ED Push - January 2016 Second Issue
Emergency Medicine Reports - Trauma Reports
Pediatric Emergency Medicine Reports
ED Management - ED Legal Letter - Critical Care Alert
EDs Hit Hard by Shortages of Life-saving Drugs in Recent Years
WASHINGTON, DC – Emergency physicians have been facing one of their biggest nightmares for years now: desperately seeking a drug to save a life only to find that it is unavailable because of a shortage.
A study published recently in Academic Emergency Medicine notes that drug shortages affecting emergency care have grown dramatically since 2008, and that most of the shortages are for drugs used for lifesaving interventions or high-acuity conditions. Furthermore, according to the George Washington University-led study, some of them have no viable substitutions.
For the study, researchers analyzed drug shortage data from the University of Utah Drug Information Service from January 2001 to March 2014. Two board-certified emergency physicians classified drug shortages based on whether:
- They were within the scope of emergency medicine (EM) practice,
- They were used for lifesaving interventions or high-acuity conditions, and
- A substitute for the drug exists for its routine use in emergency care.
Researchers then calculated trends in the length of shortages for drugs used in EM practice.
Results indicate that, of the 1,798 drug shortages over the approximately 13-year period, 610 shortages (33.9%) were classified as within the scope of EM practice. Of those, 321 (52.6%) were for drugs used as lifesaving interventions or for high-acuity conditions. About 10% (32) were for drugs with no available substitute.
While the prevalence of ED drug shortages fell between 2002 and 2007, the rate sharply increased 435% from 23 to 123 between January 2008 and March 2014, according to the study. During that time period, shortages in drugs used as a direct lifesaving intervention or for high-acuity conditions increased 393% from 14 to 69, and shortages for drugs with no available substitute grew 125% from four to nine.
Study authors noted that nearly half (46.6%) of all ED drug shortages were caused by unknown reasons, i.e., the manufacturer did not cite a specific reason when contacted.
The most common EM drugs in short supply were those used to treat infectious disease. Overall, there were 148 drug shortages totaling 2,213 months during the study period.
New Guidelines Released on Optimal Treatment of VTE
HAMILTON, ONTARIO -- With about 10 million cases of venous thromboembolism (VTE) worldwide each year, emergency physicians are constantly faced with finding the most appropriate ways to treat those patients.
Now, the American College of Chest Physicians has provided 53 updated recommendations in an effort to improve treatment. The 10th edition, “Antithrombotic Therapy for VTE Disease: CHEST Guideline, from the American College of Chest Physicians,” appeared recently in the journal Chest.
"This guideline article, another from CHEST living guidelines, provides the most up-to-date treatment options for patients with VTE,” said lead author Clive Kearon, MD, of McMaster University in Ontario. “The guideline presents stronger recommendations and weaker suggestions for treatment based on the best available evidence, and identifies gaps in our knowledge and areas for future research."
The guidelines include strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence.
Among the most significant new recommendations is the recommendation of non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin for initial and long-term treatment of VTE in patients without cancer. New research has shown that NOACs are as effective with reduced risk of bleeding and more convenience for patients and healthcare providers than warfarin, which requires routine bloodwork, according to the document.
“For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C),” guideline authors wrote. “For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B).”
The 10th edition also provides more specific information on subsegmental pulmonary embolism treatment recommendations, distinguishing which patients diagnosed with isolated subsegmental pulmonary embolism (SSPE) should receive anticoagulant therapy and which should not.
In terms of prevention, the guidelines recommend against the routine use of compression stockings to prevent patients with acute DVT from developing post-thrombotic syndrome, a chronic condition of the leg with swelling, pain, skin discoloration, and possibly ulcers.
The authors further noted that “of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research."
Increasing Number of Hypertension Patients Seeking Emergency Care
NASHVILLE – This probably won’t come as much of a surprise to emergency physicians, but a new study finds that the number and percentage of hypertension patients treated at EDs are on the rise in the United States.
The report in the American Journal of Cardiology notes that uncontrolled hypertension is a risk factor for the development of cardiovascular disease and a significant cause of death in the United States even though it is usually treatable.
"We found that around 25% of all ED visits involved patients with hypertension, and that the rate of hypertension-related visits has gone up more than 20% since 2006," explained co-author Candace McNaughton, MD, MPH.
