Healthcare risk stratification model for emergency departments based on drugs, income and comorbidities: the DICER-score.

BACKGROUND: During the last decade, the progressive increase in age and associated chronic comorbidities and polypharmacy. However, assessments of the risk of emergency department (ED) revisiting published to date often neglect patients' pharmacotherapy plans, thus overseeing the Drug-related problems (DRP) risks associated with the therapy burden. The aim of this study is to develop a predictive model for ED revisit, hospital admission, and mortality based on patient's characteristics and pharmacotherapy. METHODS: Retrospective cohort study including adult patients visited in the ED (triage 1, 2, or 3) of multiple hospitals in Catalonia (Spain) during 2019. The primary endpoint was a composite of ED visits, hospital admission, or mortality 30 days after ED discharge. The study population was randomly split into a model development (60%) and validation (40%) datasets. The model included age, sex, income level, comorbidity burden, measured with the Adjusted Morbidity Groups (GMA), and number of medications. Forty-four medication groups, associated with medication-related health problems, were assessed using ATC codes. To assess the performance of the different variables, logistic regression was used to build multivariate models for ED revisits. The models were created using a "stepwise-forward" approach based on the Bayesian Information Criterion (BIC). Area under the curve of the receiving operating characteristics (AUCROC) curve for the primary endpoint was calculated. RESULTS: 851.649 patients were included; 134.560 (15.8%) revisited the ED within 30 days from discharge, 15.2% were hospitalized and 9.1% died within 30 days from discharge. Four factors (sex, age, GMA, and income level) and 30 ATC groups were identified as risk factors and combined into a final score. The model showed an AUCROC values of 0.720 (95%CI:0.718-0.721) in the development cohort and 0.719 (95%CI.0.717-0.721) in the validation cohort. Three risk categories were generated, with the following scores and estimated risks: low risk: 18.3%; intermediate risk: 40.0%; and high risk: 62.6%. CONCLUSION: The DICER score allows identifying patients at high risk for ED revisit within 30 days based on sociodemographic, clinical, and pharmacotherapeutic characteristics, being a valuable tool to prioritize interventions on discharge.

PREDICTION OF MULTIDRUG-RESISTANT BACTERIA IN URINARY TRACT INFECTIONS IN THE EMERGENCY DEPARTMENT.

BACKGROUND: Urinary tract infections (UTI) due to multidrug-resistant bacteria are a frequent reason for visiting the emergency department (ED). OBJECTIVES: The aim of this study was to evaluate the applicability of a predictive model of infection by multidrug-resistant microorganisms in UTIs treated in an ED. METHODS: This is a retrospective observational study. Adult patients admitted to an ED with a diagnosis of UTI and positive urine culture were included. The main objective was to evaluate the area under the curve of the receiver operating characteristic (AUC-ROC), the scale proposed by González-del-Castillo, considering infection by a resistant pathogen as the dependent variable and the scale score of the predictive model used as the independent variable. RESULTS: The study included 414 patients with UTIs, 125 (30.2%) of which were caused by multidrug-resistant microorganisms. A total of 38.4% of patients were treated with antibiotics during the previous 3 months and a multidrug-resistant pathogen was isolated from 10.4% of the total during the previous 6 months. The AUC-ROC of the scale for predicting UTIs due to multidrug-resistant microorganisms was 0.79 (95% confidence interval 0.76-0.83), the optimal cut-off point being 9 points, with a sensitivity of 76.8% and a specificity of 71.6%. CONCLUSIONS: The use of the predictive model evaluated is a useful tool in real clinical practice to improve the success of empirical treatment of patients presenting to the ED with a diagnosis of UTI and positive urine culture pending identification.

Development of an Emergency Revisit Score for Patients With Drug-Related Problems.

