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Background: The Beers Criteria® medications are potentially inappropriate medications (PIMs) recommended by the American Geriatric Society to be avoided or used with caution in adults 65 years and older. The usage of PIMs in the emergency department (ED) setting is not well characterized. Objectives: The purpose of this study is to evaluate the usage of PIMS in the ED. Methods: This is a single center retrospective observational study of a random sample of patients aged 65 and older who presented to the ED during a 6-month timeframe. The primary outcome was the incidence of ED readmissions in patients administered or prescribed a PIM compared with patients who were not prescribed or administered a PIM. Secondary outcomes included ED length of stay (LOS) and hospital admission. Results: Out of 192 patients, there was a total of 58 patients (30.2%) in the PIM group and 134 patients (69.8%) in the No PIM group. ED re-presentation within 30 days occurred in 10 patients (17%) in the PIM group vs 26 patients (19%) in the No PIM group (p = 0.88). The median ED LOS was 227 minutes vs 208 minutes (p = 0.1679). Hospital admission within 30 days occurred in 4 patients (7%) in the PIM group and 13 patients (10%) in the No PIM group (p = 0.725). Conclusions: This analysis did not show statistically significant differences between patients who received a PIM compared to those who received an alternative medication with regard to re-presentation, admission, and ED LOS. ED LOS trended towards being longer in the PIM group.

Background Emergency department visits associated with Coronavirus Disease 2019 (COVID-19) continue to indicate racial and ethnic inequities. We describe the sociodemographic characteristics of individuals receiving COVID-19 vaccination in the emergency department and compare with an outpatient clinic population and emergency department (ED) patients who were eligible but not vaccinated. Methods We conducted a retrospective analysis of electronic health record data at an urban academic ED from May to July 2021. The primary aim was to characterize the ED-vaccinated population, compared with ED patients who were eligible but unvaccinated and the physically adjacent outpatient vaccination clinic population. Results A total of 627 COVID-19 vaccinations were administered in the ED. Overall, 49% of ED patients during that time had already received at least one vaccine dose prior to ED arrival. Hispanic, non-Hispanic Black patients, and patients on non-commercial insurance had higher odds of being vaccinated in the ED as compared with outpatient clinic setting. Among eligible ED patients, men and patients who were uninsured/self-pay were more likely to accept ED vaccination. Conclusions This ED COVID-19 vaccination campaign demonstrated a higher likelihood to vaccinate individuals from racial/ethnic minority groups, those with high social vulnerability, and non-commercial insurance, when compared with a co-located outpatient vaccination clinic.

There is minimal literature to support the appropriate dosing for the initiation of IV regular insulin therapy in DKA patients. A 0.1 unit/kg bolus followed by 0.1 units/kg/hour or 0.14 units/kg/hour is commonly utilized and recommended in guidelines.We sought to assess clinical and safety outcomes associated with various insulin infusion starting doses in patients diagnosed with DKA in the emergency department in an effort to help guide prescribing.A retrospective cohort study was conducted within an academic emergency department and included patients who received continuous infusion regular insulin with an ICD-10 code for DKA between January 2016 and January 2019. A predictive regression model was applied to test if predefined lab values influenced the starting insulin infusion rates. Clinical and safety outcomes were evaluated by starting insulin infusion rate. Data was analyzed based on starting insulin infusion rates.347 patients met inclusion criteria with 92 (26.5%) patients receiving0.07 units/kg/hr, 123 (35.4%) patients receiving 0.07 to 0.099 units/kg/hr, 123 (35.4%) patients receiving 0.10 to 0.139 units/kg/hr, and 9 (2.6%) patients receiving ≥0.14 units/kg/hr. After adjusting for baseline labs, glucose was the only significant predictor of the initial infusion rate (p0.001). For every 100 mg/dL increase in the baseline glucose value, the initial infusion rate increased by 0.005 units/kg/hr. There was no difference between insulin starting infusion rates and length of stay, rates of hypoglycemia, hypokalemia, or dysrhythmias.Glucose levels significantly influenced the insulin starting infusion rate, with no identified differences in adverse effects or clinical outcomes.