Researchers used the Nationwide Emergency Department Sample from 2006 to 2012 to identify hypertension-related ED visits and then linked them to U.S. Census Bureau July population estimates to determine population-based rates for each study year. Over the seven-year study period, 165,946,807 hypertension-related ED visits occurred, representing 23.6% of all adult ED visits. Hypertension was the primary diagnosis for 6,399,088 (0.9%) of all adult ED visits.
In addition to being common, hypertension-related ED visits were found to be increasing. The estimated yearly incidence rate increased 5.2% per year for hypertension-related visits and 4.4% per year for ED visits with a primary diagnosis of hypertension. Yet, with the proportion of visits rising at safety net hospitals and among uninsured patients, the rate of hospitalization actually decreased over the study period.
"The study highlights how common hypertension is, and that it's becoming an even bigger problem affecting a large number of patients who seek care in the ED," McNaughton added in a Vanderbilt press release. "ED visits for patients with a primary diagnosis of hypertension were more likely among patients who were younger and less likely to have private health insurance.
"The role of the ED in the management of chronic disease is still poorly understood,” she continued, “with hypertension as an opportunity to show how we can safely use the ED to manage patients with these [conditions]."
Emergency Care for Pediatric Medication Poisoning More Likely in Poor, Rural Areas
PITTSBURGH – How many toddlers and infants in your ED for medication poisoning is correlated to the ED’s location and level of economic disadvantage in the area around it.
A study published online by the journal Clinical Toxicology finds that children younger than 5 years of age who live in economically disadvantaged rural areas had a greater risk of medication poisoning that resulted in referral to a healthcare facility than others.
The study team, led by researchers from the University of Pittsburgh Graduate School of Public Health and the University of California, San Diego, noted that these areas tended to be rural and have high unemployment, as well as lower rates of high school graduation and reduced household income.
Study authors noted that their analysis of Pittsburgh Poison Center data offers some insight into potential geographic targets for poison prevention outreach.
"Understanding where there are geographic clusters of kids being exposed to medications that could hurt them gives us the opportunity to effectively intervene," explained senior author Anthony Fabio, PhD, MPH, of Pitt Public Health. "It also could help emergency clinicians ask the right questions and perhaps zero in on a medication exposure when a child comes in with unexplained symptoms."
For the study, researchers analyzed 26,685 Pittsburgh Poison Center records of pharmaceutical drug exposures in children under 5 years of age from 2006 through 2010, distinguishing between those where home treatment was recommended, as opposed to a recommendation to seek medical evaluation.
That revealed "exposure" and "referral" clusters throughout western and central Pennsylvania. Researchers suggested that the exposure clusters tended to be in urban areas where parents and caregivers might have been more familiar with the Pittsburgh Poison Center's hotline and, therefore, more likely to call and deal with the problem at home.
Referral clusters, meanwhile, were generally in more rural areas characterized by high unemployment. In fact, in those areas, the study found that that the risk of a child under 5 years of age referred to a healthcare facility for a medication exposure was 3.2 times greater than elsewhere.
"More study is needed to determine exactly why this is, but we believe it could be related to fewer resources for child supervision -- whether at home or at daycare centers in the community -- increasing the likelihood of a small child finding and swallowing medication," Fabio said in a Pitt press release.
UPCOMING [LIVE] WEBINARS
TJC Sentinel Event Policy, Patient Safety Systems & CMS RCA Requirements
Live: January 20 Credits: 2 CE
Telemedicine, the Cost-effective Alternative: Real-time CMS & TJC Standards
Live: January 27 Credits: 2 CE
Altered Mental Status and Neurological Disasters
Live: January 28 Credits: 1.5 CE & 1.5 CME
New Pharmacy & Medication Standards: the CMS CoPs
Live: January 28 Credits: 2 CE
Advance Care Planning Payments and Standards
Live: February 3 Credits: 2 CE
Safe Opioid Use: Meeting the CMS CoP Hospital Requirements
Live: February 9 Credits: 2 CE
Violence Prevention in Healthcare: OSHA Requirements
Live: February 9 Credits: 1 CE
Restraint and Seclusion: The Most Problematic of All CMS Standards
Live: February 17 Credits: 1.5 CE