Background: Drug-related problems (DRPs) are a frequent reason for emergency departments (EDs) visits. However, data about the risk factors associated with EDs revisits are limited. Objective: To develop and validate a predictive model indicating the risk factors associated with EDs revisit within 30 days of the first visit. Methods: A retrospective cohort study was conducted involving patients who attended an ED for DRPs related to cardiovascular drugs. A 30-day prediction model was created in a derivation cohort by logistic regression. An integer score proportional to the regression coefficient was assigned to the variables with P < .100 in the multivariate analysis. Results: 581 patients (mean age: 80.0 [12.6] years) were included, 133 (22.9%) revisited the ED within 30 days from discharge. Six factors (chronic kidney disease, chronic heart failure, visit to an ED in the preceding 3 months, high anticholinergic burden, DRPs associated with heparin, and safety-related DRPs) were identified as risk factors and combined into a final score, termed the DREAMER score. The model reached an area under the receiver operating curve values of 0.72 (95% confidence interval [CI] = 0.67-0.77) in the referral cohort and 0.71 (95% CI = 0.65-0.74) in the validation cohort (P = .273). Three risk categories were generated, with the following scores and estimated risks: low risk (0-8 points): 11.6%; intermediate risk (9-14 points): 21.3%; and high risk (>14 points): 41.2%. Conclusion and Relevance: The DREAMER score identifies patients at high risk for ED revisit within 30 days from the first visit for a DRPs, being a useful tool to prioritize interventions on discharge.

Factors associated with inappropriate intravenous antibiotic prescription in patients discharged from the emergency department.

WHAT IS KNOWN AND OBJECTIVE: Since 2011, a collaborative territorial network for urgent care has been deployed in Hospital de la Santa Creu i Sant Pau area, which allows direct and early transfer of patients with frailty from the hospital emergency department (ED) to other healthcare settings according to the destination's adequacy. This study aimed to identify factors associated with inappropriate intravenous antibiotic treatment prescribed on referral of patients with frailty based on microbiological culture and analyse the effect of inappropriate prescription on ED reconsultations for any cause 30 days after hospital discharge. METHODS: This observational, retrospective study was performed at a tertiary hospital between March 2018 and February 2019 and included 264 patients. A multivariate analysis, including variables with a P-value <.2 in the previous univariate analysis, was conducted. The variables included in the analysis were age, sex, patient comorbidities (COPD, diabetes and chronic kidney disease), antibiotic treatment in the last 30 days and patient referral (nursing home or family home). RESULTS AND DISCUSSION: Multidrug-resistant bacteria were isolated from 85 patients (51.5% of the isolates). In total, 159 patients received carbapenem, of whom 87 (54.7%) had non-drug-resistant bacteria. The antibiotic was considered inappropriate in 33 patients (12.5%) according to an antibiogram. Only 71 (26.8%) patients had a definitive culture on discharge. Moreover, 73 (28.3%) patients were readmitted after 30 days. Patients with an inappropriate antibiotic treatment had more reconsultations within 30 days than those with adequate treatment (59.3% vs 24.5%; P < .001). In a multivariate analysis, an inappropriate prescription was significantly associated with a higher number of reconsultations at 30 days (OR, 3.22 [1.37-7.57]). WHAT IS NEW AND CONCLUSION: In patients discharged from the ED with intravenous antibiotics, the empirical prescription of an inappropriate drug according to the final culture is a frequent problem and is related to a higher number of reconsultations. This highlights the need to implement early communication strategies with outpatient units to optimize antibiotic therapy once microbiological results are known.

Implication of Haemodiafiltration Flow Rate on Amikacin Pharmacokinetic Parameters in Critically Ill Patients.

BACKGROUND: To analyse the effect of haemodiafiltration (CVVHDF) flow rate on amikacin pharmacokinetics and blood concentrations. METHODS: Prospective observational study. Patients receiving CVVHDF and amikacin treatment were included. Pharmacokinetic parameters were calculated using Bayesian analysis. Spearman correlation test was used in order to assess the influence of CVVHDF flux on amikacin minimum concentration (Cmin) and plasma clearance. RESULTS: Thirty patients undergoing CVVHDF procedures were included. The treatment with amikacin started at an initial mean dose of 12.4 (4.1) mg/kg/day. An association between the flow rate and Cmin value (r = 0.261; p = 0.161) and plasma clearance was found (r = 0.268; p = 0.152). Four patients (13.3%) were not able to achieve peak concentration over MIC value higher than 8. In 4 patients, amikacin had to be discontinued due to a high Cmin value. CONCLUSIONS: Amikacin clearance in patients with CVVHDF is affected by the flow rate used. Therefore, CVVHDF dose should be taken into account when dosing amikacin.

Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial.

