Development of an Emergency Medicine Pharmacy Intensity Score Tool

Purpose Emergency medicine pharmacists (EMPs) have been demonstrated to have a positive impact on patient outcomes in a variety of clinical scenarios in the emergency department (ED), yet their distribution across the nation is suboptimal. An emergency medicine pharmacy intensity score tool (EMPIST) would not only facilitate the quantification of EMP staffing needs and ideal resource deployment times, but would also allow practitioners to triage patient care activities. The purpose of this investigation was to develop an EMPIST and evaluate its relationship to EMP activities. Methods This was a multicenter, prospective, observational analysis of an EMPIST developed by practicing EMPs. EMPs prospectively documented their clinical activities during usual care for patients in their ED. Spearman’s rank-order correlation was used to determine any correlation between the EMPIST and pharmacist activities. Results In total, 970 EMP activities and 584 EMPIST items were documented in 352 patients by 7 EMPs across 7 different EDs. The most commonly documented EMP interventions performed were bedside monitoring (12.7%), initiation of nonantimicrobial therapy (12.6%), and antimicrobial therapy initiation and streamlining (10.6%). The total EMPIST was found to significantly correlate with EMP activities, and this correlation was consistent across both “diagnostic/presentation” and “medication” items (P \u3c 0.001 for all comparisons). Conclusion The EMPIST significantly correlated with EMP activities, with consistent correlation across all subgroups. Its utilization has the potential to enhance bedside clinical practice and optimize the deployment of limited EMP services. Additional investigations are needed to examine the validity of this tool and identify any relationship it may have to patient outcomes

Two Cases of Accidental Injection of Epinephrine into a Digit Treated with Subcutaneous Phentolamine Injections

Accidental injection into the digit from an epinephrine autoinjection device can cause discoloration, pain, and paresthesias. Although loss of digit is rare, treatment in the emergency department is commonly aimed at vasodilation of the affected tissue. We report two cases of accidental injection of epinephrine into the digits that were successfully treated with subcutaneous phentolamine injection with no adverse events

A Case of Lionfish Envenomation Presenting to an Inland Emergency Department

Lionfish envenomation can cause erythema, edema, necrosis, and severe pain at the exposed site. Treatment often includes supportive wound care, pain management, and hot water immersion. We report a case of lionfish exposure presenting to an inland emergency department treated successfully with these measures

Emergency Medicine Intern Education for Best Practices in Opioid Prescribing

Introduction: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing.Methods: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education programincluded opioid prescribing guidelines for common ED disease states associated with moderate pain,clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes.Results: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4,305 vs 749) were reduced, P <0.01. There were no differences in selection of opioid product or total morphine milligram equivalents prescribed when an opioid was used. Conclusion: An opioid reduction education program targeting EM interns was associated with a reduction in opioid prescribing in the ED and at discharge. This may be an effective way to influence early prescribing patterns and best practices of EM interns

Acute Intoxication following Dimethyltryptamine Ingestion

Ayahuasca is a hallucinogenic tea that is most commonly comprised of the vine Banisteriopsis caapi alone or in combination with other plants such as Psychotria viridis. This concoction results in an orally active form of dimethyltryptamine (DMT), a hallucinogenic amine. Despite use in South America as a medicinal agent and component in religious ceremonies, interest in its recreational use and spiritual effects has led to increased use in the United States. We describe a unique case following ingestion of ayahuasca tea in a patient with history of schizophrenia resulting in personal injury and property damage. A review of ayahuasca toxicity and evaluation of serious adverse effects is also presented

Emergency Medicine Intern Education for Best Practices in Opioid Prescribing

Introduction: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing.Methods: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education programincluded opioid prescribing guidelines for common ED disease states associated with moderate pain,clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes.Results: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4,305 vs 749) were reduced, P <0.01. There were no differences in selection of opioid product or total morphine milligram equivalents prescribed when an opioid was used. Conclusion: An opioid reduction education program targeting EM interns was associated with a reduction in opioid prescribing in the ED and at discharge. This may be an effective way to influence early prescribing patterns and best practices of EM interns

MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors in emergency department patients with skin and soft tissue infections

Objectives Skin and soft tissue infections (SSTI) caused by methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in the emergency department (ED). We determined whether MRSA nasal carriage better identifies patients with MRSA wound infection than clinical risk factors or emergency medicine (EM) provider’s choice of discharge prescriptions. Methods Adult patients presenting to a large academic medical centre ED in the USA with SSTI between May 2010 and November 2011 were screened. Research assistants administered a questionnaire regarding MRSA risk factors, and MRSA nares swab PCR testing, wound culture results and information on antibiotics prescribed at discharge were collected. Measures of classification accuracy for nares swab, individual risk factors and physician’s prescription for MRSA coverage were compared with gold standard wound culture. Results During the study period, 116 patients with SSTI had both wound cultures and nares swabs for MRSA. S. aureus was isolated in 59.5%, most often MRSA (75.4%). Thirty patients (25.9%) had a positive MRSA nares swab and culture for a sensitivity of 57.7% and specificity of 92.2%. Positive predictive value (PPV) for MRSA nares swab was 85.7% and positive likelihood ratio was 7.4, while negative predictive value was 72.8% and negative likelihood ratio 0.5. None of the individual risk factors nor EM provider’s prescription for MRSA coverage had a PPV or positive likelihood ratio higher than nares swabs. Conclusions MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors or EM provider’s choice of antibiotics. MRSA nares swab may be a useful tool in the ED