Article

Where do they need us? Determining the future of emergency medicine

Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983 1965

Differences in patient populations regarding cause of hypotension
  • Decreased considerations for usual management of disease, hypoten- sion and expected medication related adverse effects
  • PDP preparation during acute patient management and dose errors
  • We report PDP errors with phenylephrine and epinephrine at our institution. The first case, a post-surgical patient with known blood loss/hypovolemic shock, developed hypotension during transport. Op- timization of medications the patient was receiving (midazolam, fen- tanyl, hydromorphone) along with fluid resuscitation was not implemented initially. Phenylephrine PDP and propofol were used in- stead to treat hypotension and resultant hypertension. At presentation to the ICU, phenylephrine “50” was ordered and 50 mg (50 mg/5 mL vials available in the ICU for continuous infusion admixing) was administered instead of intended 50 ug. The second case, a post- laminectomy patient recently receiving norepinephrine continuous in- fusion for hemodynamic support, developed atrial fibrillation with rapid ventricular rate and was treated with diltiazem IV boluses/con- tinuous infusion. The patient developed asymptomatic hypotension and phenylephrine PDP was ordered instead of fluid resuscitation/ restarting norepinephrine (still at bedside) resulting in the entire phenylephrine pre-mixed syringe being administered by a physician, 1000 ug [1000 ug/10 mL], instead of intended 100 ug. Epinephrine er- rors occurred with 0.3 and 1 mg administered IV for angioedema and allergic reaction (neither patient received intramuscular epinephrine) and 0.1 (100 ug), 0.3, 0.5, and 1 mg IV administered to patients for hy- potension instead of intended 5-20 ug. Adverse effects in phenyleph- rine and epinephrine cases were transient blood pressure elevations (N 300 mm Hg), ST depressions, and QTc prolongation. These cases highlight our concerns using PDP in ED/ICU settings. In the phenyleph- rine cases, it appears that PDP were the first resuscitation measure in- stead of fluid/blood administration. Also, better understanding of pharmacokinetics, Adverse drug effects, and optimization of other medications the patient was receiving may have changed decision- making and prevented PDP administration.

    FOAMed videos describe preparation of epinephrine PDP using cardi- ac arrest epinephrine syringes [1], however in acute stressful situations there is confusion regarding preparation and dose [4]. Since recent FOAMed discussions and recommendations for IV epinephrine for ana- phylaxis [2] there are more errors related to this indication at our institu- tion. Other near miss errors that we have encountered are physicians asking for epinephrine mixed to 100 ug/mL concentration (misinterpre- tation of the 5-20 ug dose vs. phenylephrine 100 ug) and nurses asking to give 0.3 mg doses IV since the patient has IV access. It seems that first line therapy with IM epinephrine for anaphylaxis and initiation of fluids/nor- epinephrine for hypotension is not being considered.

    Furthermore, EM/ICU physicians are not traditionally trained in medi- cation manipulation. Phenylephrine (available 1 mg/mL) and epinephrine (available 1 mg/mL, 0.1 mg/mL) causes confusion regarding the number of dilutions to achieve the recommended ug/mL concentration and dose. A proposed benefit of PDP is availability at bedside, but we feel the time taken to manipulate these concentrations to provide small doses of vaso- pressor actually take the same amount of time as admixing and initiating continuous infusion vasopressor. In some situations (e.g. peri-intubation period) hypotension can be anticipated and having continuous infusion vasopressor ready at bedside would be a safer alternative due to increased familiarity. Some may argue that having pre-filled PDP syringes available may alleviate this confusion, however in one case we describe a ten-fold medication error with pre-filled phenylephrine syringes.

    There are limited data regarding PDP use and safety in the ED/ICU. An evaluation of phenylephrine PDP for peri-intubation hypotension in the ED found use was not systematic and 70% of patients were also treated with continuous infusion vasopressor [3]. Author’s conclude PDP are used as a “bridge to vasopressor infusion or aggressive fluid resuscitation” which we would argue should be first line treatment. They infer that non- systematic use of phenylephrine may cause inadvertent negative effects

    for undifferentiated hypotension due to worsening shock secondary to in- adequate fluid resuscitation. Although significant adverse effects were not seen in our patients past 1 h, there are several reports of epinephrine IV errors ranging from 0.04 to 1 mg with significant adverse effects (intra- cerebral bleed, myocardial ischemia/infarction and dysrhythmias) [5-10]. There has been overwhelming positive support through FOAMed for PDP, but we believe it is important to present an opposing discussion regarding Medication errors, patient safety, and potential risk.