Study objectives Older adults who sustain hip fractures are susceptible to high rates of morbidity and mortality. The systemic administration of opioids is associated with side effects disproportionately affecting the elderly. The ultrasound-guided fascia iliaca compartment block procedure (FICB) is associated with a reduced patient need for oral and parenteral opioids and with improved functional outcomes. We designed a multi-disciplinary quality improvement initiative to train emergency physicians (EPs) to perform the ultrasound-guided FICB procedure for geriatric hip fracture patients. We examined the lessons derived from the EPs' resistance to implementing a practice-changing behavior. Methods This study was a prospective observational cohort study. We included all emergency department (ED) patients > 65 years with X-ray confirmation of isolated hip fractures. We also enrolled the treating EPs. Patients were enrolled from March 2016 to January 2017 in an urban, academic ED with 100,000 annual visits. The ED ultrasound faculty trained ED faculty and residents in the FICB procedure. Seventeen of 50 attending EPs completed the training: classroom lecture and online narrated video instruction. The hands-on sessions consisted of three stations: scan a human model volunteer to review the sonoanatomy, practice the needle technique using a Blue PhantomTM Regional Anesthesia Ultrasound Training Block Model (Simulaids, Inc., NY, US), and practice the needle technique using a static simulator. We created a multi-disciplinary geriatric hip fracture order set for the electronic medical record. The attending EPs, caring for eligible patients, were asked to complete a Research Electronic Data Capture (REDCap) survey, and we analyzed the data using descriptive statistics. Results We enrolled 77 geriatric hip fracture patients. Two of the 77 patients received FICB. Thirty-two EPs participated as providers for these patients while 97% of these providers completed the post-intervention survey. Providers used the geriatric hip fracture order set in 10 of 77 encounters. Most EPs did not perform the block because they were not trained or did not feel comfortable performing it. Conclusion Despite the efficacy supported by the literature and training sessions offered, the EPs in this study did not adopt the FICB procedure. Future efforts could include developing a FICB on-call team, increasing the proportion of trained EPs through initial supervised hands-on practice, and partnering financial or education incentives with getting trained.

Patient: Female, 51-year-old Final Diagnosis: Diabetic ketoacidosis Symptoms: Abdominal pain • diarrhea Medication: Pembrolizumab Clinical Procedure: — Specialty: Endocrinology and Metabolic Objective: Unusual or unexpected effect of treatment Background: Immune checkpoint inhibitors (ICIs) are a novel class of antibodies, which have been increasingly utilized in cancer immunotherapies. Pembrolizumab is a humanized IgG4 monoclonal antibody, which acts against programmed cell death (PD)-1 receptors to help restore the body’s T-cell and immune response. Case Report: In this case, we present a 51-year-old woman with a past medical history of lung adenocarcinoma and triple-positive breast cancer who was actively receiving therapy with pembrolizumab. Following her second chemo-therapy cycle, she developed a severe case of diabetic ketoacidosis (DKA), with concern for new-onset auto-immune type 1 diabetes mellitus (T1DM), secondary to her recent ICI therapy. The patient was initiated on a high-dose insulin infusion for rapid glycemic control and was successfully transitioned to a subcutaneous regimen approximately 24 h after presentation. She additionally developed other autoimmune-related complications, including hepatoxicity, duodenitis, and a maculopapular rash, which all resolved upon discontinuation of the ICI treatment. Her laboratory test results were consistent with positive anti-glutamic acid decarboxylase (anti-GAD) antibodies and undetectable c-peptides, illustrating the uniqueness of an ICI potentially precipitating an autoimmune T1DM. Conclusions: Immune-related adverse events from ICI therapy warrant further investigation to acknowledge the risk of potentially life-threatening adverse reactions, such as the development of DKA. Patients receiving ICI therapy should be educated on signs and symptoms of hyperglycemia, and routine measurements of blood glucose levels should be completed during each chemotherapy cycle. Future research in assessing potential biomarkers of beta cell dysfunction, such as anti-GAD antibodies and c-peptides, is of interest, particularly for patients receiving ICI therapies.

Background Acute bacterial skin and skin structure infections (ABSSSIs) are a frequent cause of emergency department (ED) visits. Providers in the ED have many decisions to make during the initial treatment of ABSSSI. There are limited data on the patient factors that influence these provider decisions. Methods An anonymous survey was administered to providers at 6 EDs across the United States. The survey presented patient cases with ABSSSIs ≥75 cm2 and escalating clinical scenarios including relapse, controlled diabetes, and sepsis. For each case, participants were queried on their decision for admission vs discharge and antibiotic therapy (intravenous, oral, or both) and to rank the factors that influenced their antibiotic decision. Results The survey was completed by 130 providers. For simple ABSSSI, the majority of providers chose an oral antibiotic and discharged patients home. The presence of recurrence or controlled diabetes resulted in more variation in responses. Thirty-four (40%) and 51 (60%) providers chose intravenous followed by oral antibiotics and discharged the recurrence and diabetes cases, respectively. Presentation with sepsis resulted in initiation with intravenous antibiotics (122, 95.3%) and admission (125, 96.1%) in most responses. Conclusions Variability in responses to certain patient scenarios suggests opportunities for education of providers in the ED and the development of an ABSSSI clinical pathway to help guide treatment.

