Craig McCammon

Reducing Door-to-Needle Times Using Toyota’s Lean Manufacturing Principles and Value Stream Analysis

Background and Purpose— Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke increases efficacy, prompting national efforts to reduce door-to-needle times. We used lean process improvement methodology to develop a streamlined intravenous tPA protocol. Methods— In early 2011, a multidisciplinary team analyzed the steps required to treat patients with acute ischemic stroke with intravenous tPA using value stream analysis (VSA). We directly compared the tPA-treated patients in the “pre-VSA” epoch with the “post-VSA” epoch with regard to baseline characteristics, protocol metrics, and clinical outcomes. Results— The VSA revealed several tPA protocol inefficiencies: routing of patients to room, then to CT, then back to the room; serial processing of workflow; and delays in waiting for laboratory results. On March 1, 2011, a new protocol incorporated changes to minimize delays: routing patients directly to head CT before the patient room, using parallel process workflow, and implementing point-of-care laboratories. In the pre and post-VSA epochs, 132 and 87 patients were treated with intravenous tPA, respectively. Compared with pre-VSA, door-to-needle times and percent of patients treated ⩽60 minutes from hospital arrival were improved in the post-VSA epoch: 60 minutes versus 39 minutes (P<0.0001) and 52% versus 78% (P<0.0001), respectively, with no change in symptomatic hemorrhage rate. Conclusions— Lean process improvement methodology can expedite time-dependent stroke care without compromising safety.

Mechanical Ventilation and Acute Lung Injury in Emergency Department Patients With Severe Sepsis and Septic Shock: An Observational Study

OBJECTIVES The objectives were to characterize the use of mechanical ventilation in the emergency department (ED), with respect to ventilator settings, monitoring, and titration and to determine the incidence of progression to acute lung injury (ALI) after admission, examining the influence of factors present in the ED on ALI progression. METHODS This was a retrospective, observational cohort study of mechanically ventilated patients with severe sepsis and septic shock (June 2005 to May 2010), presenting to an academic ED with an annual census of >95,000 patients. All patients in the study (n = 251) were analyzed for characterization of mechanical ventilation use in the ED. The primary outcome variable of interest was the incidence of ALI progression after intensive care unit (ICU) admission from the ED and risk factors present in the ED associated with this outcome. Secondary analyses included ALI present in the ED and clinical outcomes comparing all patients progressing to ALI versus no ALI. To assess predictors of progression to ALI, significant variables in univariable analyses at a p ≤ 0.10 level were candidates for inclusion in a bidirectional, stepwise, multivariable logistic regression analysis. RESULTS Lung-protective ventilation was used in 68 patients (27.1%) and did not differ based on ALI status. Delivered tidal volume was highly variable, with a median tidal volume delivered of 8.8 mL/kg ideal body weight (IBW; interquartile range [IQR] = 7.8 to 10.0) and a range of 5.2 to 14.6 mL/kg IBW. Sixty-nine patients (27.5%) in the entire cohort progressed to ALI after admission to the hospital, with a mean (±SD) onset of 2.1 (±1) days. Multivariable logistic regression analysis demonstrated that a higher body mass index (BMI), higher Sequential Organ Failure Assessment (SOFA) score, and ED vasopressor use were associated with progression to ALI. There was no association between ED ventilator settings and progression to ALI. Compared to patients who did not progress to ALI, patients progressing to ALI after admission from the ED had an increase in mechanical ventilator duration, vasopressor dependence, and hospital length of stay (LOS). CONCLUSIONS Lung-protective ventilation is uncommon in the ED, regardless of ALI status. Given the frequency of ALI in the ED, the progression shortly after ICU admission, and the clinical consequences of this syndrome, the effect of ED-based interventions aimed at reducing the sequelae of ALI should be investigated further.

Evaluation of a Simplified N-Acetylcysteine Dosing Regimen for the Treatment of Acetaminophen Toxicity

BACKGROUND: Acetaminophen overdose is the most common pharmaceutical poisoning in the US. The labeled dosing regimen for Acetadote, the only intravenous N-acetylcysteine (IV-NAC) product approved by the Food and Drug Administration (FDA) for treatment of acetaminophen toxicity, is a complex 3-step process that produces frequent medication errors. We have been using an off-label, uncomplicated dosing regimen consisting of a standard preparation of IV-NAC 30 g in 1 L of 5% dextrose in water, with a 150-mg/kg loading dose administered over 1 hour followed by an infusion of 14 mg/kg/h for 20 hours. OBJECTIVE: To evaluate the frequency of medication errors, resolution of hepatotoxicity, and tolerability of the protocol used in our institution for treatment of acetaminophen toxicity. METHODS: This single-center, retrospective chart review evaluated patients receiving IV-NAC for acetaminophen toxicity from August 2006 to August 2008. Charts were reviewed for prescribing practices, dosing errors, and clinical outcomes. RESULTS: Among 70 patients who met inclusion criteria, 35 medication errors occurred, including 22 administration errors and 13 protocol initiation errors. The frequency of administration errors was 13.5 errors per 100 administration interventions. Loading dose errors were most common with 11 rate-related and 8 dose-related errors. Interruptions longer than 60 minutes occurred in only 3 patients. No adverse outcomes were associated with medication errors. The mean (SD) duration of therapy was 25.6 hours (n = 60 pts. [17.8], range 1-76.5), and mean length of stay was 2.99 days ([3.82], range 0.1-25.7). All patients with hepatotoxicity (aspartate aminotransferase >1000 units/L) due to acute acetaminophen toxicity had resolution of the toxicity and were successfully discharged. CONCLUSIONS: This single intravenous bag protocol is effective and well tolerated, and there is infrequent interruption of therapy. The overall rate of administration errors is similar to that in reports on the FDA regimen; thus, our protocol may be an acceptable alternative.

