Do Patients Require Emergency Department Interventions After Prehospital Naloxone?

OBJECTIVE: Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS <14 after prehospital naloxone. METHODS: Our retrospective observational study included patients ≥18 years old treated with naloxone and transported by an inner-city hospital-based Emergency Medical Services (EMS) to its affiliated ED from January 2, 2016 to December 31, 2016. Investigators collected demographic data, prehospital interventions, GCS, ED interventions, and dispositions. Institutional Review Board approval was obtained. The main outcome measures were repeat doses of naloxone and ED interventions. RESULTS: In all, 473 patient encounters were reviewed. Most common route of prehospital naloxone administration was intranasal (68%). Nearly two-thirds (n = 473) of patients had GCS ≥14 upon ED arrival. Repeat naloxone was administered to 3.5% (n = 314) of patients with GCS ≥14 versus 14.6% (n = 159) of patients with GCS <14. ED interventions, such as airway maneuvers, laboratory and radiology testing, and cardiac monitoring, were less common among patients who had improved GCS of 14 or higher (n = 314). There were 8 deaths among patients with GCS <14 (n = 159) and no deaths among patients with GCS ≥14 (n = 314). CONCLUSION: Patients with GCS score ≥14 after administration of prehospital naloxone are less likely to receive additional naloxone doses and medical interventions in the ED compared with those with a GCS score <14 after prehospital naloxone and may present an invaluable opportunity for the ED to initiate an addiction treatment program for patients with nonfatal overdose.

Time to antibiotics for septic shock: evaluating a proposed performance measure.

PURPOSES: International guidelines recommend antibiotics within 1 hour of septic shock recognition; however, a recently proposed performance measure is focused on measuring antibiotic administration within 3 hours of emergency department (ED) arrival. Our objective was to describe the time course of septic shock and subsequent implications for performance measurement. BASIC PROCEDURES: Cross-sectional study of consecutive ED patients ultimately diagnosed with septic shock. All patients were evaluated at an urban, academic ED in 2006 to 2008. Primary outcomes included time to definition of septic shock and performance on 2 measures: antibiotics within 3 hours of ED arrival vs antibiotics within 1 hour of septic shock definition. MAIN FINDINGS: Of 267 patients with septic shock, the median time to definition was 88 minutes (interquartile range, 37-156), and 217 patients (81.9%) met the definition within 3 hours of arrival. Of 221 (83.4%) of patients who received antibiotics within 3 hours of arrival, 38 (17.2%) did not receive antibiotics within 1 hour of definition. Of 207 patients who received antibiotics within 1 hour of definition, 11.6% (n = 24) did not receive antibiotics within 3 hours of arrival. The arrival measure did not accurately classify performance in 23.4% of patients. PRINCIPAL CONCLUSIONS: Nearly 1 of 5 patients cannot be captured for performance measurement within 3 hours of ED arrival due to the variable progression of septic shock. Use of this measure would misclassify performance in 23% of patients. Measuring antibiotic administration based on the clinical course of septic shock rather than from ED arrival would be more appropriate.

Prevalence of automated external defibrillators at cardiac arrest high-risk sites.

OBJECTIVE: Automated external defibrillators (AEDs) distributed throughout communities may improve survival from cardiac arrest. The purpose of this study was to determine if AEDs were present at high-risk locations for cardiac arrest in King County, Washington. METHODS: The authors compiled a list of sites based on a five-year study that identified public sites with the highest incidence of cardiac arrests in King County. They conducted a structured telephone survey with the manager, director, or owner of those high-risk sites. RESULTS: Of the 263 identified high-risk cardiac arrest sites, we obtained information for 228 (87%) sites. Overall, 87 of 228 (38%) high-risk sites had one or more AEDs. The AED dissemination varied greatly by type of site. The airport, the two county jails, the five public sports venues, and the nine ferries/train terminals each reported at least one AED on site. In contrast, none of the 13 shelters and 19% of health clubs/gyms reported an AED on site. Nearly half (44%) of sites without AEDs cited cost as a factor preventing them from purchasing AEDs in the future. CONCLUSION: Although AEDs have diffused into high-risk sites in this community, the diffusion appears to vary by the type of site.