The effects of ceftriaxone by intravenous push on adverse drug reactions in the emergency department.

OBJECTIVE: At our hospital, a shortage of sterile saline bags led to changing ceftriaxone from intravenous infusion to intravenous push. We examined if this change led to an increase in adverse reactions. METHODS: We conducted a retrospective chart analysis on patients 18 and older that were administered ceftriaxone in the ED between January to March 2018. Research assistants recorded information about possible adverse reactions. Adverse reactions were defined as any noxious or unintended response to a drug given at therapeutic doses. Potential adverse reactions were independently reviewed by three EM clinicians and confirmed by an adverse drug reaction probability scale. The primary outcome was the rate of adverse reactions for IVP administration of ceftriaxone. RESULTS: 831 encounters were identified, 77 were excluded due to erroneous or missing data, and a total of 753 were included. Study demographics include an average age of 52.8, a female majority (54.2%) and predominantly black patient population (41.5%). A total of 24 cases were potential adverse reactions. After independent review, only one of the 24 cases was determined to be an adverse reaction to ceftriaxone from IVP. The total adverse event rate observed was 1/753 or 0.13%. CONCLUSIONS: Our study demonstrates that the rate of adverse reactions for IVP is lower than previously reported. Given the demonstrated safety of IVP administration, future studies are warranted to determine the implications for ED efficiency and cost benefits from this change in drug delivery.

Decreased Nursing Staffing Adversely Affects Emergency Department Throughput Metrics.

INTRODUCTION: The effect of nurse staffing on emergency department (ED) efficiency remains a significant area of interest to administrators, physicians, and nurses. We believe that decreased nursing staffing adversely affects key ED throughput metrics. METHODS: We conducted a retrospective observational review of our electronic medical record database from 1/1/2015 to 12/31/2015 at a high-volume, urban public hospital. We report nursing hours, door-to-discharge length of stay (LOS) and door-to-admit LOS, and percentage of patients who left without being seen (LWBS). ED nursing hours per day was examined across quartiles with the effect evaluated using analysis of covariance and controlled for total daily ED volume, hospital occupancy and ED admission rate. RESULTS: From 1/1/15-12/31/15, 105,887 patients presented to the ED with a range of 336 to 580 nursing hours per day with a median of 464.7. Independent of daily ED volume, hospital occupancy and ED admission rate, days in the lowest quartile of nursing hours experienced a 28.2-minute increase per patient in door-to-discharge LOS compared to days in the highest quartile of nursing hours. Door-to-admit LOS showed no significant change across quartiles. There was also an increase of nine patients per day who left without being seen by a provider in the lowest quartile of nursing hours compared to the highest quartile. CONCLUSION: Lower nursing hours contribute to a statistically significant increase in door-to-discharge LOS and number of LWBS patients, independent of daily ED volume, hospital occupancy and ED admission rate. Consideration of the impact of nursing staffing is needed to optimize throughput metrics for our urban, safety-net hospital.

Comparison of Result Times Between Urine and Whole Blood Point-of-care Pregnancy Testing.

INTRODUCTION: Point-of-care (POC) pregnancy testing is commonly performed in the emergency department (ED). One prior study demonstrated equivalent accuracy between urine and whole blood for one common brand of POC pregnancy testing. Our study sought to determine the difference in result times when comparing whole blood versus urine for the same brand of POC pregnancy testing. METHODS: We conducted a prospective, observational study at an urban, academic, tertiary care hospital comparing the turnaround time between order and result for urine and whole blood pregnancy tests collected according to standard protocol without intervention from the investigators. After the blood was collected, the nurse would place three drops onto a Beckman Coulter ICON 25 Rapid HCG bedside pregnancy test and set a timer for 10 minutes. At the end of the 10 minutes, the result and time were recorded on an encoded data sheet and not used clinically. The same make and model analyzer was also used for urine tests in the lab located within the ED. The primary outcome was the difference in mean turnaround time between whole blood in the ED and urine testing in the adjacent lab results. Concordance between samples was assessed as a secondary outcome. RESULTS: 265 total patients were included in the study. The use of whole blood resulted in a mean time savings of 21 minutes (95% CI 16-25 minutes) when compared with urine (p<0.001). There was 99.6% concordance between results, with one false negative urine specimen with a quantitative HCG level of 81 mIU/L. CONCLUSION: Our results suggest that the use of whole blood in place of urine for bedside pregnancy testing may reduce the total result turnaround time without significant changes in accuracy in this single-center study.

The bougie: an inexpensive lifesaving airway device.

BACKGROUND: "Bougies," otherwise known as endotracheal tube introducers, remain preferred devices for the emergency physician when faced with a difficult airway. Bougies have high success rates for the prehospital provider and the first-time emergency department (ED) user, with few reported complications. Inexpensive, disposable models provide simple yet valuable tools in the challenging patient with an anterior airway or limited neck mobility. OBJECTIVES: Use of the bougie is similar to standard endotracheal intubation. Correct placement is determined by feeling "clicks" as the device passes over the tracheal rings and a "hold up" when entering the distal airways. CASE REPORTS: Three recent cases from our ED are briefly reported, in which the bougie was invaluable in the management of the difficult airway. All patients had limited visualization of the glottis but were intubated successfully. CONCLUSION: This article discusses three example cases, and then reviews the history of the bougie, placement technique, and current evidence for use.