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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.

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 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