Purpose Barriers to and clinical implications of patient nonadherence to filling discharge medication prescriptions from the emergency department (ED) were evaluated. Methods This was a retrospective, observational analysis of patients discharged from the ED from April 2013 through May 2015 with medication prescriptions. Patients age 18–89 years who were seen in the ED and did not retrieve discharge medication prescriptions from the onsite, 24-hour ED discharge pharmacy were included in this study. Patients who did not pick up prescriptions were called and asked about barriers to prescription filling. These charts were then retrospectively reviewed and categorized. The primary study outcome was the frequency of nonadherence to filling discharge medications prescribed during the ED visit at the ED outpatient pharmacy. Secondary outcomes included identifying barriers to medication adherence, the rate of return ED visits within 30 days of ED discharge, and the rate of 30-day hospital admissions. Associations between patient and medication variables and the rates of return ED visits within 30 days of discharge and 30-day hospital admissions were analyzed. Results Of the 4,444 patients discharged from the ED with a prescription to be filled at the satellite pharmacy, 510 were nonadherent. Of these patients, 505 had complete chart information available for evaluation. A large proportion of nonadherent patients revisited the ED within 30 days of ED discharge. Multivariate logistic regression found payer class, ethnicity, and sex were independently associated with return ED visits. Conclusion The majority of patients who received a prescription during an ED visit filled their discharge medications. Sex, ethnicity, and payer class were independently associated with nonadherence.

Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.

Background Appropriate application of antimicrobial PK/PD properties is crucial to optimizing patient outcomes. Although β-lactams are among the most utilized and effective antibiotics, optimal dosing strategies in obese populations are largely unknown. The objective of this study was to compare PK/PD of CPM in non-obese (NO, weight 80–100 kg) and obese (O, weight > 100 kg) patients. Methods A prospective comparative PK/PD analysis was conducted in NO and O patients receiving CPM. Blood samples were obtained at 30, 60, 120, 240, 360, and 480 minutes after CPM infusion. CPM concentrations were determined by reversed-phase high-performance liquid chromatography. Non-compartmental PK analyses were performed, followed by Monte Carlo simulations (Oracle Crystal Ball®, 5,000 simulated patients) to estimate probability of target attainment (PTA) against common Gram-negative pathogens. The desired PD target for CPM was % time above MIC of unbound drug (%fT > MIC) ≥ 60%. Chi-squared and Mann–Whitney U tests were used for analysis. Results Seventeen patients were enrolled and most (94%) received CPM 2 g q8h. A significant difference in actual body weight and body mass index was observed (P < 0.001). There were no differences in other baseline or PK characteristics between the two groups. Utilizing CPM 2 g q8h, PTA ≥ 90% was not observed for organisms with an MIC of 8 μg/mL, the current CLSI breakpoint for P. aeruginosa and A. baumannii (PTA = 88% vs. 81% in NO and O groups, respectively). With a 6 g continuous infusion (CI), however, ≥ 90% PTA was achieved in both groups (PTA = 100%) for organisms with an MIC of 8 μg/mL, while a regimen of 2 g q8h (infused over 3 hours [EI]) also provided PTA of ≥ 90% in both groups (PTA = 98% vs. 92% in NO and O groups, respectively). Goal PTA was not obtained in either group for organisms with an MIC of 4 μg/mL with CPM 1 g q8h or 2 g q12h (i.e., CLSI recommended dosing for organisms with MICs of 4 μg/mL). Conclusion Optimizing PK/PD parameters through novel dosing strategies are essential in both the NO and O populations for optimal CPM exposure in susceptible pathogens with higher MICs. CPM 6 grams/day by either CI or EI provides more optimal PK/PD characteristics in obese patients for pathogens with MICs at or near the current CLSI-recommended breakpoint. Disclosures All authors: No reported disclosures.

