A Retrospective Evaluation of Adjunctive Phenobarbital vs. Benzodiazepine Alone for the Treatment of Moderate Alcohol Withdrawal in the Emergency Department.

BACKGROUND: Phenobarbital has been used in the emergency department (ED) as both a primary and adjunctive medication for alcohol withdrawal, but previous studies evaluating its impact on patient outcomes are limited by heterogenous symptom severity. OBJECTIVES: We compared the clinical outcomes of ED patients with moderate alcohol withdrawal who received phenobarbital, with or without benzodiazepines, with patients who received benzodiazepine treatment alone. METHODS: This is a retrospective cohort study conducted at a single academic medical center utilizing chart review of ED patients with moderate alcohol withdrawal between 2015 and 2020. Patient encounters were classified into two treatment categories based on medication treatment: phenobarbital alone or in combination with benzodiazepines vs. benzodiazepines alone. Chi-square test or Fisher's exact was used to analyze categorical variables and the Student's t-test for continuous data. RESULTS: Among the 287 encounters that met inclusion criteria, 100 received phenobarbital, compared with 187 that received benzodiazepines alone. Patients who received phenobarbital were provided significantly more lorazepam equivalents. There was a significant difference in the percentage of patient encounters that required admission to the hospital in the phenobarbital cohort compared with the benzodiazepine cohort (75% vs. 43.3%, p < 0.001). However, there was no difference in admission level of care to the floor (51.2% vs. 52.0%), stepdown (33.8% vs. 28%), or intensive care unit (15% vs. 20%), respectively. CONCLUSIONS: Patients who received phenobarbital for moderate alcohol withdrawal were more likely to be admitted to the hospital, but there was no difference in admission level of care when compared with patients who received benzodiazepines alone. Patients who received phenobarbital were provided greater lorazepam equivalents in the ED.

Prospective evaluation of single-dose aminoglycosides for treatment of complicated cystitis in the emergency department.

BACKGROUND: Antimicrobial resistance among Enterobacterales continues to be a growing problem, particularly in those with urinary infections. Previous studies have demonstrated safety and efficacy with the use of single-dose aminoglycosides in uncomplicated cystitis. However, data in complicated infections are limited. Single-dose aminoglycosides may provide a convenient alternative for those with or at risk for resistant pathogens causing complicated urinary infections, especially when oral options are unavailable due to resistance, allergy, intolerance, or interactions with other medications. This study evaluated the safety and effectiveness of single-dose aminoglycosides in treatment of complicated cystitis in the emergency department (ED). METHODS: This was a multicenter, prospective study performed between July 2022 and March 2023 of patients who met criteria for complicated cystitis and were otherwise stable for discharge at an academic ED. Primary outcomes were clinical or microbiologic failure within 14 days of treatment. Safety was assessed by review of adverse events. Descriptive statistics were used. RESULTS: Thirteen patients were included. Complicating factors were male sex (n = 4), kidney stone (n = 2), urinary catheter (n = 6), recent urologic procedure (n = 1), urinary hardware (n = 1), antibiotic allergy precluding use of alternate oral options (n = 4), immunocompromised status (n = 2), and <1-year history of multidrug-resistant organisms on urine culture (n = 8). Eleven patients (85%) had positive urine cultures in the preceding 12 months with no oral antimicrobial option. Eight patients (62%) received amikacin (median dose 15 mg/kg), four patients (31%) received gentamicin (median dose 5 mg/kg), and one patient (8%) received tobramycin (5 mg/kg) for treatment. Ten patients (77%) reported resolved urinary symptoms after treatment and 11 patients (85%) reported no new urinary symptoms since discharge. No patient required hospital admission for treatment failure, and no adverse events were noted. CONCLUSIONS: Single-dose aminoglycosides appear to be a reasonably effective and safe treatment for complicated cystitis, which avoided hospital admission in this cohort.

ED-based COVID-19 vaccination campaign finds higher vaccination rates for individuals from racial and ethnic minority groups compared with clinic setting.

