Emergency Department Management of Acute Venous Thromboembolism in Patients With Obesity With Intravenous Unfractionated Heparin and Anti-Xa Monitoring.

Background: Unfractionated heparin (UFH) remains a frequently utilized agent in the emergency department (ED) for management of acute venous thromboembolism (VTE). While various protocols of UFH dosing have been proposed for patients with obesity, the optimal dosing and monitoring strategy is unclear. Objective: This study aims to compare the time to the first therapeutic anti-Xa level in obese acute VTE patients following the use of either total body weight (TBW) or adjusted body weight-based (AdjBW) dosing of UFH in the ED, and to analyze the impact of different dosing strategies on patient outcomes. Methods: Inclusion criteria included adult patients with a BMI > 30 kg/m2, and suspected VTE managed with UFH per institutional protocol utilizing a bolus dose followed by maintenance infusion and anti-Xa monitoring. The primary outcome was time to the first therapeutic anti-Xa level in the group dosed per TBW compared with the group dosed per AdjBW. Safety outcomes included incidence of bleeding events, protamine administration, and mortality. Results: There were 32 patients included in the study. Patients dosed per TBW achieved a median time to first therapeutic anti-Xa level of 14.5 hours compared with 15 hours in the AdjBW group (P = .613). The median therapeutic UFH infusion rate was 16 units/kg/hr in the TBW group compared with 13.5 units/kg/hr in the AdjBW group (P < .001). Safety outcomes were not significantly different between groups. Conclusion: Patients presenting to the ED with acute VTE may be managed with UFH using either a TBW or AdjBW dosing strategy.

Ketamine for Pain Management: A Review of Literature and Clinical Application.

Ketamine is a dissociative anesthetic used increasingly as analgesia for different manifestations of pain, including acute, chronic, cancer and perioperative pain as well as pain in the critically ill patient population. Its distinctive pharmacologic properties may provide benefits to individuals suffering from pain, including increased pain control and reduction in opioid consumption and tolerance. Despite wide variability in proposed dosing and method of administration when used for analgesia, it is important all clinicians be familiar with the pharmacodynamics of ketamine in order to appropriately anticipate its therapeutic and adverse effects.

A Multifaceted Intervention to Improve Patient Knowledge and Safe Use of Opioids: Results of the ED EMC2 Randomized Controlled Trial.

OBJECTIVES: Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC2 ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids. METHODS: This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC2 intervention, or 3) EMC2  + short message service (SMS) text messaging. The ED EMC2 intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC2  + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment. RESULTS: Among the 652 enrolled, 343 completed follow-up (57% women; mean ± SD age = 42 ± 14.0 years). Demonstrated safe opioid use occurred more often in the EMC2 group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC2  + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC2  + SMS group (ß = 0.57, 95% CI = 0.09 to 1.06) than usual care. CONCLUSIONS: The study found that the EMC2 tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.

A Review on the New and Old Anticoagulants.

Anticoagulants serve as the primary strategy for the prevention and treatment of both arterial and venous thromboembolism. Anticoagulants disrupt coagulation by interfering at various points in the coagulation cascade. This class of medications does not lyse clots that already exist; rather, it prevents thrombus formation and prevents or slows the extension of an existing clot. For decades, the standard therapy for patients requiring oral anticoagulation was warfarin. However, due to some of the shortcomings of warfarin, including the need for continuous routine monitoring, longtime onset and offset of anticoagulation effect, major food and drug interactions, and high incidence of bleeding, newer agents, termed direct oral anticoagulants, or DOACs were developed. This article will provide a review of clinically important information regarding the most commonly used anticoagulants and their reversal agents.

Common Medication Management Approaches for Older Adults in the Emergency Department.

Adverse drug events (ADEs) can lead to emergency department (ED) visits and hospitalizations. Many ADEs are preventable. Incomplete information, poor understanding, and time constraints often lead to use of potentially inappropriate medications and drug-drug interactions. In an ED, physiologic changes, such as lean body mass, kidney and liver function, and susceptibility to central nervous system depressants, must be considered. High-risk medications should be reviewed and potential drug-drug interactions should be discussed and avoided when possible. Programs, such as medication therapy management, or transitional care nursing may be helpful in preventing drug-drug interactions and use of potentially inappropriate medications.

