Customizing anaphylaxis guidelines for emergency medicine.

BACKGROUND: Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition. OBJECTIVE: Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements. DISCUSSION: Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode--regardless of severity--is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as "possible anaphylaxis," it is generally better to err on the side of caution and administer epinephrine. CONCLUSION: We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.

Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice.

BACKGROUND: Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations. METHODS: This was an online anonymous survey of a random sample of EM health providers in US EDs. RESULTS: Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended. CONCLUSIONS: This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.

The effects of resident level of training on the rate of pediatric prescription errors in an academic emergency department.

BACKGROUND: Medication errors are a leading cause of increased cost and iatrogenic injury in the pediatric population. In the academic setting, studies have suggested that these increased error rates are related primarily to resident inexperience, thus advocating a higher level of supervision. STUDY OBJECTIVE: We sought to identify the number of prescription errors in our institution's academic Emergency Department, how this varied between the beginning and end of the academic year and between practitioners at varying levels of training. METHODS: A retrospective review of computer-based outpatient prescriptions for children aged 0-12 years old was performed. Outpatient prescriptions were reviewed during a 2-week time block at the end of the academic year and beginning of the academic year (109 [June] and 111 [July] data sets, respectively). Prescriptions were retrieved electronically and reviewed for appropriate dosing. Errors were defined as those that varied>10% above or below recommended weight-based dosing. RESULTS: Twenty-nine (16.1%) of 180 written prescription orders were determined to be incorrectly written. Error rates were not significantly different between the beginning and end of the academic year. In both sampling periods, a higher percentage were found to be derived from senior level practitioners in both data sets (9/14 and 10/15; respectively), but few of these were considered high-grade prescription errors. CONCLUSIONS: Overall prescription error rates at our institution are comparable to nationally reported error rates in children. Error rates were not associated with newly matriculated residents. These findings dispute previously held opinion that physician level of training is a factor of prescription errors.

The outcomes of emergency pharmacist participation during acute myocardial infarction.

BACKGROUND: Current guidelines recommend door-to-balloon times of 90 min or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction (STEMI). OBJECTIVES: To determine if a clinical pharmacist for the ED (EPh) is associated with decreased door/diagnosis-to-cardiac catheterization laboratory (CCL) time and decreased door-to-balloon time. METHODS: A retrospective observational cohort study of ED patients with STEMI requiring urgent cardiac catheterization was conducted. Blinded data collection included timing of ED and CCL arrival, diagnostic electrocardiogram (ECG), and balloon angioplasty. For cases diagnosed after ED arrival, diagnosis time was substituted for door time. Diagnosis was the time ST elevations were evident on serial ECG. EPh present and not-present groups were compared. During the study period there were two EPhs and presence was determined by their scheduled time in the ED. Univariate and multivariate analyses was used to detect differences. RESULTS: Multivariate analysis of 120 patients, controlled for CCL staff presence and arrival by pre-hospital services, determined that EPh presence is associated with a mean 13.1-min (95% confidence interval [CI] 6.5-21.9) and 11.5-min (95% CI 3.9-21.5) decrease in door/diagnosis-to-CCL and door-to-balloon times, respectively. Patients were more likely to achieve a door/diagnosis-to-CCL time≤ 30 min (odds ratio [OR] 3.1, 95% CI 1.3-7.8) and≤ 45 min (OR 2.9, 95% CI-1.0, 8.5) and a door-to-balloon time≤ 90 min (OR 1.9, 95% CI 0.7-5.5) more likely when the EPh was present. CONCLUSIONS: EPh presence during STEMI presentation to the ED is independently associated with a decrease in door/diagnosis-to-CCL and door-to-balloon times.

Severity and probability of harm of medication errors intercepted by an emergency department pharmacist.

OBJECTIVES The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. METHODS The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. KEY FINDINGS There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). CONCLUSIONS A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.

The role of the emergency pharmacist in trauma resuscitation.