Background Reducing hospital admission and improving transitions of care can lessen the burden of ABSSSIs in EDs and hospitals. Limited research to date has assessed the patient’s preference for ABSSSI treatment. Understanding patient preferences may provide insights that encourage optimal treatment plans and improve satisfaction with their care. Methods A patient survey was conducted across 5 hospital EDs in the US. After providing informed consent, patients with ABSSSI completed a baseline survey assessing their ABSSSI history and preferences for antibiotic (ABX) therapy [intravenous (IV) vs. oral] and treatment location. Patient characteristics and ensuing treatment details were collected from the medical record after the ED or hospitalization was completed. Descriptive statistics were used for analyses. Results Seventy-one patients were enrolled and completed the baseline survey. The mean ± SD age was 50 ± 17 years, 22 (31%) had diabetes, and 47 (66.2%) had a previous ABSSSI. The median (25th-75th quartile) lesion size was 190 (53-613) cm2; 51 (71.8%) presented with cellulitis, an abscess, or both. Fifty-four (76.1%) were admitted to the hospital with a median (25th-75thquartile) length of stay of 4.5 (2-9) days. In the ED, vancomycin (39.4%) and β-lactams (36.6%) were the most common ABX; IV was prescribed in 58/63 (92.1%) patients. Once admitted, 37 (68.5%) and 34 (63%) patients received vancomycin and β-lactams, respectively. When surveyed, 26 (36.6%) patients preferred to receive ABX at home, while 22 (31.0%) chose hospital stay for one or more nights. The most common ABX preference was a single IV dose to complete treatment, selected by 29 (40.8%) patients. The most important ABX factors were efficacy and their doctor’s opinion, then convenience and route of administration; least important were treatment location, adverse events, and cost. Conclusion In these patients presenting to the ED with ABSSSI, the majority were admitted to the hospital and received IV ABX. Patient preferences for treatment location varied, but many valued therapies that could prevent admission. These data suggest opportunities for improving ABSSSI care by engaging the patient and offering treatment alternatives they may not be aware of. Disclosures K. R. Keyloun, Allergan: Employee, Salary. D. P. Nicolau, Allergan: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. J. L. Kuti, Allergan: Grant Investigator, Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium

Background ABSSSI are a frequent cause of emergency room visits. Physicians (PHY) and Advanced Practice Providers (APP) have many decisions to make during the initial treatment of ABSSSI, including intravenous (IV) vs. oral (PO) ABX, and hospital admission vs. discharge home. There are limited data, however, on factors that influence the provider’s decision for the treatment of ABSSSI. Methods An anonymous survey was offered to EM providers at 5 hospitals across the US. The survey presented patient cases with ABSSSI ≥ 75cm2 and escalating clinical scenarios including relapse, controlled diabetes (DM), and SIRS. For each case, participants were queried on their decision for admission vs. discharge, ABX therapy (IV, PO, or both), and to rank factors that influenced their ABX decision. Descriptive and inferential statistics were used for analyses. Results Across the 5 hospitals, 104 providers completed the survey; 59 (56.7%) were PHY and 45 (43.3%) were APP. Experience was evenly represented with 50 (48.1%) providers practicing for ≥5 years and 54 (51.9%) less than 5 years. For the first case with no relapse, DM, or SIRS, most providers selected PO ABX [95 (91.4%)] and discharge [100 (96.2%)]. In case 2, the presence of relapse resulted in PO ABX for 50 (48.1%) and discharge in 54 (51.9%) of responses. In case 3, the presence of controlled DM resulted in PO ABX for 55 (53.4%) and discharge home in 65 (63.1%) of responses. Four (3.8%) and 13 (12.5%) providers chose to give 1–2 IV doses followed by PO and discharge the relapsed and DM cases, respectively. Compared with APP, PHY more frequently prescribed PO ABX for the DM case (62.7% vs. 40.9%, P = 0.046) and incorporated PO ABX into the treatment of the SIRS case (48.3% vs. 22.7%, P = 0.015). The addition of SIRS criteria in case 4 resulted in initiation with IV ABX [97 (95.1%)] and admission [100 (96.2%)]. The highest ranked factors influencing ABX selection were infection severity and co-morbidities; the lowest were patient convenience, adverse events, and cost. Conclusion These data highlight factors influencing EM provider decisions in the treatment of ABSSSI. Variability in responses to patient cases suggests opportunities for education and the development of an ABSSSI clinical pathway to guide treatment. Disclosures K. R. Keyloun, Allergan: Employee, Salary. D. P. Nicolau, Allergan: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. J. L. Kuti, Allergan: Grant Investigator, Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium