Adjunct Analgesic Use for Acute Pain in the Emergency Department

Purpose Multimodal analgesia is common practice in the postoperative setting, but the utility of adjunctive analgesia in the emergency department (ED) is less understood. The primary objective of this study was to analyze ED prescriber ordering habits for adjunct nonopioid pain medication for opioid-naïve patients who require intravenous (IV) morphine or hydromorphone for acute pain. Secondary objectives were to assess initial and total opioid consumption in morphine equivalent units (MEU), pain scores, and ED length of stay (LOS) between groups. Methods A retrospective chart review of adult patients who presented to the ED at a large academic medical center and received IV morphine or hydromorphone for acute pain was conducted. Patients were analyzed according to initial opioid received and presence or absence of adjunct nonopioid analgesics. Results A total of 102 patient charts were analyzed. Adjunctive nonopioid analgesics were ordered on 38% of patients. Patients who received an adjunct nonopioid analgesic received a smaller mean initial opioid dose than those who did not (4.73 vs 5.48 MEU, p = .08). Initial pain score reduction on the 11-point Numeric Rating Scale (NRS) did not differ between patients who received adjunct analgesics versus those who did not (3 vs 4, p = .75). Patients who received adjunct analgesics were associated with a decreased ED LOS (294 vs 342 minutes, p = .04). Conclusion A small proportion of patients with acute pain received a nonopioid analgesic in conjunction to IV opioids. Further studies are warranted to assess the impact of adjunct analgesics for patients with acute pain.

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Communication about opioid versus nonopioid analgesics in the emergency department

Journal of Opioid Management ◽

10.5055/jom.2015.0271 ◽

2015 ◽

Vol 11 (3) ◽

pp. 229 ◽

Cited By ~ 14

Author(s):

Danielle M. McCarthy, MD, MS ◽

Kenzie A. Cameron, PhD, MPH ◽

D. Mark Courtney, MD, MS ◽

James G. Adams, MD ◽

Kirsten G. Engel, MD

Keyword(s):

Emergency Department ◽

Adverse Effects ◽

Medical Center ◽

Academic Medical Center ◽

Multivariable Analysis ◽

Secondary Analysis ◽

Academic Medical ◽

Frequency Of Use ◽

Nonopioid Analgesics ◽

Attending Physicians

Objective: The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioid analgesics in the Emergency Department (ED) setting.Design: Secondary analysis of prospectively collected audio recordings of ED patient visits.Setting: Urban, academic medical center (>85,000 annual patient visits). Participants: Patient participants aged >18 years with one of four low acuity diagnoses: ankle sprain, back pain, head injury, and laceration. ED clinician participants included resident and attending physicians, nursing staff, and ED technicians.Main outcome measures: The MCI is a five-point index that assigns points for communicating the following: medication name (1), purpose (1), duration (1), adverse effects (1), number of tablets (0.5), and frequency of use (0.5). Recording transcripts were scored with the MCI, and total scores were compared between drug classes.Results: The 41 patients received 56 prescriptions (27 nonopioids, 29 opioids). Nonopioid median MCI score was 3 and opioid score was 4.5 (p = 0.0008). Patients were counseled equally about name (nonopioid 100 percent, opioid 96.6 percent, p = 0.34) and purpose (88.9 percent, 89.7 percent, p = 0.93). However, patients receiving opioids were counseled more frequently about duration of use (nonopioid 40.7 percent, opioid 69.0 percent, p = 0.03) and adverse effects (18.5 percent, 93.1 percent, p < 0.001). In multivariable analysis, opioids (β = 0.54, p = 0.04), number of medications prescribed (β = −0.49, p = 0.05), and time spent in the ED (β = 0.007, p = 0.006) were all predictors of total MCI score.Conclusions: The extent of counseling about analgesic medications in the ED differs by drug class. When counseling patients about all analgesic medications, providers should address not only medication name and purpose but also the less frequently covered topics of medication dosing, timing, and adverse effects.

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Warfarin Patients With Anemia Show Trend of Out-of-Range International Normalized Ratio Frequency With Point-of-Care Testing in an Anticoagulation Clinic

Journal of Pharmacy Practice ◽

10.1177/0897190018768114 ◽

2018 ◽

Vol 32 (5) ◽

pp. 499-502 ◽

Cited By ~ 1

Author(s):

Christina E. DeRemer ◽

Bliss McMichael ◽

Henry N. Young

Keyword(s):

Regression Model ◽

Medical Center ◽

Point Of Care ◽

Academic Medical Center ◽

International Normalized Ratio ◽

Primary Objective ◽

Anticoagulation Clinic ◽

Care Practice ◽

Study Results ◽

The Impact

Introduction: Many factors influence international normalized ratio (INR); however, few studies have examined the impact of anemia in warfarin patients. The primary objective of this study was to explore the relationship between in-clinic anemia and the control of INR within an anticoagulation clinic. Methods: A retrospective chart review was performed on a random sample of patients seen in an academic medical center pharmacy-managed anticoagulation clinic. Hemochron® Signature Elite machine was utilized to monitor point-of-care (POC) INR. In-clinic anemia was defined as hematocrit <32%. Statistical analyses were conducted using STATA MP a webbased platform ( https://www.stata.com/statamp/ ). Results: Of the 300 patients analyzed, 45 (15%) patients had in-clinic anemia. Patients with in-clinic anemia were more likely to be younger ( P < .05), female ( P < .05), and have a diagnosis of sickle cell disease or anemia ( P < .05). In the unadjusted logistic regression model, patients with in-clinic anemia were less likely to have an in-range INR ( OR: 0.52; 95% CI: 0.27-0.98). The adjusted regression model did not show significance. Conclusion: Study results suggest that in-clinic anemia may be more prevalent among younger, female patients prescribed warfarin, and patients diagnosed with in-clinic anemia may be a risk factor for out-of-range INR. Pharmacists practicing in anticoagulation clinics can incorporate this information into patient care practice in efforts to maintain optimal management.

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Effect of Immersive Virtual Reality on Pain and Anxiety at a Veterans Affairs Health Care Facility

Frontiers in Virtual Reality ◽

10.3389/frvir.2021.719681 ◽

2021 ◽

Vol 2 ◽

Author(s):

Caitlin R. Rawlins ◽

Zachary Veigulis ◽

Catherine Hebert ◽

Catherine Curtin ◽

Thomas F. Osborne

Keyword(s):

Health Care ◽

Virtual Reality ◽

Rating Scale ◽

Medical Center ◽

Care Facility ◽

Veterans Affairs ◽

Primary Objective ◽

Head Mounted Display ◽

Anxiety Levels ◽

The Impact

Objectives: The primary objective of this evaluation is to determine the impact of virtual reality (VR) distraction on acute and chronic pain in Veterans within the Veterans Affairs Health Care System (VA). A secondary objective is to determine the impact of VR on the experience of stress and anxiety in Veterans utilizing VR for the indication of pain. A third objective is to develop an understanding of the Veteran experience of using VR in a healthcare setting.Methods: This prospective, pretest-posttest mixed methods assessment was performed at a VA medical center from August 30, 2019 to November 23, 2020. VR experiences lasted between 10 and 30 min utilizing an immersive head-mounted display with multiple, autonomously chosen virtual environments. Qualitative data was collected concurrently to provide context to quantitative measures which included pain scores and stress/anxiety levels. Data from 79 participants was included in this analysis. Data included pre- and post-VR session Defense and Veterans Pain Rating Scale and stress/anxiety levels.Results: Results for the cohort demonstrated a statistically significant decrease in pain intensity (p <0 .001) with an average 12% decrease in pain levels and an 92% reduction in anxiety for those in concurrent pain.Conclusion: VR as a non-pharmacological adjunct or alternative modality, appears to be a viable option for improving pain management and reducing anxiety in Veteran populations across various age ranges, and levels of acuity and chronicity. VR was found to be an effective distraction from pain, a pleasurable experience for the majority, and opened the door to other non-pharmacological modalities in a Veteran population.

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Privileging pharmacists improves time to patient notification in the microbiological test review process for patients discharged from the emergency department

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz335 ◽

2020 ◽

Vol 77 (Supplement_1) ◽

pp. S19-S24

Author(s):

Steven M Loborec ◽

Jose A Bazan ◽

Nicole V Brown ◽

Mary Beth Shirk ◽

Trisha A Jordan

Keyword(s):

Emergency Department ◽

Medical Center ◽

Academic Medical Center ◽

Test Results ◽

Infectious Disease Physician ◽

Microbiological Test ◽

Test Review ◽

Academic Medical ◽

Before And After ◽

The Impact

Abstract Purpose Results of a study evaluating the impact of privileging pharmacists to manage microbiologic test results for patients discharged from the emergency department (ED) are reported. Methods This was a single-center, retrospective pre-post study that was conducted at an urban academic medical center. Patients discharged from the ED with a subsequent positive microbiologic test result before and after privileging of an ED specialty practice pharmacist (ED-SPP) to manage the results independently were screened for inclusion. Time to patient notification of a required change in antimicrobial therapy was compared between groups. Numbers of erroneous interventions before and after pharmacist privileging were compared to assess the safety of implementation. Results One hundred seventy-eight positive microbiologic test results (n = 92 pre- and n = 86 postimplementation) were included. The median time to patient notification in the pre-implementation group was 23.6 hours (range, 12.4-93 hours) and in the postimplementation group was 14.9 hours (range, 2.5-27.9 hours; P = 0.0023). As determined by the board-certified infectious disease physician, 1.1% of reviewed microbiologic test results (1 of 92) was erroneous prior to implementation of pharmacist privileging compared with 2.3% (2 of 86) after implementation (P = 0.6105). Conclusion Privileging ED-SPPs to assess microbiologic test results improved the time to patient notification with no statistical difference in the number of erroneous interventions between groups. These findings demonstrate the benefit of clinical privileging and provide support for expansion of this role to other ED-SPPs.