    Nicole M. Acquisto Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY 14642, United States Department of Pharmacy, Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 638, Rochester, NY

    14642, United States

    Corresponding author.

    E-mail address: [email protected]

    Ryan P. Bodkin Christine Johnstone

    Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY 14642, United States

    6 February 2017

    https://doi.org/10.1016/j.ajem.2017.06.013

    References

    1. Weingart S. EMCrit Podcast 6 – push-dose pressors. Available at: www.emcrit.org/ podcasts/bolus-dose-pressors; July 10, 2009.
    2. Emergency Medicine: Reviews and Perspectives (EMRAP). The doc in the bay: underutilizing epi in anaphylaxis, 15 (12); December 2015Available at: www.emrap.org.
    3. Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of bolus-dose phenylephrine for peri-intubation hypotension. J Emerg Med 2015;49:488-94.
    4. Emergency Medicine: Reviews and Perspectives (EMRAP). Strayerisms: anaphylaxis rebuttal, 16 (5); May 2016Available at: www.emrap.org.
    5. Kanwar M, Irvin CB, Frank JJ, Webber K, Rosman H. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med 2010;55:341-4.
    6. Anchor J, Settipane RA. Appropriate use of epinephrine in anaphylaxis. Am J Emerg

      Med 2004;22:488-90.

      Campbell RL, Bellolio F, Knutson BD, et al. Epinephrine in anaphylaxis: higher risk of Cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract 2015;3:76-80.

    7. Shaver KJ, Adams C, Weiss SJ. Acute myocardial infarction after administration of

      low-dose intravenous ephinephrine for anaphylaxis. CEJM 2006;8:289-94.

      Park JS, Min JH, In YN. Acute myocardial infarction due to Stent thrombosis after ad- ministration of intravenous epinephrine for anaphylaxis. Chin Med J (Engl) 2015; 128:2692-3.

    8. Khoueiry G, Rafeh NA, Azab B, et al. Reverse takotsubo cardiomyopathy in the set- ting of anaphylaxis treated with high dose intravenous epinephrine. J Emerg Med 2013;44:96-9.

      Where do they need us? Determining the future of emergency medicine

      Emergency medicine was born out of necessity in hospital base- ments to serve the critically sick and injured arriving without warning. By meeting the needs of the desperate and most vulnerable, we grew into departments that cared for patients left out of the disjointed American health system. In the face of terror, we bolstered our capacity for mass casualties and CBRNE events. Policymakers recognized the value of our work, if not the cost, and legislated a universal right to emergency care in the United States [1].

      Health care policies are always changing and our specialty has questioned how best to adapt [2]. Freestanding emergency departments

      1966 Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983

      have long existed to extend our specialty services far from medical cen- ters, but the unprecedented growth of EDs is not occurring in the com- munities in most need [3]. They are built where residents have private insurance [4], far from public transportation, regardless of population density [5].

      An “attractive” payer mix is profitable, especially under the old fee- for service model, but letting profit opportunity drive ED locations con- trary to patient needs opposes the ethos of our specialty and fails society in the long-term. Expansion into well-served markets increases health care utilization and costs [6] while we face cost-containment pressure. It does nothing to improve population health or access to care in urban and rural areas where hospitals are closing and need is greatest. The unregulated status that free-standing EDs enjoy where they are most numerous [7] is likely to change as insurers and legislators align payments with outcomes.

      No doctor would triage patients by payment method and no doctor should work in a facility that has effectively done just that. If we no lon- ger serve all the critically sick and injured, then whom do we serve? Our specialty was founded to provide excellent care for the most challenging patients and this should be our guide to the future.

      We should focus on improving Care coordination and addressing so- cial determinants of health. Any one of us could face uncoordinated doc- tors, transportation problems, strained caregivers, or addiction. Systems equipped to handle the most vulnerable patients will treat patients of any socioeconomic status well.

      There is a role for freestanding EDs for acute care access where hos- pitals can no longer operate. The certificate-of-need process, which re- quires community input and approval before a new center can open, is useful in assessing where those resources are needed.

      At our origin we provided the care that was needed without regard for whether it was profitable. Our specialty has been wildly successful be- cause of it. Instead of turning away from our guiding principles, now more than ever, we must return to them. By providing excellent care to everyone who comes to our door, we will demonstrate our value to our policymakers, our colleagues, and most importantly, our patients.

      Acknowledgment

      The manuscript was copyedited by Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine.

      Daniel B. Gingold, MD Robert M. Brown, MD*

      Department of Emergency Medicine, University of Maryland School of

      Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201,

      United States

      *Corresponding author.