Impact of Discharge Anticoagulation Education by Emergency Department Pharmacists at a Tertiary Academic Medical Center.

BACKGROUND: Although pharmacists commonly provide patient education and help manage high-risk anticoagulant medications in inpatient and outpatient settings, the evidence for these interventions in the emergency department (ED) is less established, especially in the era of direct-acting oral anticoagulants. In 2013, a formal program was initiated whereby patients discharged with a new prescription for any anticoagulant receive education from an ED pharmacist when on-site. In addition, they received follow-up phone calls from an ED pharmacist within 72 hours of discharge. OBJECTIVE: We sought to identify the impact of pharmacist education, defined as the need for intervention on callback, versus physician and nursing-driven discharge measures on patient understanding and appropriate use of anticoagulant medications. METHODS: A single-center retrospective analysis included patients discharged from the ED between May 2013 and May 2016 with a new anticoagulant prescription. Electronic callback records were reviewed to assess patients' adherence and understanding of discharge instructions as well as for an anticoagulant-related hospital readmission within 90 days. RESULTS: One hundred seventy-four patients were evaluated in a per protocol analysis. Patients who did not receive pharmacist education prior to discharge required an increased need for intervention during callback versus those who did (36.4% vs. 12.9%, p = 0.0005) related to adherence, inappropriate administration, and continued use of interacting medications or supplements, among other concerns. In addition, patients who had not received pharmacist counseling were more likely to be readmitted to a hospital or return to the ED within 90 days after their initial visit for an anticoagulation-related problem versus patients who had (12.12% vs. 1.85%, p = 0.0069). CONCLUSION: Discharge education by ED pharmacists leads to improved patient understanding and appropriate use of anticoagulants.

Electronic medication complete communication strategy for opioid prescriptions in the emergency department: Rationale and design for a three-arm provider randomized trial.

BACKGROUND: Thousands of people die annually from prescription opioid overdoses; however there are few strategies to ensure patients receive medication risk information at the time of prescribing. OBJECTIVES: To compare the effectiveness of the Emergency Department (ED) Electronic Medication Complete Communication (EMC2) Opioid Strategy (with and without text messaging) to promote safe medication use and improved patient knowledge as compared to usual care. METHODS: The ED EMC2 Opioid Strategy consists of 5 automated components to promote safe medication use: 1) physician reminder to counsel, 2) inbox message sent on to the patient's primary care physician, 3) pharmacist message on the prescription to counsel, 4) MedSheet supporting prescription information, and 5) patient-centered Take-Wait-Stop wording of prescription instructions. This strategy will be assessed both with and without the addition of text messages via a three-arm randomized trial. The study will take place at an urban academic ED (annual volume>85,000) in Chicago, IL. Patients being discharged with a new prescription for hydrocodone-acetaminophen will be enrolled and randomized (based on their prescribing physician). The primary outcome of the study is medication safe use as measured by a demonstrated dosing task. Additionally actual safe use, patient knowledge and provider counseling will be measured. Implementation fidelity as well as costs will be reported. CONCLUSIONS: The ED EMC2 Opioid Strategy embeds a risk communication strategy into the electronic health record and promotes medication counseling with minimal workflow disruption. This trial will evaluate the strategy's effectiveness and implementation fidelity as compared to usual care. TRIAL REGISTRATION: This trial is registered on clinicaltrials.gov with identifier NCT02431793.

Management of hemorrhage complicated by novel oral anticoagulants in the emergency department: case report from the northwestern emergency medicine residency.

Anticoagulation has long complicated the care of hemorrhage in the emergency department and other acute care settings. With the advent of novel anticoagulants such as direct thrombin inhibitors and direct factor Xa inhibitors, the absence of any direct antidote for these medications presents new and difficult challenges in the management of hemorrhagic complications in these patients. We present 2 cases of patients with hemorrhagic complications taking novel oral anticoagulants, their management, and outcomes.