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Trends in Acute Pain Management for Renal Colic in the Emergency Department at a Tertiary Care Academic Medical Center

Journal of Endourology ◽

10.1089/end.2020.0402 ◽

2020 ◽

Vol 34 (11) ◽

pp. 1195-1202

Author(s):

Hal D. Kominsky ◽

Justin Rose ◽

Amy Lehman ◽

Marilly Palettas ◽

Tasha Posid ◽

...

Keyword(s):

Emergency Department ◽

Pain Management ◽

Acute Pain ◽

Renal Colic ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Acute Pain Management ◽

Academic Medical

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Evaluation of the Use of Ketamine for Acute Pain in the Emergency Department at a Tertiary Academic Medical Center

Pharmacology &amp Pharmacy ◽

10.4236/pp.2016.71003 ◽

2016 ◽

Vol 07 (01) ◽

pp. 19-24 ◽

Cited By ~ 2

Author(s):

Nahal Beik ◽

Katelyn Sylvester ◽

Megan Rocchio ◽

Michael B. Stone

Keyword(s):

Emergency Department ◽

Acute Pain ◽

Medical Center ◽

Academic Medical Center ◽

Academic Medical

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The Impact of Biofire Filmarray Respiratory Panel on Antibiotic Usage in the Emergency Department at an Academic Medical Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.854 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S354-S354

Author(s):

Meera Mehta ◽

Douglas Slain ◽

Lisa Keller ◽

P Rocco Lasala

Keyword(s):

Emergency Department ◽

Respiratory Infections ◽

Medical Center ◽

Academic Medical Center ◽

Antibiotic Usage ◽

Academic Medical ◽

Days Of Therapy ◽

The Impact ◽

Pcr Test ◽

Viral Respiratory

Abstract Background Biofire respiratory panel is a multiplex PCR test designed to detect 17 pathogens within 1 hour. It has greater sensitivity, specificity, and number of pathogens detected compared with older testing methods. The aim of this research was to evaluate the impact of Biofire respiratory panel on antibiotic usage in the emergency department (ED) of an academic medical center. Methods This was an observational chart review. Patients with positive RSV or influenza rapid antigen test or PCR test, and patients with a positive Biofire test were included. RSV or influenza tests were reviewed from July to December 2015, and Biofire tests were reviewed from July to December 2016. The primary outcome was to evaluate the duration of antibiotic therapy in patients with viral respiratory infections diagnosed with RSV and influenza rapid antigen and PCR testing compared with Biofire viral respiratory panel. Secondary outcomes included virus type, antibiotic prescription rates on discharge, number of addmissions, procalcitonin levels, and oseltamivir usage. Results In 2016, 67% (105/155) of biofire tests were positive. The most common pathogen was rhinovirus and enterovirus (42%). Of the positive results, 23/105 (22%) received antibiotics with 6 patients having antibiotics discontinued within 72 hours. Another 6 patients had bacterial coinfections. A total of 18/105 (17%) received antibiotic prescriptions on discharge. Median days of therapy (DOT) in hospital was 1 day and median DOT for prescriptions was 8.5 days. There were 5 procalcitonin tests and no oseltamivir usage. Overall 38/105 (36%) patients were admitted to inpatient. In 2015, 3% (20/1313) of RSV (14) and influenza (6) rapid antigen and PCR tests were positive. A total of 5/20 (25%) patients received antibiotics, with 3/20 (15%) patients receiving a prescription for outpatient antibiotics. Median DOT in the hospital was 3 days and median DOT for prescriptions was 10 days. There were 2 procalcitonin tests and 2 cases used oseltamivir. Overall 19 patients were admitted. Conclusion Antibiotics are witheld in the majority of patients with positive Biofire testing. Most patients were treated with supportive care measures only. Biofire continues to be a useful tool to identify candidates for antibiotic avoidance in the ED at our institution. Disclosures All authors: No reported disclosures.