BACKGROUND: Emergency department visits associated with Coronavirus Disease 2019 (COVID-19) continue to indicate racial and ethnic inequities. We describe the sociodemographic characteristics of individuals receiving COVID-19 vaccination in the emergency department and compare with an outpatient clinic population and emergency department (ED) patients who were eligible but not vaccinated. METHODS: We conducted a retrospective analysis of electronic health record data at an urban academic ED from May to July 2021. The primary aim was to characterize the ED-vaccinated population, compared with ED patients who were eligible but unvaccinated and the physically adjacent outpatient vaccination clinic population. RESULTS: A total of 627 COVID-19 vaccinations were administered in the ED. Overall, 49% of ED patients during that time had already received at least one vaccine dose prior to ED arrival. Hispanic, non-Hispanic Black patients, and patients on non-commercial insurance had higher odds of being vaccinated in the ED as compared with outpatient clinic setting. Among eligible ED patients, men and patients who were uninsured/self-pay were more likely to accept ED vaccination. CONCLUSIONS: This ED COVID-19 vaccination campaign demonstrated a higher likelihood to vaccinate individuals from racial/ethnic minority groups, those with high social vulnerability, and non-commercial insurance, when compared with a co-located outpatient vaccination clinic.

Evaluation of Insulin Infusion Rates for the Treatment of Diabetic Ketoacidosis in the Emergency Department.

Introduction: There is minimal literature to support the appropriate dosing for the initiation of IV regular insulin therapy in DKA patients. A 0.1 unit/kg bolus followed by 0.1 units/kg/hour or 0.14 units/kg/hour is commonly utilized and recommended in guidelines. Objective: We sought to assess clinical and safety outcomes associated with various insulin infusion starting doses in patients diagnosed with DKA in the emergency department in an effort to help guide prescribing. Methods: A retrospective cohort study was conducted within an academic emergency department and included patients who received continuous infusion regular insulin with an ICD-10 code for DKA between January 2016 and January 2019. A predictive regression model was applied to test if predefined lab values influenced the starting insulin infusion rates. Clinical and safety outcomes were evaluated by starting insulin infusion rate. Data was analyzed based on starting insulin infusion rates. Results: 347 patients met inclusion criteria with 92 (26.5%) patients receiving <0.07 units/kg/hr, 123 (35.4%) patients receiving 0.07 to 0.099 units/kg/hr, 123 (35.4%) patients receiving 0.10 to 0.139 units/kg/hr, and 9 (2.6%) patients receiving ≥0.14 units/kg/hr. After adjusting for baseline labs, glucose was the only significant predictor of the initial infusion rate (p < 0.001). For every 100 mg/dL increase in the baseline glucose value, the initial infusion rate increased by 0.005 units/kg/hr. There was no difference between insulin starting infusion rates and length of stay, rates of hypoglycemia, hypokalemia, or dysrhythmias. Conclusion: Glucose levels significantly influenced the insulin starting infusion rate, with no identified differences in adverse effects or clinical outcomes.

Potentially Inappropriate Medication Usage in Older Adults in a Tertiary Academic Medical Center Emergency Department.

BACKGROUND: The Beers Criteria® medications are potentially inappropriate medications (PIMs) recommended by the American Geriatric Society to be avoided or used with caution in adults 65 years and older. The usage of PIMs in the emergency department (ED) setting is not well characterized. OBJECTIVES: The purpose of this study is to evaluate the usage of PIMS in the ED. METHODS: This is a single center retrospective observational study of a random sample of patients aged 65 and older who presented to the ED during a 6-month timeframe. The primary outcome was the incidence of ED readmissions in patients administered or prescribed a PIM compared with patients who were not prescribed or administered a PIM. Secondary outcomes included ED length of stay (LOS) and hospital admission. RESULTS: Out of 192 patients, there was a total of 58 patients (30.2%) in the PIM group and 134 patients (69.8%) in the No PIM group. ED re-presentation within 30 days occurred in 10 patients (17%) in the PIM group vs 26 patients (19%) in the No PIM group (p = 0.88). The median ED LOS was 227 minutes vs 208 minutes (p = 0.1679). Hospital admission within 30 days occurred in 4 patients (7%) in the PIM group and 13 patients (10%) in the No PIM group (p = 0.725). CONCLUSIONS: This analysis did not show statistically significant differences between patients who received a PIM compared to those who received an alternative medication with regard to re-presentation, admission, and ED LOS. ED LOS trended towards being longer in the PIM group.

A Severe Case of Diabetic Ketoacidosis and New-Onset Type 1 Diabetes Mellitus Associated with Anti-Glutamic Acid Decarboxylase Antibodies Following Immunotherapy with Pembrolizumab.