Importance: The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective: To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, Setting, and Participants: Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum ß-lactamase-producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions: Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main Outcomes and Measures: The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results: A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, -0.6% to 1.1%), 0.6% (95% CI, -0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and Relevance: Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care. Trial Registration: ClinicalTrials.gov Identifier: NCT02208154.

Drug Interaction Between Oral Cyclosporine Modified and Iron.

OBJECTIVE: To describe a recent case of suspected interaction between oral cyclosporine modified and iron. CASE SUMMARY: A 33-year-old man underwent urgent cardiac transplantation for refractory cardiogenic shock caused by acute myocarditis. The patient had persistently low levels of cyclosporine despite a dose increase of the drug after the change of administration route from intravenous to oral. Spacing the administration of cyclosporine modified from oral iron resolved the problem. This drug interaction was reported as "probable" as determined by a Drug Interaction Probability Scale score of 7. Using this scoring system, the patient experienced a probable drug interaction between cyclosporine and iron both administered orally, and we surmise that the mechanism is that iron physicochemically destabilizes the cyclosporine microemulsion when both are administered concurrently. DISCUSSION: This may be because of the interaction between cyclosporine microemulsion and iron because this cation can destabilize the immunosuppressant dosage form. CONCLUSIONS: Taking into account that joint administration of oral iron and cyclosporine modified can generate a physicochemical interaction that involves a decrease in the absorption of cyclosporine modified, we believe that it is necessary to recommend spacing administrations of both drugs as well as monitoring levels of cyclosporine in order to ensure optimal levels of immunosuppression.

[Experience in the management of immunosuppressant treatment with hepatitis C virus protease inhibitors]. / Experiencia en el manejo de inmunosupresores con los fármacos inhibidores de proteasa frente al virus de la hepatitis C.

INTRODUCTION: Antiviral drugs for the treatment of hepatitis C virus (HCV) infections have a large number of interactions. The aim of this study was to describe the interactions of telaprevir, boceprevir and sofosbuvir with immunosuppressive drugs in liver transplant recipients. METHODS: A retrospective observational study was performed in liver transplant patients with HCV infection who started treatment with telaprevir, boceprevir or sofosbuvir. Dose, regimens and plasma levels of tacrolimus, cyclosporine and sirolimus before and after antiviral treatment initiation were collected. Average variations in dose, dosing interval and immunosuppressive plasma levels after the start of treatment were calculated. RESULTS: Thirty-five patients were included. In patients treated with telaprevir (n = 18), the cyclosporine dose was reduced by an average of 59.1% (SD = 14.6%), yielding an average reduction of 14.6% (18.8%) in plasma levels. The dose of tacrolimus was reduced by 34.3% (31.7%), increasing the dosing interval by a mean of 73.4 (38.2) hours. After this variation, tacrolimus levels were increased by an average of 59.7% (89.6%). In patients treated with boceprevir (n = 4), tacrolimus started with a reduction of 18.1% (9.8%) of the initial dose and an average increase in the dosing interval of 12.0 (16.9) hours, showing a mean reduction in plasma levels of 37.7% (21.8%). Sofosbuvir therapy (n = 13) showed no significant variations in immunosuppressive drug levels. CONCLUSIONS: The interaction of telaprevir and boceprevir with immunosuppressive drugs requires a substantial dose reduction at the beginning of treatment and close monitoring of plasma levels.

[Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department.

OBJECTIVE: To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS: A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round. RESULTS: 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS: The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. / Diseño de un panel de indicadores para programas de optimización del uso de antimicrobianos en los Servicios de Urgencias.

OBJECTIVE: To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS: A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. RESULTS: 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS: The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Sex- and age-related patterns in the use of analgesics in older patients in the emergency department.

BACKGROUND: Treatment of acute pain in older patients is a common challenge faced in emergency departments (EDs). Despite many studies that have investigated chronic analgesic use in the elderly, data on patterns of acute use, especially in EDs, of analgesics according to patient characteristics is scarce. OBJECTIVE: To investigate sex- and age-related patterns of analgesic use in the Spanish EDs and determine differences in age-related patterns according to patient sex. DESIGN: A secondary analysis of the Emergency Department and Elderly Needs (EDEN) multipurpose cohort. SETTING: Fifty-two Spanish EDs (17% of Spanish EDs covering 25% of Spanish population). PARTICIPANTS: All patients' ≥65 years attending ED during 1 week (April 1-7, 2019). Patient characteristics recorded included age, sex, chronic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and opiates, comorbidity, dependence, dementia, depression, ability to walk and previous falls. Analgesics used in the ED were categorized in three groups: non-NSAID non-opioids (mainly paracetamol and metamizole, PM), NSAIDs, and opiates. OUTCOME MEASURES: Frequency of analgesic use was quantified, and the relationship between sex and age and analgesic use (in general and for each analgesic group) was assessed by unadjusted and adjusted logistic regression and restricted cubic spline models. Interaction between sex and age was explored. MAIN RESULTS: We included 24 573 patients, and 6678 (27.2%) received analgesics in the ED: 5551 (22.6%) PM, 1661 (6.8%) NSAIDs and 937 (3.8%) opiates (1312 received combinations). Analgesics were more frequently used in women (adjusted OR = 1.076, 95%CI = 1.014-1.142), as well as with NSAID (1.205, 1.083-1.341). Analgesic use increased with age, increasing PM and decreasing NSAIDs use. Opiate use remained quite constant across age and sex. Interaction of sex with age was present for the use of analgesics in general ( P  = 0.006), for PM ( P  < 0.001) and for opiates ( P  = 0.033), with higher use of all these analgesics in women. CONCLUSION: Use of analgesics in older individuals in EDs is mildly augmented in women and increases with age, with PM use increasing and NSAIDs decreasing with age. Conversely, opiate use is quite constant according to sex and age. Age-related patterns differ according to sex, with age-related curves of women showing higher probabilities than those of men to receive any analgesic, PM or opiates.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project.

Background: Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs. Methods: A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed. Results: A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively. Conclusion: Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project Management elderly patients with polypharmacy is becoming a major challenge to the emergency services. The progressive aging of the population is producing a progressive increase in the number of patients treated with multiple comorbidities and chronic medications. It's well known that polypharmacy is associated with an increase in hospital admissions and health care system costs. However, the impact of polypharmacy over the risk of new visits to the emergency rooms is not well defined. Understanding the impact of polypharmacy on the frequency of new visits to the emergency room and on patient mortality is the first step to establish prevention measures for new visits, proposing improvements in chronic treatment at discharge. This study aimed to determine the prevalence and effect on short-term prognosis of polypharmacy in elderly patients treated in Emergency departments. The authors used a retrospective multipurpose registry in 52 hospitals in Spain. This study includes 25,557 patients with a mean age of 78 years. On admission, the median number of drugs was 6 (IQR: 3­9), with 10,534 (41.2%) patients taking 5­9 drugs and 5,678 (22.2%) taking ⩾10 drugs. In these patients comorbidities were associated with an increase in the number of drugs. In the patients with severe polypharmacy (⩾10 drugs), diuretics were the most frequently drugs prescribed, followed by antihypertensives and statins. The results obtained indicate that polypharmacy is a frequent phenomenon among the elderly population treated in Emergency departments, being antihypertensives the most frequently used drugs in this population. Those patients who takes ⩾10 drugs have a higher risk of new visits to the emergency room and hospital readmissions in short term period.

Paclitaxel and carboplatin treatment for advanced ovarian cancer during pregnancy.

Ovarian carcinoma during pregnancy is a rare event that should be treated. In these cases, due to the lack of information available, doubts about the safety of mother and fetus are present. In this report, a 42-year-old woman who was diagnosed with a stage III ovarian carcinoma received six cycles of chemotherapy with carboplatin and paclitaxel from the 16th until 36th week of gestation. At 38 weeks, a normal male baby was born. There were no abnormalities during birth and during a 2-month follow-up period. This case adds to the available literature and supports the use of these chemotherapy agents during pregnancy, if the risk-benefit balance is appropriate.

Drug-related problems as reason for emergency department visit: 3 years of the FARM-URG registry.

