Editor’s note: The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by the Hong Kong Journal of Emergency Medicine.
Annals of Emergency Medicine
(The print version of this article has been scheduled for September 2023)
Barriers and facilitators to the outpatient management of low-risk pulmonary embolism from the emergency department
Lauren M Westafer, Erica Jessen, Michael Zampi, Eric Boccio, Scott D Casey, Peter K Lindenauer, David R Vinson
Study objective: Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism from emergency departments in the United States remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of pulmonary embolism from the emergency department using implementation science methodology.
Methods: We conducted semi-structured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk pulmonary embolism. We developed an interview guide using the implementation science frameworks—the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process.
Results: We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of pulmonary embolism. Although outer setting determinants, such as medicolegal climate, follow-up and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes.
Conclusion: In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute pulmonary embolism should be informed by these barriers and facilitators, which are aligned with the de-implementation theory.
How to cite this article:
Westafer LM, Jessen E, Zampi M, et al. Barriers and facilitators to the outpatient management of low-risk pulmonary embolism from the emergency department. Ann Emerg Med 2023. DOI: 10.1016/j.annemergmed.2023.02.021.
(The print version of this article has been scheduled for October 2023)
Sedative dose for rapid sequence intubation and post-intubation hypotension: is there an association?
Brian E Driver, Stacy A Trent, Matthew E Prekker, Robert F Reardon, Calvin A Brown III
Study objective: For patients with hemodynamic instability undergoing rapid sequence intubation, experts recommend reducing the sedative medication dose to minimize the risk of further hemodynamic deterioration. Scant data support this practice for etomidate and ketamine. We sought to determine if the dose of etomidate or ketamine was independently associated with post-intubation hypotension.
Methods: We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018. Patients aged 14 years or older were included if the first intubation attempt was facilitated with etomidate or ketamine. We used multivariable modeling to determine whether drug dose in milligrams per kilogram of patient weight was independently associated with post-intubation hypotension (systolic blood pressure < 100 mm Hg).
Results: We analyzed 12,175 intubation encounters facilitated by etomidate and 1849 facilitated by ketamine. The median drug doses were 0.28 mg/kg (interquartile range = 0.22–0.32 mg/kg) for etomidate and 1.33 mg/kg (interquartile range = 1–1.8 mg/kg) for ketamine. Post-intubation hypotension occurred in 1976 patients (16.2%) who received etomidate and in 537 patients (29.0%) who received ketamine. In multivariable models, neither the etomidate dose (adjusted odds ratio = 0.95, 95% confidence interval = 0.90–1.01) nor ketamine dose (adjusted odds ratio = 0.97, 95% confidence interval = 0.81–1.17) was associated with post-intubation hypotension. Results were similar in sensitivity analyses excluding patients with pre-intubation hypotension and including only patients intubated for shock.
Conclusion: In this large registry of patients intubated after receiving either etomidate or ketamine, we observed no association between the weight-based sedative dose and post-intubation hypotension.
How to cite this article:
Driver BE, Trent SA, Prekker ME, et al. Sedative dose for rapid sequence intubation and post-intubation hypotension: is there an association? Ann Emerg Med 2023. DOI: 10.1016/j.annemergmed.2023.05.014.
Emergencias
(The print version of this article has been scheduled for September 2023)
Pharmacist care in hospital emergency departments: a consensus paper from the Spanish hospital pharmacy and emergency medicine associations
Jesús Ruiz Ramos, Beatriz Calderón Hernanz, Yolanda Castellanos Clemente, Manuel Bonete Sánchez, Emili Vallve Alcon, M Rosario Santolaya Perrin, M Ángeles García Martín, Ana De Lorenzo Pinto, José Manuel Real Campaña, Javier Ramos Rodríguez, Cristina Calzón Blanco, Milagros García Peláez, Héctor Alonso Ramos, Joan Altimiras Ruiz, Paloma Sempere Serrano, María Martín Cerezuela, Leonor Periañez Parraga, Ana María Juanes Borrego, Beatriz Somoza Fernández, Juan Manuel Rodríguez Camacho, Mireia Puig Campmany, Iria Miguens Blanco, Santiago Tomás Vecina, Catalina Nadal Galmes, Javier Povar Marco
Cited: Ruiz Ramos J, Calderón Hernanz B, Castellanos Clemente Y, et al. Atención farmacéutica en los servicios de urgencias: documento de posicionamiento de la Sociedad Española de Farmacia Hospitalaria (SEFH) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). Emergencias 2023; 35: 205–217. http://emergencias.portalsemes.org/descargar/atencin-farmacutica-en-los-servicios-de-urgencias-documento-de-posicionamiento-de-la-sociedad-espaola-de-farmacia-hospitalaria-sefh-y-la-sociedad-espaola-de-medicina-de-urgencias-y-emergencias-semes/
Objective: To draft a list of actions and quality indicators for pharmacist care in hospital emergency departments, based on consensus among a panel of experts regarding which actions to prioritize in this setting.
Material and methods: A panel of experts from the Spanish Society of Hospital Pharmacy and the Spanish Society of Emergency Medicine evaluated a preliminary list of potential actions and quality-of-care indicators. The experts used a questionnaire to assess the proposals on the basis of available evidence. In the first round, each expert individually assessed the importance of each proposed action based on four dimensions: evidence base, impact on clinical response and patient safety, ease of implementation and priority. In the second round, the experts attended a virtual meeting to reach consensus on a revised list of proposals; suggestions and comments that had been made anonymously in the first round were included. The group then prioritized each action as basic, intermediate or advanced.
Results: The experts evaluated a total of 26 potential actions and associated quality indicators. No items were eliminated in the analysis of scores and comments from the first round. After the second round, 25 actions survived. Nine were considered basic, 10 intermediate, and 6 advanced.
Conclusion: The expert panel’s list of pharmacist actions and care quality indicators provides a basis for developing a pharmacist care program in Spanish emergency departments on three levels of priority. The list can serve as a guide to pharmacists, managers, physicians, and nurses involved in the effort to improve drug therapy in this hospital setting.
Keywords: Evidence-based pharmacy practice, emergency department, pharmacists
