied significantly by patient and clinical characteristics. RESULTS: Of the 1,635 medications prescribed, 74% were filled according to the pharmacy claims. Subjects reported filling 90% of prescriptions for a difference of 16% (95% confidence interval [CI] 14% to 18%). The self-reported data had high sensitivity (0.96; 95% CI 0.95 to 0.97) but low specificity (0.30; 95% CI 0.26 to 0.34). The positive likelihood ratio (1.37; 95% CI 1.29 to 2.46) and negative likelihood ratio (0.13; 95% CI 0.09 to 0.17) tests indicate that self-reported data are not a good indicator of prescription filling but are a moderately good indicator of nonfulfillment. Several factors were significantly associated with lower sensitivity (drug class and over-the-counter medications) and specificity (drug class, as needed, site and previous ED use). CONCLUSION: Self-reported prescription filling is overestimated and associated with few factors.

Does providing prescription information or services improve medication adherence among patients discharged from the emergency department? A randomized controlled trial.

STUDY OBJECTIVE: We determine whether prescription information or services improve the medication adherence of emergency department (ED) patients. METHODS: Adult patients treated at one of 3 EDs between November 2010 and September 2011 and prescribed an antibiotic, central nervous system, gastrointestinal, cardiac, or respiratory drug at discharge were eligible. Subjects were randomly assigned to usual care or one of 3 prescription information or services intervention groups: (1) practical services to reduce barriers to prescription filling (practical prescription information or services); (2) consumer drug information from MedlinePlus (MedlinePlus prescription information or services); or (3) both services and information (combination prescription information or services). Self-reported medication adherence, measured by primary adherence (prescription filling) and persistence (receiving medicine as prescribed) rates, was determined during a telephone interview 1 week postdischarge. RESULTS: Of the 3,940 subjects enrolled and randomly allocated to treatment, 86% (N=3,386) completed the follow-up interview. Overall, primary adherence was 88% and persistence was 48%. Across the sites, primary adherence and persistence did not differ significantly between usual care and the prescription information or services groups. However, at site C, subjects who received the practical prescription information or services (odds ratio [OR]=2.4; 95% confidence interval [CI] 1.4 to 4.3) or combination prescription information or services (OR=1.8; 95% CI 1.1 to 3.1) were more likely to fill their prescription compared with usual care. Among subjects prescribed a drug that treats an underlying condition, subjects who received the practical prescription information or services were more likely to fill their prescription (OR=1.8; 95% CI 1.0 to 3.1) compared with subjects who received usual care. CONCLUSION: Prescription filling and receiving medications as prescribed was not meaningfully improved by offering patients patient-centered prescription information and services.

Management of first-trimester complications in the emergency department.

PURPOSE: The pharmacologic management and the nonpharmacologic management of first-trimester complications in the emergency department are reviewed. SUMMARY: The obstetric complications most commonly seen in early pregnancy (less than 20 weeks' gestation) include ectopic pregnancy, threatened and inevitable abortions, and incomplete, complete, and missed abortions. The treatment options for ectopic pregnancy include expectant management, medical management with methotrexate, and surgery. If patients have signs and symptoms of tubal rupture, surgery must be performed immediately. In other cases, the choice of management technique is based on the patient's clinical condition, factors related to the ectopic pregnancy, and the patient's preferences. Pharmacologic therapies for women with confirmed threatened abortion include human chorionic gonadotropin, progesterone, uterine muscle relaxants, and Rh immune globulin prophylaxis. Treatment goals for women whose condition has advanced to inevitable abortion include evacuating any retained products of conception, either with expectant (conservative) management or pharmacologic or surgical intervention. The best treatment option is often determined by the mother's clinical status at the time of presentation and her preference of management strategy. Management of complete abortion may not require any further intervention; however, it is often difficult to identify a complete versus incomplete abortion. Treatment options for complete, incomplete, and missed abortions include expectant, surgical, and medical management. CONCLUSION: Ectopic pregnancy, threatened and inevitable abortions, and incomplete, complete, and missed abortions are common complications during early pregnancy. Various medical and surgical treatment options are available for managing these complications, including expectant management, medical management, and surgery.