OBJECTIVES: Drug-related problems (DRPs) are a well-known cause of emergency department (ED) visits. The objective of the FARM-URG project was to assess the prevalence of DRPs using an annual cross-sectional registry. Herein we report results of the first 3 years, indicating the prevalence of DRPs, drugs involved, and patient characteristics. METHODS: A point-prevalence multicenter study was conducted across EDs of hospitals in Spain. A specified day and hour was assigned to collect data from all adult patients attending the ED due to DRPs during three consecutive years. Medical records were retrospectively reviewed, with data recorded in REDCap. KEY FINDINGS: Overall, 4752 patients were evaluated at 32 centres, of which 366 (7.7%) visited the ED due to DRPs, with a prevalence ranging from 0 to 16.7%. Antithrombotic drugs accounted for the highest number of DRPs, responsible for 96 (26.8%) episodes. Falls (n = 29; 8.0%) were the most frequent DRPs, followed by haemorrhage (n = 26; 7.12%). Furthermore, 198 (54.2%) reported DRPs were unrelated to medication errors, 80 (21.2%) were overdose errors, and 40 (11.0%) were attributed to poor treatment adherence. Of 366 DRPs-related visits, 54 (14.8%) were due to inappropriately prescribed drugs according to the STOPP-START criteria. Overall, 86 (23.5%) patients revisited the ED within 30 days of discharge, with 34 (9.4%) returning to the ED for new DRPs. CONCLUSIONS: DRPs are frequently responsible for ED visits and are associated with a considerable percentage of post-discharge visits. The goal of the FARM-URG project is to periodically gather data to design and implement preventive measures.

Antimicrobial Pharmacokinetics and Pharmacodynamics in Critical Care: Adjusting the Dose in Extracorporeal Circulation and to Prevent the Genesis of Multiresistant Bacteria.

Critically ill patients suffering from severe infections are prone to pathophysiological pharmacokinetic changes that are frequently associated with inadequate antibiotic serum concentrations. Minimum inhibitory concentrations (MICs) of the causative pathogens tend to be higher in intensive care units. Both pharmacokinetic changes and high antibiotic resistance likely jeopardize the efficacy of treatment. The use of extracorporeal circulation devices to support hemodynamic, respiratory, or renal failure enables pharmacokinetic changes and makes it even more difficult to achieve an adequate antibiotic dose. Besides a clinical response, antibiotic pharmacokinetic optimization is important to reduce the selection of strains resistant to common antibiotics. In this review, we summarize the present knowledge regarding pharmacokinetic changes in critically ill patients and we discuss the effects of extra-corporeal devices on antibiotic treatment together with potential solutions.

The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department.

Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services.

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.

[Translated article] Usefulness of ICD-10 diagnostic triggers to identify adverse drug events in emergency care.

OBJECTIVES: To assess the usefulness of a tool based on ICD-10 diagnostic codes to identify patients who consult an emergency department for adverse drug events (ADE). METHODS: Prospective observational study, in which patients discharged from an emergency department during May to August 2022 with a diagnosis coded with one of the 27 ICD-10 diagnoses considered as triggers were included. ADE confirmation was carried out by analyzing drugs prescribed prior to admission, and through a discussion among experts and a phone interview with patients after hospital discharge. RESULTS: 1143 patients with trigger diagnoses were evaluated, of which 310 (27.1%) corresponded to patients whose emergency visit was attributed to an ADE. A 58.4% of ADE consultations were found with three diagnostic codes: K59.0-Constipation (n = 87; 28.1%), I16.9-Hypertensive Crisis (n = 72; 23.2%) and I95.1-Orthostatic hypotension (n = 22; 7.1%). The diagnoses with the highest degree of association with consultations attributed to ADE were E16.2-Hypoglycemia, unspecified (73.7%) and E11.65-Type 2 diabetes mellitus with hyperglycemia (71.4%), while diagnoses D62-Acute posthemorrhagic anemia and I74.3-Embolism and thrombosis of arteries of the lower limbs were not attributed to any case of ADE. CONCLUSIONS: The ICD-10 codes associated with trigger diagnoses are a useful tool to identify patients who consult the emergency services with ADE and could be used to apply secondary prevention programs to avoid new consultations to the health care system.

Pharmacist care in hospital emergency departments: a consensus paper from the Spanish hospital pharmacy and emergency medicine associations. / Atención farmacéutica en los servicios de urgencias: documento de posicionamiento de la Sociedad Española de Farmacia Hospitalaria (SEFH) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES).