EMERGENCY DEPARTMENT VANCOMYCIN USE: DOSING PRACTICES AND ASSOCIATED OUTCOMES

BACKGROUND Emergency Department (ED) dosing of vancomycin and its effect on outcomes has not been examined. STUDY OBJECTIVE To describe current vancomycin dosing practices for ED patients, focusing on patient factors associated with administration, dosing accuracy based on patient body weight, and clinical outcomes. METHODS Single-center, retrospective cohort study of vancomycin administered in the ED over 18 months in an academic, tertiary care ED. Data were collected on 4656 patients. Data were analyzed using a generalized estimating equations model to account for multiple doses being administered to the same patient. RESULTS The ED dose was continued, unchanged, in 2560 admitted patients (83.8%). The correct dose was given 980 times (22.1%), 3143 doses (70.7%) were underdosed, and 318 were overdosed (7.2%). Increasing weight was associated with underdosing (adjusted odds ratio 1.52 per 10 kg body weight, p < 0.001). Patients who received doses of vancomycin > 20 mg/kg had longer hospital length of stay (p = 0.005); were more likely to spend ≥ 3 days in the hospital (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.12-1.98, p = 0.006); and more likely to die (OR 1.88; 95% CI 1.22-2.90, p = 0.004). CONCLUSION In this largest study to date examining ED vancomycin dosing, vancomycin was commonly given. Dosing outside the recommended range was frequent, and especially prevalent in patients with a higher body weight. The ED dose of vancomycin was frequently continued as an inpatient, regardless of dosing accuracy. There is significant room for improvement in dosing accuracy and indication. Vancomycin dosing in the ED may also affect clinical outcomes.

Life-threatening diphenhydramine toxicity presenting with seizures and a wide complex tachycardia improved with intravenous fat emulsion.

Diphenhydramine toxicity manifests with signs of anticholinergic toxicity; therapy is generally supportive. In rare cases, patients can also present with a wide complex tachycardia due to sodium channel blockade. Treatment involves sodium bicarbonate. Lidocaine and hypertonic saline are used for arrhythmias refractory to sodium bicarbonate. Although intravenous fat emulsion (IFE) therapy is proposed as an adjunctive therapy due to the lipophilicity of diphenhydramine (octanol/water partition coefficient of 3.3), successful use of IFE after a confirmed sole ingestion of diphenhydramine is not previously reported. We present the case of a 30-year-old woman presenting with seizures, a wide complex tachycardia, and cardiovascular collapse after an ingestion of diphenhydramine refractory to other therapies with rapid improvement after IFE administration.

Vancomycin Use in Patients Discharged From the Emergency Department: A Retrospective Observational Cohort Study

BACKGROUND Infections due to methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant morbidity and mortality and are typically treated with intravenous vancomycin. Given vancomycins time-dependent mechanism of action, it is unlikely that vancomycin administration in the emergency department (ED) prior to disposition home could be beneficial. STUDY OBJECTIVES To characterize the indications, dosing, and appropriateness of vancomycin use in patients discharged from the ED. METHODS This is a single-center retrospective observational cohort study of patients who received vancomycin in an urban, academic, tertiary care ED. The subjects were consecutive adult patients administered intravenous vancomycin in the ED and then discharged home over an 18-month period. Outcomes were measured 1) to characterize patients receiving vancomycin prior to discharge home from the ED; and 2) to identify patients that did not meet indications for appropriate use based on the 2011 Infectious Diseases Society of America guidelines for treating MRSA infections. RESULTS There were 526 patients that received vancomycin in the ED prior to discharge during the study period. In this cohort, 368 (70%) patients were diagnosed with skin and soft tissue infections. A MRSA risk factor was present in 396 (75%) patients. Prior to discharge, one dose of vancomycin was administered to 357 (68%) patients. Underdosing of vancomycin occurred in 239 (73%) patients. CONCLUSIONS Vancomycin was given frequently to patients discharged home from the ED, most commonly for conditions where vancomycin was not indicated, such as skin and soft tissue infections. The majority of these patients received a vancomycin dosing strategy that is not only unlikely to lead to clinical improvement, but also has the potential to contribute adversely to the development of antibiotic resistance. Further investigation is needed into the impact of vancomycin use, the emergence of vancomycin resistance, and the role of ED-based antibiotic stewardship.