BACKGROUND Immune checkpoint inhibitors (ICIs) are a novel class of antibodies, which have been increasingly utilized in cancer immunotherapies. Pembrolizumab is a humanized IgG4 monoclonal antibody, which acts against programmed cell death (PD)-1 receptors to help restore the body's T-cell and immune response. CASE REPORT In this case, we present a 51-year-old woman with a past medical history of lung adenocarcinoma and triple-positive breast cancer who was actively receiving therapy with pembrolizumab. Following her second chemotherapy cycle, she developed a severe case of diabetic ketoacidosis (DKA), with concern for new-onset autoimmune type 1 diabetes mellitus (T1DM), secondary to her recent ICI therapy. The patient was initiated on a high-dose insulin infusion for rapid glycemic control and was successfully transitioned to a subcutaneous regimen approximately 24 h after presentation. She additionally developed other autoimmune-related complications, including hepatoxicity, duodenitis, and a maculopapular rash, which all resolved upon discontinuation of the ICI treatment. Her laboratory test results were consistent with positive anti-glutamic acid decarboxylase (anti-GAD) antibodies and undetectable c-peptides, illustrating the uniqueness of an ICI potentially precipitating an autoimmune T1DM. CONCLUSIONS Immune-related adverse events from ICI therapy warrant further investigation to acknowledge the risk of potentially life-threatening adverse reactions, such as the development of DKA. Patients receiving ICI therapy should be educated on signs and symptoms of hyperglycemia, and routine measurements of blood glucose levels should be completed during each chemotherapy cycle. Future research in assessing potential biomarkers of beta cell dysfunction, such as anti-GAD antibodies and c-peptides, is of interest, particularly for patients receiving ICI therapies.

Training Emergency Physicians in Ultrasound-guided Fascia Iliaca Compartment Blocks: Lessons in Change Management.

Study objectives Older adults who sustain hip fractures are susceptible to high rates of morbidity and mortality. The systemic administration of opioids is associated with side effects disproportionately affecting the elderly. The ultrasound-guided fascia iliaca compartment block procedure (FICB) is associated with a reduced patient need for oral and parenteral opioids and with improved functional outcomes. We designed a multi-disciplinary quality improvement initiative to train emergency physicians (EPs) to perform the ultrasound-guided FICB procedure for geriatric hip fracture patients. We examined the lessons derived from the EPs' resistance to implementing a practice-changing behavior. Methods This study was a prospective observational cohort study. We included all emergency department (ED) patients > 65 years with X-ray confirmation of isolated hip fractures. We also enrolled the treating EPs. Patients were enrolled from March 2016 to January 2017 in an urban, academic ED with 100,000 annual visits. The ED ultrasound faculty trained ED faculty and residents in the FICB procedure. Seventeen of 50 attending EPs completed the training: classroom lecture and online narrated video instruction. The hands-on sessions consisted of three stations: scan a human model volunteer to review the sonoanatomy, practice the needle technique using a Blue PhantomTM Regional Anesthesia Ultrasound Training Block Model (Simulaids, Inc., NY, US), and practice the needle technique using a static simulator. We created a multi-disciplinary geriatric hip fracture order set for the electronic medical record. The attending EPs, caring for eligible patients, were asked to complete a Research Electronic Data Capture (REDCap) survey, and we analyzed the data using descriptive statistics. Results We enrolled 77 geriatric hip fracture patients. Two of the 77 patients received FICB. Thirty-two EPs participated as providers for these patients while 97% of these providers completed the post-intervention survey. Providers used the geriatric hip fracture order set in 10 of 77 encounters. Most EPs did not perform the block because they were not trained or did not feel comfortable performing it. Conclusion Despite the efficacy supported by the literature and training sessions offered, the EPs in this study did not adopt the FICB procedure. Future efforts could include developing a FICB on-call team, increasing the proportion of trained EPs through initial supervised hands-on practice, and partnering financial or education incentives with getting trained.

Patient preferences for treatment of acute bacterial skin and skin structure infections in the emergency department.

