Retrospective Review for Medication Dose Errors in Pediatric Emergency Department Medication Orders That Bypassed Pharmacist Review

OBJECTIVE

To identify and evaluate dose errors on medication orders that bypassed pharmacist verification in a pediatric emergency department (PED).

METHODS

Descriptive, retrospective study about dose errors in an academic PED over 1 year. A report of automatically verified orders (those that bypassed pharmacist verification) was obtained from the electronic medical record. Potential medication dose errors were defined as those greater than 20% above or below standard dose ranges by age or weight. A retrospective chart review was performed for all identified dose errors. For orders deemed erroneous, additional metrics collected included order time of day and day of week and provider training level.

RESULTS

A total of 46,185 medication orders were placed; 32,928 (71%) bypassed pharmacist review. Altogether, 676 orders (2%) were outside standard dose ranges. Ondansetron represented 569 of the 676 orders; most were doses rounded down to 4 mg and technically qualifying as underdoses, but were attributed to practice variance and not further analyzed. The number of orders deemed potentially erroneous was 107: most were wrong dose (75 overdose and 21 underdose), 5 were wrong patient, and 6 were wrong formulation. Ibuprofen, benzodiazepine, and corticosteroid orders had the most errors. No errors resulted in identifiable harm to the patient: 49 were near misses, and 47 reached the patient with no evident harm.

CONCLUSIONS

The overall number of dose errors in autoverified orders was low. Certain medications or ordering modalities may be targeted to enhance patient safety and satisfaction.

Offspring Self-Disclosure Predicts Substance-Related Outcomes in an Emergency Department Sample of Young Adults with Traumatic Injury

Background

Hundreds of thousands of individuals visit the emergency department (ED) every year, with many visits occurring following alcohol misuse. Parent-child relationship factors are associated with alcohol-related outcomes. For example, offspring choice to self-disclose information about their lives to parents, rather than parents actively soliciting this information, is associated with substance use. However, it is unclear whether self-disclosure uniquely predicts alcohol-related outcomes in a young adult ED sample.

Methods

Data were collected from young adults (age 18-30 years) visiting an ED for a traumatic injury (n=79). Participants were about 24.4 years old, majority male (53.7%), and Caucasian (76%; 24% African-American). A bifactor model within a structural equation model tested unique effects of self-disclosure on age at first drink, propensity for risky drinking, and likelihood of consuming substances prior to ED visit, over and above parental solicitation and a general factor and gender.

Results

Those who shared more information with their caregivers reported an older age at first drink, lower propensity for risky drinking and lower propensity to consume substances prior to their ED visit.

Conclusions

These findings suggest that self-disclosure may be a unique risk factor in the initiation of alcohol use, development of problem use, and consequences following use.

Pediatric Readiness in the Emergency Department

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Management of Pediatric Isolated Skull Fractures: A Decision Tree and Cost Analysis on Emergency Department Disposition Strategies

OBJECTIVE

Pediatric isolated skull fractures (ISFs) are common injuries that represent challenging disposition decisions for clinicians. The purpose of this study is to use a decision analysis to compare the clinical and cost-effectiveness of 3 emergency department (ED)-based disposition scenarios for a pediatric patient presenting with ISF.

METHODS

We conducted a cost-effectiveness analysis comparing ED disposition scenarios that included current practice, increased at-home surveillance, and observation unit utilization. Current rates of admission, deterioration after initial diagnosis, and ED return after discharge, as well as cost of observation-only status, were obtained through literature review. Cost calculations using Healthcare Cost and Utilization Project data included total ED cost, admission without complication, and admission with deterioration.

RESULTS

In current practice, 76% of subjects with ISF are admitted and 2.5% of those develop persistent or new symptoms. No patient diagnosed with ISF required neurosurgical intervention. Of those discharged home from the ED, 2.8% return with a new concern with 7.4% having new findings on imaging leading to admission. Total cost per 100 patients by current practice was US $583,587. Increasing at-home surveillance by 20% resulted in a total cost saving of US $113,176 per 100 patients while increasing returns to the ED from less than 1% to 1.1%. Admitting at the current rate to an observation unit resulted in a US $205,395 cost saving per 100 patients.

CONCLUSIONS

Decreased inpatient utilization through home surveillance or observation unit use reduced cost associated with pediatric ISF management without increasing clinical risk owing to the low probability of clinical deterioration after initial diagnosis.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

To Give Epinephrine or Not to Give Epinephrine-That Is (No Longer) The Question!

It is vital that school nurses be able to assess students who are at risk for anaphylaxis and that nurses train school staff to identify the symptoms of a life-threatening allergic reaction. When a reaction occurs, school nurses and staff must be prepared to administer epinephrine immediately.

"Beat the Shock Clock": An Interprofessional Team Improves Pediatric Septic Shock Care

Ideal care for septic shock (SS) is difficult. This interprofessional quality improvement intervention in a mid-volume pediatric emergency department aimed to reduce time to vascular access, fluid resuscitation, and antibiotics for SS. Intensive education, a care pathway, and an order set were applied. Outcome measures for patients with criteria for SS before and after intervention were compared. There were 43 patients pre-intervention (January 2009 to June 2011) and 63 post-intervention (June 2012 to June 2013). Median time to vascular access decreased from 37 minutes pre-intervention to 24 minutes post-intervention (p = 0.05). Median time to first fluid bolus decreased from 35 to 26 minutes (p = 0.08). Percentage of boluses delivered rapidly by pressure method increased from 21% to 74% (p < 0.0001). Median time to antibiotics decreased from 92 to 55 minutes (p = 0.02). In conclusion, a multimodal, interprofessional quality improvement intervention in a mid-sized pediatric emergency department improved the time to critical interventions for SS.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

OBJECTIVE

Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge.