      E-mail address: [email protected] (R. M. Brown)

      30 April 2017

      https://doi.org/10.1016/j.ajem.2017.06.018

      References

      Comstock N. Emergency medical treatment and Active Labor Act (EMTALA). January: Salem Press Encyclopedia; 2016.

    9. Sayah A, Lai-Becker M, Kingsley-Rocker L, Scott-Long T, O’Connor K, Lobon LF. Emer- gency department expansion versus patient flow improvement: impact on patient experience of care. J Emerg Med 2016;50:339-48.
    10. Schuur JD, Baker O, Freshman J, Wilson M, Cutler DM. Where do freestanding emer- gency departments choose to locate? A national inventory and geographic analysis in three states. Ann Emerg Med 2016 Jul 12 [Epub ahead of print].
    11. Simon EL, Griffin G, Orlik K, et al. Patient insurance profiles: a tertiary care compared to three freestanding emergency departments. J Emerg Med 2016;51(4):466-70.
    12. Carlson L, Baker O, Schuur J. 171 Emergency department proximity to public trans- portation: a comparison of freestanding and hospital emergency departments in three metropolitan areas. Ann Emerg Med 2016;68(4):S67.
    13. Simon EL, Griffin PL, Jouriles NJ. The impact of two freestanding emergency depart- ments on a tertiary care center. J Emerg Med 2012;43(6):1127-31.
    14. Gutierrez C, Lindor RA, Baker O, Cutler D, Schuur JD. State regulation of freestanding emergency departments varies widely, affecting location, growth, and services pro- vided. Health Aff (Millwood) 2016;35(10):1857-66.

      US emergency department visits for adults with abdominal and pelvic pain (2007-13):

      Trends in demographics, resource utilization and medication usage

      To the Editor:

      Abdominal pain is the most common complaint encountered in US emergency departments (EDs). In this study, we explored na- tional trends in recent years (2007-2013) in demographics, dispo- sition decisions, medication use, and CT scan utilization for adult ED patients with abdominal pain, using the National Hospital Am- bulatory Medical Care Survey (NHAMCS). NHAMCS is a yearly survey released by the Centers for Disease Control and Prevention (CDC) that can be used to make national estimates about U.S. ED visits. Changes in patient and hospital characteristics were investi- gated in NHAMCS using survey-weighted linear combinations of estimators. We also modeled the risk factors for two important public health issues surrounding abdominal pain: ED opioid anal- gesic use and CT scan utilization using a survey-weighted logistic regression.

      Overall, there were an estimated 18.7 million ED visits for abdom- inal pain in 2007 and 23.0 million in 2013 representing a 22.6% abso- lute increase over the 7-year interval, and a 7.7% relative increase compared to total ED visits. Over the study period, there were in- creases in the proportions of young patients, female patients, white patients, Medicaid patients, and patients who were ultimately discharged after ED care, specifically 5.3% more patients were discharged in 2013 as compared to 2007 (p b 0.05, Table 1).

      CT scans were used in 25.3% of all abdominal pain encounters in 2007, which peaked at 30.1% in 2010; subsequently, CT use trended downward to 28.6% in 2013. (Fig. 1) The leveling off of CT scans may reflect the success of campaigns that sought to raise awareness about radiation risks [1] or an increased cost-consciousness on be- half of doctors and patients [2]. Another possible explanation is that improvements in information technology have translated into fewer repeat CT scans. Patients were more likely to receive a CT scan if they were older, white, male gender, had private insurance, and reported severe pain. (Table 2) While the increase use in older adults may reflect an increased concern for ‘dangerous’ causes of ab- dominal pain and the decreased use in women may reflect concern about radiation in addition to the use of ultrasound for pelvic pathol- ogy, the decrease in non-white and Medicaid patients requires fur- ther investigation to explain.

      Medication use is extremely common in ED abdominal pain patients

      with N 85% of patients receiving medications in the ED. Over the study period, there was a 33.1% increase in the mean number of medications to 3.1 meds administered in the ED per patient per visit. Regarding opioid analgesics in particular, use increased from 35.2% to a peak of 39.4% in 2011 before falling to 34.4% in 2013: a 2.3% relative decrease over the 7 year period. Patients were more likely to receive opioids in the ED if they were white, younger than 65, had private insurance, or severe pain (N 8 on pain score). (Table 3) The leveling off of opioid use may also reflect increased public awareness of the adverse effects of opioid medications and abuse.

      Our study underscores the high resource intensity of caring for patients with abdominal pain in the ED. Of the approximately 20

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