BACKGROUND: Limited research has assessed patient preferences for treatment disposition and antibiotic therapy of acute bacterial skin and skin structure infection (ABSSSI) in the emergency department (ED). Understanding patient preference for the treatment of ABSSSI may influence treatment selection and improve satisfaction. METHODS: A survey was conducted across 6 US hospital EDs. Patients with ABSSSI completed a baseline survey assessing preferences for antibiotic therapy (intravenous versus oral) and treatment location. A follow-up survey was conducted within 30-40 days after ED discharge to reassess preferences and determine satisfaction with care. RESULTS: A total of 94 patients completed both baseline and follow-up surveys. Sixty (63.8%) participants had a history of ABSSSI, and 69 (73.4%) were admitted to the hospital. Treatment at home was the most common preference reported on baseline and follow-up surveys. Patients with higher education were 82.2% less likely to prefer treatment in the hospital. Single dose intravenous therapy was the most commonly preferred antibiotic regimen on baseline and follow-up surveys (39.8 and 19.1%, respectively). Median satisfaction scores for care in the ED, hospital, home, and with overall antibiotic therapy were all 8 out of a maximum of 10. CONCLUSIONS: In these patients, the most common preference was for outpatient care and single dose intravenous antibiotics. Patient characteristics including higher education, younger age, and current employment were associated with these preferences. Opportunities exist for improving ABSSSI care and satisfaction rates by engaging patients and offering multiple treatment choices.

Variability in Emergency Medicine Provider Decisions on Hospital Admission and Antibiotic Treatment in a Survey Study for Acute Bacterial Skin and Skin Structure Infections: Opportunities for Antimicrobial Stewardship Education.

BACKGROUND: Acute bacterial skin and skin structure infections (ABSSSIs) are a frequent cause of emergency department (ED) visits. Providers in the ED have many decisions to make during the initial treatment of ABSSSI. There are limited data on the patient factors that influence these provider decisions. METHODS: An anonymous survey was administered to providers at 6 EDs across the United States. The survey presented patient cases with ABSSSIs ≥75 cm2 and escalating clinical scenarios including relapse, controlled diabetes, and sepsis. For each case, participants were queried on their decision for admission vs discharge and antibiotic therapy (intravenous, oral, or both) and to rank the factors that influenced their antibiotic decision. RESULTS: The survey was completed by 130 providers. For simple ABSSSI, the majority of providers chose an oral antibiotic and discharged patients home. The presence of recurrence or controlled diabetes resulted in more variation in responses. Thirty-four (40%) and 51 (60%) providers chose intravenous followed by oral antibiotics and discharged the recurrence and diabetes cases, respectively. Presentation with sepsis resulted in initiation with intravenous antibiotics (122, 95.3%) and admission (125, 96.1%) in most responses. CONCLUSIONS: Variability in responses to certain patient scenarios suggests opportunities for education of providers in the ED and the development of an ABSSSI clinical pathway to help guide treatment.

Patient nonadherence to filling discharge medication prescriptions from the emergency department: Barriers and clinical implications.

PURPOSE: Barriers to and clinical implications of patient nonadherence to filling discharge medication prescriptions from the emergency department (ED) were evaluated. METHODS: This was a retrospective, observational analysis of patients discharged from the ED from April 2013 through May 2015 with medication prescriptions. Patients age 18-89 years who were seen in the ED and did not retrieve discharge medication prescriptions from the onsite, 24-hour ED discharge pharmacy were included in this study. Patients who did not pick up prescriptions were called and asked about barriers to prescription filling. These charts were then retrospectively reviewed and categorized. The primary study outcome was the frequency of nonadherence to filling discharge medications prescribed during the ED visit at the ED outpatient pharmacy. Secondary outcomes included identifying barriers to medication adherence, the rate of return ED visits within 30 days of ED discharge, and the rate of 30-day hospital admissions. Associations between patient and medication variables and the rates of return ED visits within 30 days of discharge and 30-day hospital admissions were analyzed. RESULTS: Of the 4,444 patients discharged from the ED with a prescription to be filled at the satellite pharmacy, 510 were nonadherent. Of these patients, 505 had complete chart information available for evaluation. A large proportion of nonadherent patients revisited the ED within 30 days of ED discharge. Multivariate logistic regression found payer class, ethnicity, and sex were independently associated with return ED visits. CONCLUSION: The majority of patients who received a prescription during an ED visit filled their discharge medications. Sex, ethnicity, and payer class were independently associated with nonadherence.

Using pharmacists to optimize patient outcomes and costs in the ED.

Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.