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.

Intravenous opioid dosing and outcomes in emergency patients: a prospective cohort analysis.

OBJECTIVES: Pain management in emergency department (ED) patients is variable and often inadequate. This study sought to (1) describe the variability in intravenous opioid dosing and (2) compare the outcomes that result from the most commonly prescribed opioid doses. METHODS: This prospective cohort study enrolled emergency patients who were prescribed intravenous morphine or hydromorphone as their initial analgesic. Subjects were interviewed at the time of opioid administration and 1 to 2 hours after opioid administration. Outcomes included the numeric pain score change (using a 0-10 scale), the proportion achieving a 50% pain score reduction, and the proportion developing side effects. Logistic regression was used to assess the effects of demographic, clinical, and treatment variables on outcomes. RESULTS: Six hundred ninety-one patients were analyzed. Initial equianalgesic dosages varied by a factor of 27 (from 1 mg morphine to 4 mg hydromorphone). Opioid dose titration occurred in only 21% of patients. Outcomes were similar across the range of opioid dosages before and after adjusting for potentially confounding variables. Among patients not taking opioids at home who received a total of 4 mg of morphine or less. 48% achieved at least a 50% pain score reduction and 60% did not want additional analgesics. CONCLUSIONS: We found marked opioid dosing variability and infrequent opioid dose titration. A substantial number of ED patients with severe pain responded well to relatively low opioid dosages. Improved ability to predict opioid dose requirements and strategies that increase the use of opioid dose titration in ED patients are needed.

Pharmacist's activities on a trauma response team in the emergency department.

PURPOSE: The interventions of a clinical pharmacist on an emergency department (ED) trauma response team were studied. METHODS: The study site was an academic, tertiary care hospital designated as a level 1 trauma center, with a clinical pharmacist present in the ED 40 hours per week. For a two-month period, interventions by the pharmacist in trauma cases were documented in an electronic quality-improvement database. RESULTS: A total of 304 interventions were recorded; the most common were dosage recommendations (60%) and provision of drug information (27%). The top five drug classes involved were analgesics, sedatives, antimicrobials, vaccines, and fluids. In 83% of the interventions, the pharmacist documented involvement in facilitating drug administration. CONCLUSION: A pharmacist participating on the ED trauma response team commonly provided dosage recommendations and drug information, facilitated drug administration, and optimized sedation, analgesia, and antimicrobial therapy.

Strategies for implementing emergency department pharmacy services: results from the 2007 ASHP Patient Care Impact Program.

PURPOSE: Strategies proposed during a patient care impact program for implementing emergency department (ED) pharmacy services are described. SUMMARY: In June 2007, the American Society of Health-System Pharmacists developed a patient care impact program entitled "Introducing an Emergency Department Pharmacist into Your Institution" to provide experiential training to practicing pharmacists seeking to establish ED services in their institutions. Under the guidance of four mentors, 19 pharmacists from a variety of practice settings, including community-based hospitals and academic and tertiary-care-based institutions, were selected for participation the six-month program. Participants were divided into two groups, and each group was assigned two mentors. During their initial meeting, participants identified anticipated challenges to implementation of pharmacy services in the ED and began to define strategies with their mentors for effectively managing the anticipated challenges. Each group participated in one-hour monthly teleconferences with their mentors. In addition to monthly teleconferences, participants regularly contacted their mentors for additional assistance and several visited their mentors' institutions. Participants developed job descriptions for an ED pharmacist, developed a rationale and justification for implementing pharmacy services in the ED, obtained approval and support from appropriate parties for the ED pharmacist's role, developed plans for introducing a pharmacist to the ED, and developed quality-assurance methods to monitor the effectiveness of the pharmacist's role. CONCLUSION: Despite the diversity in practice settings, participants of the program faced similar challenges in implementing ED pharmacy services at their institutions. Various strategies toward solutions to these challenges were shared among participants and mentors.

