IntroductionChronic salicylate toxicity is an uncommon, potentially life-threatening poisoning that requires high clinical suspicion in order to make the diagnosis. We created a simulation case that challenges learners to analyze case information, construct a differential diagnosis of an elevated anion gap metabolic acidosis with respiratory alkalosis, and initiate treatment for this toxicity.MethodsThe simulation case was designed for emergency medicine residents and pediatric emergency medicine fellows. The activity began with a brief overview of the monitors, equipment, and simulation experience. For interns, a team of two learners comanaged the case; for senior learners, the case was managed solo. The learners had 15 minutes to complete a focused history and physical exam, request and interpret labs and studies, and initiate specific treatments. The simulation was followed by a 15-minute facilitated debrief session that included an overview of key learning points and learner performance based on an evaluation checklist.ResultsResidents completed a postparticipation questionnaire consisting of six questions rated on a 5-point Likert scale. Overall, residents reported a high degree of satisfaction with the simulation experience. The case and debrief were effective in meeting the educational objectives and proved to be an effective modality to fill this educational gap.DiscussionThis simulation exercise was effective in showing residents the uncommon presentation of chronic salicylate toxicity. Learners reported increased confidence in recognizing and managing this ingestion. The simulation experience closed an identified education gap and provided an experiential learning opportunity that accomplished the targeted learning objectives.
Objective: The objective of this study is to examine the patterns of snakebite injury in pediatric patients that require antivenom therapy and to evaluate whether and when sex group differences exist.Methods: We performed a nationwide, multicenter, retrospective evaluation of 24 regional poison centers from 2002 and through 2004 of data for antivenom therapy for Crotaline snakebites. Data points abstracted included the age of the victim, sex of the victim, and location of bite. We calculated contingency tables of the data with statistical significance by Fisher's exact test.Results: We evaluated 204 records that involved pediatric patients; 3 of the patients had no recorded age. In 16 of the records, the bite location was not documented (2 children and 1 unknown age) or was listed as head/neck (1 child). These records were not included in the data analysis. There were bites in 136 males and 65 females. Males were more likely than females to suffer an injury to the upper extremity (56.6% vs. 26.2%; p Ͻ 0.01). Males were more likely to suffer injuries to the upper extremity in all age groups (p Ͻ 0.05) except for the group aged 10 through 12 years; in the group aged 10 through 12, we did not see significant differences between the sexes (p ϭ 0.729). Males are more likely to suffer an upper extremity bite with increasing age (p ϭ 0.029), while females showed no significant change in the location of bites (p ϭ 0.223).Conclusion: Male children were more likely than female children to suffer Crotaline snakebites that required antivenom therapy. In this population, significant differences between locations of snakebites were found. Males were more likely than females to be bitten in the upper extremities. This difference appears as early as 1 to 4 years of age.
Intravenous injection of poison hemlock alkaloids can result in significant toxicity, including cardiopulmonary arrest, prolonged weakness, and encephalopathy.
BackgroundAntibiotic treatment of asymptomatic bacteriuria (AB) provides no benefit and can lead to negative outcomes. The impact of asymptomatic pyuria (AP) on antibiotic use is not well characterized, nor is the impact of treating AB/AP in the emergency department (ED). The purpose of this study was to determine whether a multi-faceted stewardship initiative decreased unnecessary antibiotic treatment of AB/AP in the ED of an 885-bed academic medical center.MethodsBeginning in Dec 2015, a series of interventions were implemented, including inservices, pocket cards, electronic order entry alerts, and elimination of reflex urine cultures for abnormal urinalyses. Patients discharged from the ED in Aug-Oct 2015 (pre-intervention group) and Dec 2016-Feb 2017 (post-intervention group) were consecutively screened retrospectively. Asymptomatic patients ≥18 yrs old with ≥105 CFU/mL organisms on urine culture or >12 WBC/hpf on urinalysis were included. Patients with pregnancy, separate infection requiring antibiotics, immunocompromised state, paraplegia, neurogenic bladder, or altered genitourinary anatomy were excluded. The primary outcome was the proportion of patients with AB and/or AP prescribed antibiotics within 72 hours of ED discharge. Secondary outcomes were the number of urine cultures ordered in the ED and the number of patients returning to the ED with symptomatic urinary tract infection (UTI) within 30 days. 32 patients in each group were required to achieve 80% power, assuming 30% difference in primary outcome.Results74 patients met study criteria (37 in each group). 52 patients (70%) had AP without AB. Antibiotic treatment and the number of urine cultures ordered decreased significantly in the post group. Outcome Pre Post P Value Patients treated for AB and/or AP37/37 (100%)12/27 (32%)<0.001Patients treated for AP without AB25/25 (100%)6/27 (22%)<0.001Urine cultures ordered per 1,000 ED discharges66.337.90.004Patients returning to ED within 30 days3/374/37NSConclusionA multi-faceted stewardship initiative significantly decreased treatment of AB/AP in the ED. AP appears to contribute significantly to unnecessary antibiotic use in the ED and would be a valid target for stewardship initiatives.Disclosures All authors: No reported disclosures.
Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Culture response programs are an important antimicrobial stewardship strategy in the emergency department. Pharmacists often have a key role in culture response but are most often dependent on other providers to optimize a patient’s antimicrobial therapy. This study assessed the impact of advanced practice pharmacists, with independent prescribing authority, on an emergency department culture response program. Methods This was a quasi-experimental preimplementation vs postimplementation evaluation performed at an academic medical center, with a 91-bed adult and pediatric emergency department, during the transition from a nurse-driven to an advanced practice pharmacist–driven program. The primary endpoint was time elapsed between initial culture review and intervention. Results Data on 200 interventions were collected from both the pre- and postimplementation phases. Median time from culture review to intervention was 5.26 hours (interquartile range [IQR], 21.39 hours) before implementation, compared to 2.95 hours (IQR, 4.7) after implementation (P < 0.001). The nurse-driven program intervened on 27% of positive cultures, while pharmacists intervened on 42% of positive cultures. The types of interventions performed and antibiotic prescribing patterns differed between the 2 study phases, but all choices were deemed appropriate by the criteria set for the purposes of this study. Conclusion The roles of advanced practice pharmacists allowed for the establishment of a streamlined culture response workflow. Culture responses occurred at a faster rate than with the previous nurse-driven program while maintaining high-quality clinical decision-making.
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