METHODS

Within the Pediatric ED (PED) at a tertiary children's hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart.

RESULTS

Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%.

CONCLUSIONS

This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.

Parental preference for short- versus long-course corticosteroid therapy in children with asthma presenting to the pediatric emergency department

Asthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (ED). We aimed to determine parental preference between short- and long-term courses of oral corticosteroids for use in children with mild to moderate asthma presenting to our pediatric ED with acute asthma exacerbations. We surveyed parents of asthmatic children who presented to our pediatric ED from August 2011 to April 2012. Questions characterized each patient's asthma severity, assessed parental preference among systemic steroid and inhaled medication delivery options for acute asthma management, and inquired about compliance, medication costs, and intention to follow up. The majority of our parents prefer the use of 1 to 2 days of steroids to 5 days for acute asthma exacerbations in the ED. Thus, dexamethasone is an attractive alternative to prednisone/prednisolone and should be considered in the management of acute asthma exacerbations in the ED.

Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice

BACKGROUND

Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.

METHODS

This was an online anonymous survey of a random sample of EM health providers in US EDs.

RESULTS

Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.

CONCLUSIONS

This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.

A cost-effectiveness analysis of dexamethasone versus prednisone in pediatric acute asthma exacerbations

OBJECTIVES

The objective was to evaluate the cost-effectiveness of dexamethasone versus prednisone for the treatment of pediatric asthma exacerbations in the emergency department (ED).

METHODS

This was a cost-effectiveness analysis using a decision analysis model to compare two oral steroid options for pediatric asthma patients: 5 days of oral prednisone and 2 days of oral dexamethasone (with two dispensing possibilities: either a prescription for the second dose or the second dose dispensed at the time of ED discharge). Using estimates from published studies for rates of prescription filling, compliance, and steroid efficacy, the projected rates of ED relapse visits, hospitalizations within 7 to 10 days of the sentinel ED visit, direct costs, and indirect costs between the two arms were compared.

RESULTS

The rate of return to the ED per 100 patients within 7 to 10 days of the sentinel ED visit for the prednisone arm was 12, for the dexamethasone/prescription arm was 10, and for the dexamethasone/dispense arm was 8. Rates of hospitalization per 100 patients were 2.8, 2.4, and 1.9, respectively. Direct costs per 100 patients for each arm were $20,500, $17,200, and $13,900, respectively. Including indirect costs related to missed parental work, total costs per 100 patients were $22,000, $18,500, and $15,000, respectively. Total cost savings per 100 patients for the dexamethasone/prescription arm compared to the prednisone arm was $3,500 and for the dexamethasone/dispense arm compared to the prednisone arm was $7,000.

CONCLUSIONS

This decision analysis model illustrates that use of 2 days of dexamethasone instead of 5 days of prednisone at the time of ED visit for asthma leads to a decreased number of ED visits and hospital admissions within 7 to 10 days of the sentinel ED visit and provides cost savings.

Nippostrongylus brasiliensis: infection induces upregulation of acetylcholinesterase activity on rat intestinal epithelial cells

Expression of cholines terases and muscarinic acetylcholine receptors in the jejunal mucosa has been investigated during infection of rats with the nematode parasite Nippostrongylus brasiliensis. Selective expression of m3 receptors was observed on epithelial cells from uninfected rats and animals 7 days postinfection, and saturation binding with [(3)H]quinuclidinyl benzilate indicated that receptor expression on cell membranes was unaltered by infection. Butyrylcholinesterase was highly expressed in mucosal epithelia, but acetylcholinesterase was present at low levels in uninfected animals. In contrast, discrete foci of intense acetylcholinesterase activity were observed on the basement membrane of intestinal epithelial cells in animals infected with N. brasiliensis. This was demonstrated to be due to upregulation of expression of endogenous enzyme, which peaked at Day 10 postinfection and subsequently declined to preinfection levels. It is suggested that this occurs in response to hyper-activation of the enteric nervous system as a result of infection, and may benefit the host by limiting excessive fluid secretion due to cholinergic stimulation.

Natural language storage and retrieval of medical diagnostic information. Experience at the UCLA hospital and clinics over a 10-year period

A natural language storage and retrieval system initially designed for pathology reports has been in operation for ten years at UCLA Hospital and Clinics. The original system has been improved to provide a thesaurus processor with added capabilities for expanding search request terms and a newly developed set of search programs with user options that make complex and more accurate retrievals possible. Summarized diagnostic statements or impressions from five specialities (Surgical Pathology, Bone Marrow, Autopsy, Nuclear Medicine, and Neuroradiology), are automatically encoded by referencing a master computer dictionary containing a unique numeric code for each English word. Input and retrievals are batch, off-line operations in free text, and are currently processed on the IBM 370/145. User acceptance is high, quality of retrievals improved, and cost is nominal. This paper describes an expanded natural language system which in now providing a viable form of information storage and retrieval for research, medical education, patient care, quality control, statistics and administrative purposes.