Antiemetic therapy for nausea and vomiting in the emergency department.

BACKGROUND: Antiemetic agents are among the most frequently prescribed medications in the emergency department (ED). Nevertheless, there are no widely accepted evidence-based guidelines to optimize the use of these medications for nausea or vomiting in this setting. OBJECTIVE: The objective of this article is to briefly review the evidence supporting the use of antiemetic agents for the treatment of nausea or vomiting for adults in the ED, and to provide recommendations to help guide therapy. DISCUSSION: The antiemetic agents studied include droperidol, promethazine, prochlorperazine, metoclopramide, and ondansetron. Droperidol was commonly used in the past, and is more effective than prochlorperazine or metoclopramide, but due to the US Food and Drug Administration black box warning regarding the potential for QT prolongation with this drug, its use is limited to refractory cases. Promethazine is more sedating than other comparative agents, and also has the potential for vascular damage upon intravenous administration. It may be a suitable option when sedation is desirable. Patients given prochlorperazine or metoclopramide must be monitored for akathisia that can develop at any time over 48 h post administration. Decreasing the infusion rate can reduce the incidence of this adverse effect, and the effect can be treated with intravenous diphenhydramine. Ondansetron is as effective as promethazine, and is not associated with sedation or akathisia. CONCLUSION: Based on the safety and efficacy of ondansetron, it may be used as a first-line agent for relief of nausea or vomiting for most patient populations in the ED.

Outcomes after intravenous opioids in emergency patients: a prospective cohort analysis.

OBJECTIVES: Pain management continues to be suboptimal in emergency departments (EDs). Several studies have documented failures in the processes of care, such as whether opioid analgesics were given. The objectives of this study were to measure the outcomes following administration of intravenous (IV) opioids and to identify clinical factors that may predict poor analgesic outcomes in these patients. METHODS: In this prospective cohort study, emergency patients were enrolled if they were prescribed IV morphine or hydromorphone (the most commonly used IV opioids in the study hospital) as their initial analgesic. Patients were surveyed at the time of opioid administration and 1 to 2 hours after the initial opioid dosage. They scored their pain using a verbal 0-10 pain scale. The following binary analgesic variables were primarily used to identify patients with poor analgesic outcomes: 1) a pain score reduction of less than 50%, 2) a postanalgesic pain score of 7 or greater (using the 0-10 numeric rating scale), and 3) the development of opioid-related side effects. Logistic regression analyses were used to study the effects of demographic, clinical, and treatment covariates on the outcome variables. RESULTS: A total of 2,414 were approached for enrollment, of whom 1,312 were ineligible (658 were identified more than 2 hours after IV opioid was administered and 341 received another analgesic before or with the IV opioid) and 369 declined to consent. A total of 691 patients with a median baseline pain score of 9 were included in the final analyses. Following treatment, 57% of the cohort failed to achieve a 50% pain score reduction, 36% had a pain score of 7 or greater, 48% wanted additional analgesics, and 23% developed opioid-related side effects. In the logistic regression analyses, the factors associated with poor analgesia (both <50% pain score reduction and postanalgesic pain score of >or=7) were the use of long-acting opioids at home, administration of additional analgesics, provider concern for drug-seeking behavior, and older age. An initial pain score of 10 was also strongly associated with a postanalgesic pain score of >or=7. African American patients who were not taking opioids at home were less likely to achieve a 50% pain score reduction than other patients, despite receiving similar initial and total equianalgesic dosages. None of the variables we assessed were significantly associated with the development of opioid-related side effects. CONCLUSIONS: Poor analgesic outcomes were common in this cohort of ED patients prescribed IV opioids. Patients taking long-acting opioids, those thought to be drug-seeking, older patients, those with an initial pain score of 10, and possibly African American patients are at especially high risk of poor analgesia following IV opioid administration.

Survey of physicians regarding clinical pharmacy services in academic emergency departments.