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Impact of embedded medication assistance program specialists on medication access in outpatient oncology clinics

Journal of Oncology Pharmacy Practice ◽

10.1177/1078155220970269 ◽

2020 ◽

pp. 107815522097026

Author(s):

Seyram S Fudzie ◽

Brandon Luong ◽

Stephanie J Jean ◽

Suzanne J Francart

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Cost Savings ◽

Retrospective Chart Review ◽

Turnaround Time ◽

Primary Objective ◽

Financial Assistance ◽

Assistance Program ◽

Assistance Programs ◽

The Impact

Introduction Medication prior authorizations (PA) required by insurance payers can be time-consuming to complete and may lead to delays in treatment for cancer patients. The primary objective of this study is to assess the impact of Medication Assistance Program (MAP) specialists embedded in adult hematology and oncology clinics on the PA and financial assistance process. Methods This was a retrospective chart review study performed at a large academic medical center that examined medication referrals completed by MAP specialists in four hematology and oncology clinics. The primary outcome was the median PA turnaround time, defined as time from initial referral creation to final referral completion. Secondary outcomes assessed median turnaround time for financial assistance programs and total patient savings. Results A total of 176 prior authorization, 92 manufacturer patient assistance program (PAP), and 37 copay assistance referrals were completed. The median turnaround times were 24, 154, and 19 hours for PA, manufacturer PAP, and copay assistance program referrals, respectively. Total cost savings amounted to over $1.8 million for patients approved to receive medications through manufacturer PAPs. Conclusions Embedding MAP specialists in adult hematology/oncology clinics supports an efficient and timely process for PA approvals while also providing patient cost-savings.

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Alcohol Hand Rub Significantly Reduces Overall Bacterial Bioburden on Stethoscopes in a Real-World Clinical Setting

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.620 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s114-s115

Author(s):

Alexandra Johnson ◽

Bobby Warren ◽

Deverick John Anderson ◽

Melissa Johnson ◽

Isabella Gamez ◽

...

Keyword(s):

Real World ◽

Medical Center ◽

Academic Medical Center ◽

Randomized Study ◽

Healthcare Providers ◽

Clinical Workflow ◽

Provider Type ◽

Academic Medical ◽

Rn Students ◽

The Impact

Background: Stethoscopes are a known vector for microbial transmission; however, common strategies used to clean stethoscopes pose certain barriers that prevent routine cleaning after every use. We aimed to determine whether using readily available alcohol-based hand rub (ABHR) would effectively reduce bacterial bioburden on stethoscopes in a real-world setting. Methods: We performed a randomized study on inpatient wards of an academic medical center to assess the impact of using ABHR (AlcareExtra; ethyl alcohol, 80%) on the bacterial bioburden of stethoscopes. Stethoscopes were obtained from healthcare providers after routine use during an inpatient examination and were randomized to control (no intervention) or ABHR disinfection (2 pumps applied to tubing and bell or diaphragm by study personnel, then allowed to dry). Cultures of the tubing and bell or diaphragm were obtained with premoistened cellulose sponges. Sponges were combined with 1% Tween20-PBS and mixed in the Seward Stomacher. The homogenate was centrifuged and all but ~5 mL of the supernatant was discarded. Samples were plated on sheep’s blood agar and selective media for clinically important pathogens (CIPs) including S. aureus, Enterococcus spp, and gram-negative bacteria (GNB). CFU count was determined by counting the number of colonies on each plate and using dilution calculations to calculate the CFU of the original ~5 mL homogenate. Results: In total, 80 stethoscopes (40 disinfection, 40 control) were sampled from 46 physicians (MDs) and MD students (57.5%), 13 advanced practice providers (16.3%), and 21 nurses (RNs) and RN students (26.3%). The median CFU count was ~30-fold lower in the disinfection arm compared to control (106 [IQR, 50–381] vs 3,320 [986–4,834]; P < .0001). The effect was consistent across provider type, frequency of recent usual stethoscope cleaning, age, and status of pet ownership (Fig. 1). Overall, 26 of 80 (33%) of stethoscopes harbored CIP. The presence of CIP was lower but not significantly different for stethoscopes that underwent disinfection versus controls: S. aureus (25% vs 32.5%), Enterococcus (2.5% vs 10%), and GNB (2.5% vs 5%). Conclusions: Stethoscopes may serve as vectors for clean hands to become recontaminated immediately prior to performing patient care activities. Using ABHR to clean stethoscopes after every use is a practical and effective strategy to reduce overall bacterial contamination that can be easily incorporated into clinical workflow. Larger studies are needed to determine the efficacy of ABHR at removing CIP from stethoscopes as stethoscopes in both arms were frequently contaminated with CIP. Prior cleaning of stethoscopes on the study day did not seem to impact contamination rates, suggesting the impact of alcohol foam disinfection is short-lived and may need to be repeated frequently (ie, after each use).Funding: NoneDisclosures: NoneDisclosures: NoneFunding: None

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Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.578 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s84-s84

Author(s):

Lorinda Sheeler ◽

Mary Kukla ◽

Oluchi Abosi ◽

Holly Meacham ◽

Stephanie Holley ◽

...

Keyword(s):

Screening Tool ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The United States ◽

World Health ◽

Communication Campaign ◽

Electronic Screening ◽

Novel Coronavirus ◽

The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

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