OBJECTIVES: To draft a list of actions and quality indicators for pharmacist care in hospital emergency departments, based on consensus among a panel of experts regarding which actions to prioritize in this setting. MATERIAL AND METHODS: A panel of experts from the Spanish Society of Hospital Pharmacy (SEFH) and the Spanish Society of Emergency Medicine (SEMES) evaluated a preliminary list of potential actions and quality of care indicators. The experts used a questionnaire to assess the proposals on the basis of available evidence. In the first round, each expert individually assessed the importance of each proposed action based on 4 dimensions: evidence base, impact on clinical response and patient safety, ease of implementation, and priority. In the second round the experts attended a virtual meeting to reach consensus on a revised list of proposals; suggestions and comments that had been made anonymously in the first round were included. The group then prioritized each action as basic, intermediate, or advanced. RESULTS: The experts evaluated a total of 26 potential actions and associated quality indicators. No items were eliminated in the analysis of scores and comments from the first round. After the second round, 25 actions survived. Nine were considered basic, 10 intermediate, and 6 advanced. CONCLUSION: The expert panel's list of pharmacist actions and care quality indicators provides a basis for developing a pharmacist care program in Spanish emergency departments on 3 levels of priority. The list can serve as a guide to pharmacists, managers, physicians, and nurses involved in the effort to improve drug therapy in this hospital setting.

OBJETIVO: Desarrollar un conjunto de actividades e indicadores de atención farmacéutica en los servicios de urgencias hospitalarios mediante un consenso colectivo de un panel de expertos que permita priorizar las actividades a realizar por los farmacéuticos en estas unidades. METODO: Un comité formado por miembros de la Sociedad Española de Farmacia Hospitalaria (SEFH) y de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) evaluó una propuesta inicial de actividades e indicadores potenciales, basados en la evidencia científica disponible, en formato de cuestionario. En una primera ronda, cada uno de los expertos del panel clasificó de forma individual la relevancia de cada una de las actividades propuestas en cuatro dimensiones: evidencia científica, impacto en la respuesta clínica y seguridad para el paciente, facilidad de implementación y grado de prioridad. La segunda ronda se realizó mediante una reunión grupal de forma virtual, a partir del cuestionario modificado de acuerdo con las sugerencias planteadas, así como los comentarios vertidos por los participantes del panel de forma anónima. En esta ronda, cada actividad fue clasificada por consenso como básica, intermedia o avanzada en función del grado de prioridad de implantación considerado por el grupo de expertos. RESULTADOS: Se propusieron un total de 26 potenciales actividades a los expertos, con indicadores asociados. Tras el análisis de las puntuaciones y los comentarios realizados en la primera ronda, no se eliminó ninguna de las actividades propuestas. Tras la segunda ronda, se mantuvieron 25 actividades, de las cuales se puntuaron 9 como actividades básicas, 10 actividades como intermedias y 6 actividades como avanzadas. CONCLUSIONES: El desarrollo del conjunto de actividades e indicadores de atención farmacéutica en urgencias, priorizados por grado de relevancia para la unidad, es la base para el desarrollo de esta cartera de servicios en los hospitales españoles, y sirve como guía tanto para farmacéuticos como para gestores, médicos y enfermeros de la unidad a fin de mejorar la farmacoterapia los pacientes atendidos en los servicios de urgencias.

Cefepime Dosing Requirements in Elderly Patients Attended in the Emergency Rooms.

OBJECTIVE: This study aimed to assess the probability of reaching an adequate pharmacokinetic/pharmacodynamic (pK/pD) index for different cefepime dosages in frail patients with bacteremia treated in the emergency room. METHODS: Simulation study based on Gram-negative bacterial strains that cause bacteremia. The probability of reaching a time above the minimum inhibitory concentration (MIC) at 50% and 100% dosing intervals (fT > 50 and fT > 80% MIC) was assessed for two different renal clearance intervals. RESULTS: One hundred twenty nine strains were collected, the predominant species being Escherichia coli (n = 83 [64.3%]). In patients with a ClCr of 30 mL/min, an fT > 50% MIC was reached in more than 90% of the simulations. However, a dose of at least 1 g every 12 h must be administered to reach an fT > 80% MIC. In patients with a ClCr of 30-60 mL/min, the probability of reaching an fT > 50% MIC was higher than 90% with doses of 1 g every 8 h or more, but this value was not reached in > 90% simulations for any of the doses tested in this study. CONCLUSIONS: Standard cefepime dosing can reach an adequate PK/PD index in frail patients. Nevertheless, a high dose or extended infusion is necessary to reach an fT > 80% MIC in patients with a ClCr > 60 mL/min.