PURPOSE: The prevalence and nature of clinical pharmacy services in academic emergency departments (EDs) were studied. METHODS: A Web-based survey instrument consisting of questions regarding clinical pharmacy services available in the ED was developed based on a review of the current literature and expert consensus. The revised instrument was sent to a representative of all emergency medicine (EM) residency programs listed in the Society for Academic Emergency Medicine residency catalog in June 2006. The survey included questions addressing characteristics of the institution and the availability and nature of various pharmacy services in the ED. EM physicians were deliberately targeted so that the results would represent the ED staff's perceptions of their use of pharmacy services. Only respondents' primary residency hospital sites were considered. Data were compiled and analyzed using descriptive statistics and 95% confidence intervals. RESULTS: Of the 135 EM residency programs surveyed, 99 responses (73%) were received. Eight percent of institutions reported that a dedicated pharmacist was available in the ED 24 hours a day, 22% reported partial coverage in the ED, and 70% reported no coverage. Six percent reported the presence of a satellite pharmacy located in the ED that was staffed by a pharmacist. The most common clinical pharmacy services reported in EDs with pharmacy coverage were modification of inventory according to formulary status, provision of drug or toxicology information, and adverse-drug-event reporting. CONCLUSION: A minority of respondents from academic EDs reported that clinical services are provided by a pharmacist working in the ED.

Addition of levalbuterol to a pediatric emergency department automated medication management system does not increase its use.

BACKGROUND: Although adding a drug to an emergency department-based automated medication management system is known to increase how frequently it is ordered, little is known about this effect when the added drug does not offer substantial benefit over a substitute drug that was already available. AIMS: We studied the effect of adding nebulized levalbuterol to a pediatric emergency department-based automated medication management system that already included albuterol. METHODS: All completed orders for nebulized levalbuterol or nebulized albuterol from our academic pediatric emergency department were retrospectively identified using a computerized pharmacy database. We compared ordering of these drugs for the year before levalbuterol was added to the automated medication management system, during which it was available only from the hospital central pharmacy via a pneumatic tube system, with the year following its inclusion in the system. RESULTS: There were 6 orders for nebulized levalbuterol and 1,295 orders for nebulized albuterol during the year that levalbuterol was only available from the hospital central pharmacy, and 7 orders for nebulized levalbuterol and 1,108 orders for nebulized albuterol during the year following levalbuterol's inclusion in the automated medication management system. There was no significant difference (p = 0.78). CONCLUSIONS: Use of nebulized levalbuterol, in relation to that of nebulized albuterol, for which it is a substitute, did not significantly change when it was included in the pediatric emergency department automated medication management system. This may reflect the lack of substantial benefit that levalbuterol offers over nebulized albuterol in managing children in the emergency department.

Emergency department drug orders: does drug storage location make a difference?

STUDY OBJECTIVE: We hypothesize that adding drugs previously only available from the hospital central pharmacy to an existing emergency department (ED) automated medication management system would alter the frequency with which they were ordered. METHODS: A pharmacy database of a large, urban, academic teaching hospital was used to retrospectively calculate changes in drug-ordering frequencies before and after study drugs were added to an ED automated medication management system. Study drugs had been recently added to our ED automated medication management system but were still available from the hospital central pharmacy and were not the subject of changes in hospital prescribing protocols. RESULTS: Four drug preparations met study criteria: moxifloxacin injection, moxifloxacin tablets, azithromycin injection, and pantoprazole injection. All had large increases (4.0-, 7.2-, 6.5-, and 25.0-fold, respectively) in ordering frequency after addition to the ED automated medication management system. Changes in order frequency strongly correlated with how often orders were filled from the ED automated medication management system rather than the hospital central pharmacy. CONCLUSION: Adding drug preparations to an existing ED automated medication management system increased the frequency with which they were ordered, especially when they were most reliably obtained from the system rather than the central hospital pharmacy. Adding drugs to an ED automated medication management system influences physician drug ordering.