Pharmacotherapy optimization for rapid sequence intubation in the emergency department.

PURPOSE: Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY: There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH: The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Safety and effectiveness of benzodiazepines and antipsychotics for agitation in older adults in the emergency department.

PURPOSE: To examine the safety and effectiveness of benzodiazepines (BZD) as compared to antipsychotics for the management of acute agitation in older adults in the emergency department (ED). BASIC PROCEDURES: Retrospective observational cohort study of 21 EDs across four states in the US, including adults ≥60 years old who received either BZD or antipsychotics for acute agitation in the ED and subsequently were admitted to the hospital. Safety was measured as presence of adverse events: respiratory depression, cardiovascular effects, extrapyramidal side effects, or a fall during hospitalization. Effectiveness was measured as indicators of treatment failure: need for additional medication, one-to-one observation, or physical restraints following initial medication administration. Proportions and odds ratios with 95% confidence intervals (CI) were calculated. Univariable and multivariable logistic regression were used to assess the association between potential risk factors and for efficacy and safety endpoints. MAIN FINDINGS: A total of 684 patients were included (63.9% received a BZD and 36.1% an antipsychotic). There was no difference in the incidence of adverse events between groups (20.6% vs 14.6%, difference 6.0%, 95% CI -0.2% to 11.8%), but there was a higher intubation rate in the BZD group (2.7% vs 0.4%, difference 2.3%). There were more treatment failures in the antipsychotic group for the composite primary efficacy endpoint (94.3% vs 87.6%, difference 6.7%, 95% CI 2.5% to 10.9%). This appears to have been driven by the need for 1:1 observation; sensitivity analysis excluding 1:1 observation in the composite outcome demonstrated no significant difference with a failure rate of 38.5% in the antipsychotic group and 35.2% in the benzodiazepine group. PRINCIPAL CONCLUSIONS: Overall there are high rates of treatment failure among agitated older adults receiving pharmacological treatment for agitation in the emergency department. The optimal selection of pharmacological treatment for agitation in older adults should be made considering patient-specific factors that could increase the risk of adverse effects or treatment failure.

Characteristics of Opioid Prescribing in Non-surgical Medicine Patients with Acute Pain at Hospital Discharge.

BACKGROUND: The opioid epidemic and new Joint Commission standards around opioid stewardship have made the appropriate prescribing of opioids a priority. A knowledge gap exists pertaining to the short-term prescription of opioids at hospital discharge for acute pain in non-surgical patients. OBJECTIVE: To characterize the quantity, type, and indication of opioids prescribed for non-surgical patients on hospital discharge and subsequent patient utilization. DESIGN: This multicenter, single-health system retrospective cohort study was conducted for quality improvement purposes from December 2019 to May 2020 with patient follow-up 15 to 29 days after hospital discharge. PARTICIPANTS: Patients discharged from a medicine service with new opioid prescriptions, defined as no opioid prescription documented within the past 90 days, were identified as eligible through the electronic health record. Surveys were attempted until a total of 200 were completed, with 374 surveys attempted and a 53% response rate. INTERVENTION: Patients were contacted via phone and surveyed post-discharge. Surveys consisted of 28 questions and assessed opioid consumption, duration of use, refills, patient satisfaction, and opioid disposal. MAIN MEASURES: Prescribing indications and morphine milligram equivalents (MME) quantities were collected for patients at discharge. Subsequently, the quantity of prescribed opioids utilized, remaining, and disposed of post-discharge were collected via patient self-reported survey responses. KEY RESULTS: Indications for opioid prescribing for 200 surveyed patients were grouped into eight broad prescribing categories. A median of 112.5 total MME was prescribed to patients at hospital discharge. Median MME consumed for surveyed patients was 45. The median total MME remaining at time of survey was 35 MME. Only 5.9% of patients who had leftover opioids reported disposal of the medication. CONCLUSIONS: Given the observed variation in opioid prescribing and utilization data, standardized indication-based opioid prescribing guidance in the non-surgical medical population would help curb the amount of opioids that remain unused post-discharge.

Timeliness of data entry in Wisconsin Immunization Registry by Wisconsin pharmacies.

OBJECTIVE: To assess the association of various immunization- and pharmacy-related factors with the timeliness of pharmacy data entry in a state immunization information system. DESIGN: A cross-sectional study was conducted. SETTING AND PARTICIPANTS: Data for 2,040,248 immunizations administered by pharmacies in Wisconsin during 2012-2017 were collected from the Wisconsin Immunization Registry (WIR). Variables, including the submission method, immunization administration year, vaccine type, and recipient age, were analyzed through multivariate logistic regression to determine if they had a relationship with data entry timeliness. Pharmacists were surveyed on immunization data entry practices to corroborate analysis findings. OUTCOME MEASURES: Timeliness of immunization data entry in WIR was measured as a binary variable: 7 days or fewer or more than 7 days after immunization. RESULTS: Influenza immunizations were statistically significantly less likely to be timely compared with noninfluenza immunizations (odds ratio [OR] 0.719 [95% CI 0.712-0.726]; P < 0.0001). Immunizations administered to individuals aged more than 18 years were less timely compared with immunizations administered to individuals aged 6-18 years. The magnitude showed a slight difference in timeliness but without statistical significance (0.989 [95% CI 0.972-1.006]; P > 0.05). For submission method, flat-file submission was less likely to be timely compared with manual entry (0.48 [95% CI 0.475-0.486]; P < 0.0001). Health Level-7 submission, involving the electronic exchange of information with electronic health systems, was much more likely to be timely compared with manual entry (1.989 [95% CI 1.972-2.007]; P < 0.0001). With each successive year, from 2012 to 2017, immunizations were entered in a less timely manner (0.981 [95% CI 0.979-0.983]; P < 0.0001). CONCLUSIONS: Timeliness of pharmacy data entry in WIR was associated with entry method, vaccine type, and immunization administration year. We hope to identify ways to help pharmacies improve immunization data entry in WIR and facilitate the communication of immunization information among providers.

School Wellness in Wisconsin: Evaluating Policies for Practices to Prevent Pediatric Obesity.

BACKGROUND: We examined written language in Wisconsin school wellness policies (SWPs) for federal mandate compliance, quality related to obesity prevention, and school characteristics associated with variations in quality. This is the first near census of Wisconsin SWPs and examines whether adhering to federal mandates results in strong policies aimed at preventing pediatric obesity. METHODS: Policies were coded using the WellSAT 2.0. Policy quality was computed as comprehensiveness and strength based on 6 subscales and 2 overall scores. Variations in policy quality were examined by district size, free/reduced lunch percentage, and year of last revision. RESULTS: We received SWPs from 91% of districts. Six of the 8 federal mandates were addressed by the majority of districts, although less than one fourth addressed all. Most comprehensiveness scores were weak to moderate, and strength scores were weak. All school characteristics were significantly related to overall policy quality; effect sizes were small. CONCLUSIONS: Our results confirm the necessity of statewide focus on SWP improvement and suggest that while districts may be meeting federal mandates related to pediatric obesity, few policies include health promotion practices beyond those required. Policies remain fragmented and lack focus on obesity prevention practices; we identify modifiable areas for improvement.