Daniel P. Hays

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel

PURPOSE Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented. SUMMARY Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panels consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use. CONCLUSION A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

Factor IX complex for the correction of traumatic coagulopathy.

BACKGROUND: Damage control resuscitation advocates correction of coagulopathy; however, options are limited and expensive. The use of prothrombin complex concentrate (PCC), also known as factor IX complex, can quickly accelerate reversal of coagulopathy at relatively low cost. The purpose of this study is to describe our experience in the use of factor IX complex in coagulopathic trauma patients. METHODS: All patients receiving PCC at our Level I trauma center over a two-year period (2008–2010) were reviewed. PCC was used at the discretion of the trauma attending for treatment of coagulopathy, reversal of coumadin, and when recombinant factor VIIa was indicated. RESULTS: Forty-five trauma patients received 51 doses of PCC. Sixty-two per cent were male and mean Injury Severity Score was 23 (±14.87). Standard dose was 25 units per kg and mean cost per patient was

ANTIEMETIC THERAPY FOR NAUSEA AND VOMITING IN THE EMERGENCY DEPARTMENT

1,022 (

Refractory Hypoglycemia from Ciprofloxacin and Glyburide Interaction

504–3,484). Fifty-eight per cent of patients were on warfarin before admission. Mean international normalized ratio (INR) was decreased after PCC administration (p = 0.001). Packed red blood cell transfusion was also reduced after factor IX complex (p = 0.018). Mean INR was reduced in both the nonwarfarin (p = 0.001) and warfarin (p = 0.001) groups. Packed red blood cell transfusion was less in the nonwarfarin group (p = 0.002) however was not significant in the warfarin group. Subsequent thromboembolic events were observed in 3 of the 45 patients (7%). Mortality was 16 of 45 (36%). CONCLUSION: PCC rapidly and effectively treats coagulopathy after traumatic injury. PCC therapy leads to a significant correction in INR in all trauma patients, regardless of coumadin use, and concomitant reduction in blood product transfusion. PCC should be considered as an effective tool to treat acute coagulopathy of trauma. Further prospective studies examining the safety, efficacy, cost, and outcomes comparing PCC and recombinant factor VIIa are needed. LEVEL OF EVIDENCE: III, therapeutic study.

Outcomes After Intravenous Opioids in Emergency Patients: A Prospective Cohort Analysis

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.

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

Patients taking multiple medications may suffer from unpredictable and complex drug–drug interactions resulting in significant morbidity and mortality. There are few reports in the literature of hypoglycemia with concurrent administration of an oral hyperglycemic agent and a fluoroquinolone antibiotic. We present a case of a diabetic patient taking glyburide who was prescribed ciprofloxacin and developed prolonged hypoglycemia, which persisted for over 24 hours. The mechanisms by which these agents interact to produce prolonged hypoglycemia are complex and probably multifactorial. Patients stabilized on glyburide who are started on a fluoroquinolone should have their glucose levels monitored closely.

The Outcomes of Emergency Pharmacist Participation During Acute Myocardial Infarction

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.

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

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.

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

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.

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

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.