Evaluating reduction in medical costs associated with pharmacists' presence in the emergency department using a novel cost avoidance framework.

PURPOSE: The purpose of this study was to evaluate the cost avoidance associated with emergency medicine pharmacist (EMP) presence in the emergency department (ED) using a novel cost avoidance framework. SUMMARY: This single-center, retrospective, observational study examined EMP interventions from November 1, 2021, through March 31, 2022. EMPs prospectively selected up to 10 shifts in which to log interventions during the study period. Interventions were categorized into 25 cost avoidance categories, 10 of which incorporated recently proposed probability variables. All categories were organized into 4 broad cost avoidance domains, including resource utilization, individualization of patient care, adverse drug event prevention, and hands-on care. During the study period, 894 interventions were logged, which accounted for $143,132 in cost avoidance (lower probability value of $124,186, upper probability value of $168,858), with a median cost avoidance per shift of $1,671 (interquartile range, $1,025 to $2,451). On the basis of 240 shifts, the estimated annual total cost avoidance per pharmacist was extrapolated to be $401,040. CONCLUSION: While the mean cost avoidance of $161.10 per intervention observed in our study was less than that in prior cost avoidance studies due to the conservative and potentially more realistic estimates used, implementation of this cost avoidance framework still showed substantial cost avoidance associated with EMP presence in the ED.

Prehospital Use of Whole Blood for Ill and Injured Patients During Critical Care Transport.

OBJECTIVE: Hemodynamic instability and hemorrhagic shock are frequently encountered by emergency medical services providers managing ill and injured patients during critical care transport. Although many critical care transport services commonly transfuse crystalloids and/or packed red blood cells (PRBCs), the administration of whole blood (WB) in prehospital care is currently limited. WB contains PRBCs, plasma, and platelets in a physiologic ratio to aid in oxygen delivery to tissue as well as hemostasis. This study describes a single critical care transport program's experience using WB for critically ill and injured patients and reports important clinical and safety outcomes. METHODS: This study was a retrospective review of patients who were transported by a single rotor wing-based critical care transport service to 1 of 2 tertiary care receiving hospitals within a single health system. Patients who were transported between November 1, 2018, and November 30, 2019, and who received at least 1 unit of low-titer group O WB during critical care transport were included. The primary outcomes of interest included 24-hour mortality and the total 24-hour transfusion requirement. The safety outcomes included transfusion reactions, acute lung injury, acute kidney injury, and the incidence of venous thromboembolism. RESULTS: During the study period, there were 3,084 total patients transported by our critical care transport service. There were 71 patients who received prehospital WB, 64 of whom met the inclusion criteria. The top 3 indications for WB administration included blunt trauma (n = 27, 42.2%), gastrointestinal hemorrhage (n = 15, 23.4%), and penetrating trauma (n = 11, 17.2%). The median total number of blood components transfused within 24 hours was 4.0 (interquartile range, 2.0-9.5), and the overall 24-hour mortality rate was 21.9%. CONCLUSIONS: The administration of WB by emergency medical services providers to critically ill and injured patients in the prehospital setting is feasible and is associated with low incidences of adverse events and transfusion reactions. Further research is needed to elucidate the benefits of WB relative to current prehospital standards of care.

Push Dose Epinephrine Use in the Management of Hypotension During Critical Care Transport.

Introduction: Hypotension is a critical event during the transport of critically ill patients. Push dose vasopressor use, though widely adopted by anesthesiologists, has only recently found use in the field of emergency medicine and may have utility in the management of out-of-hospital hypotension. This study aimed to characterize the hemodynamic effects and adverse events that occur following push dose epinephrine (PDE) administration by critical care transport (CCT) providers to correct documented hypotension. Methods: We performed a retrospective observational study of patients transported by a regional critical care transport service and who received PDE during transport to correct documented hypotension. Per protocol, 10-20 µg of 1:100,000 epinephrine was given intravenously every 2 min until: (1) the systolic blood pressure (SBP) was at least 90 mmHg, or (2) the mean arterial pressure (MAP) was 65 mmHg or greater. All patients were over 18 years of age and were transported between January 1, 2015 and December 31, 2016. Primary outcomes of interest were the primary diagnoses associated with PDE use, hemodynamic outcomes of the intervention, and adverse events. Results: During the study period 100 doses of push dose epinephrine were given during the transport of 58 patients. Of these, 94 (94.0%) were found to be appropriately dosed and indicated per protocol. The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). The median increase in MAP across all doses was 13.0 (5.0-34.0) mmHg, and the heart rate increase was 2.0 (-1.0-9.3) beats per minute. Hypotension was resolved in 55 of 94 instances (58.5%). A single episode of transient extreme hypertension occurred after one PDE dose and did not result in patient harm. Conclusions: Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. Further research is needed to validate these findings, establish optimal dosing, and evaluate use in non-CCT prehospital settings.

Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score.

INTRODUCTION: There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol. METHODS: We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of "stroke/TIA," "CVA," or "neurological problem" were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score's metrics were evaluated as a surrogate marker for a successful EMS triage protocol. RESULTS: We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%. CONCLUSION: In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.

A 15-Year-Old Male With Wide Complex Tachyarrhythmia.

A 15-year-old male presented with exertional syncope and was found to be in an unstable regular wide complex tachyarrhythmia (WCT). After a trial of antiarrhythmic medication, his clinical condition declined, necessitating synchronized cardioversion. Although he noted symptomatic improvement after cardioversion, he was found to be in third-degree heart block. The patient was transported by rotor wing aircraft to a pediatric cardiac intensive care unit where he was ultimately diagnosed with Lyme disease. He was treated with a course of intravenous antibiotics, his heart block resolved, and he was discharged home with a good neurologic outcome.