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Acquisto NM, Slocum GW, Bilhimer MH, Awad NI, Justice SB, Kelly GF, Makhoul T, Patanwala AE, Peksa GD, Porter B, Truoccolo DMS, Treu CN, Weant KA, Thomas MC. Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update. Am J Health Syst Pharm 2021; 77:1284-1335. [PMID: 32766731 DOI: 10.1093/ajhp/zxaa178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | | | - Nadia I Awad
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Gregory F Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Therese Makhoul
- Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, CA
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT
| | | | - Cierra N Treu
- Department of Pharmacy, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY
| | - Kyle A Weant
- Medical University of South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Michael C Thomas
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
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Netley J, Armstrong W, Meeks S. Implementation of order sets for opioid alternatives in community hospital emergency departments. Am J Health Syst Pharm 2021; 77:1258-1264. [PMID: 32601689 DOI: 10.1093/ajhp/zxaa166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The design and implementation of alternatives to opioids (ALTO) order sets for the treatment of acute pain in a community health system's emergency departments are described. SUMMARY Healthcare institutions nationwide have incorporated policies and procedures to assist prescribers in the safe and effective management of pain. These adopted approaches may be targeted at mitigating opioid prescribing as well as promoting the optimization of nonopioid analgesics. Institutions that enact innovations and track outcomes may be eligible for reimbursement through the Centers for Medicare and Medicaid Services' Merit-based Incentive Payment System. Emergency departments may monitor implementation progress and outcomes through participation in the American College of Emergency Physician's Emergency Quality Network. Clinical pharmacists were tasked with assisting an institution's emergency departments to create and implement two order sets containing ALTO analgesics and supportive medications for atraumatic headache and general acute pain management. Key steps of order set implementation included collaborative development with emergency department providers, implementation with information services, and the development of provider-focused education by project pharmacists. The implementation of ALTO order sets has set the foundation for expansion of pain control protocols and algorithms within our institution. Furthermore, the approach detailed in this article can be adapted and implemented by other healthcare systems to help reduce opioid prescribing. CONCLUSION The implementation of ALTO order sets within an electronic health record can encourage decreased prescribing of opioids for the treatment of acute pain, promote and optimize dosing of nonopioid analgesics, and may augment reimbursement for services in the emergency department.
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Affiliation(s)
- Jared Netley
- Department of Pharmacy, Parkview Health, Fort Wayne, IN
| | | | - Sarah Meeks
- Department of Pharmacy, Parkview Health, Fort Wayne, IN
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The analgesic effect of ketorolac addition for renal colic pain: A meta-analysis of randomized controlled studies. Am J Emerg Med 2020; 43:12-16. [PMID: 33476916 DOI: 10.1016/j.ajem.2020.12.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The effect of ketorolac addition for the pain control of renal colic remains controversial. We conduct a systematic review and meta-analysis to explore the analgesic efficacy of ketorolac addition for renal colic. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2020 for randomized controlled trials (RCTs) assessing the analgesic efficacy of ketorolac addition for renal colic. This meta-analysis is performed using the random-effect model. RESULTS Four RCTs are included in the meta-analysis. In patients with renal colic pain, ketorolac addition is associated with significantly lower pain scores at 10-20 min (SMD=-2.50; 95% CI=-4.31 to -0.68; P=0.007) and analgesic rescue (RR=0.68; 95% CI=0.52 to 0.89; P=0.006), but reveals no notable effect on nausea (RR=0.36; 95% CI=0.12 to 1.12; P=0.08), vomiting (RR=0.50; 95% CI=0.13 to 1.95; P=0.31), or dizziness (RR=0.68; 95% CI=0.05 to 0.60; P=0.007). CONCLUSIONS Ketorolac addition may improve the analgesic efficacy for renal colic pain.
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Minhaj FS, Hoang-Nguyen M, Tenney A, Bragg A, Zhang W, Foster J, Rotoli J, Acquisto NM. Evaluation of opioid requirements in the management of renal colic after guideline implementation in the emergency department. Am J Emerg Med 2019; 38:2564-2569. [PMID: 31932132 DOI: 10.1016/j.ajem.2019.12.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/16/2019] [Accepted: 12/20/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Evaluate opioid prescribing before and after emergency department (ED) renal colic guideline implementation focused on multi-modal pain management. METHODS Retrospective study of ED patients who received analgesia for urolithiasis before and after guideline implementation. The guideline recommends oral acetaminophen, intravenous (IV) ketorolac, and a fluid bolus as first line, IV lidocaine as second line, and opioids as refractory therapy to control pain. Opioid exposure, adverse effects, length of stay (LOS), and ED representation were evaluated. Comparisons were made with univariate analyses. Backwards stepwise binomial multivariate logistic regression to identify factors related to opioid use was performed. RESULTS Overall, 962 patients were included (451 pre- and 511 post-implementation). ED and discharge opioid use decreased; 65% vs. 58% and 71% vs. 63% in pre- and post-implementation groups, respectively. More post-implementation patients received non-opioid analgesia (65% vs. 56%) and non-opioid analgesia prior to opioids (50% vs. 38%). A longer ED LOS and higher initial pain score were associated with ED opioid administration. Guideline implementation, receiving non-opioid therapy first, and first renal colic episode were associated with decreased ED opioid administration. Seventeen adverse events (1.8%) were reported. There was no difference in change in ED pain score between groups, but patients in the post-implementation group were admitted more and had a higher 7-day ED representation (11% vs. 7%). CONCLUSIONS A multimodal analgesia protocol for renal colic was associated with decreased opioid prescribing, higher rates of admission to the hospital, and a higher 7-day ED representation rate.
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Affiliation(s)
- Faisal Syed Minhaj
- Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave., Box 638, Rochester, NY 14642, United States of America.
| | - Mercy Hoang-Nguyen
- Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave., Box 638, Rochester, NY 14642, United States of America
| | - Austin Tenney
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States of America
| | - Andrew Bragg
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States of America
| | - Wen Zhang
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States of America
| | - Justin Foster
- Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave., Box 638, Rochester, NY 14642, United States of America
| | - Jason Rotoli
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States of America
| | - Nicole M Acquisto
- Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave., Box 638, Rochester, NY 14642, United States of America; Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States of America
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Kidney stones and the opioid epidemic: recent developments and review of the literature. Curr Opin Urol 2019; 30:159-165. [PMID: 31834080 DOI: 10.1097/mou.0000000000000705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW A public health emergency has been declared in response to rising opioid addiction and opioid-related deaths in the United States. As kidney stones have been identified as an important source of initial and repeated opioid exposures, this review seeks to describe the scope of the problem and report relevant alternatives to opioid analgesia for stones. RECENT FINDINGS Recent literature summarizing the extent of opioid use among those with stones is reviewed. A number of opioid-minimizing strategies and analgesic regimens have been proposed and studied. A review of these modifications and alternatives is provided. SUMMARY Both symptomatic renal colic and surgical interventions to address stones may prompt need for analgesia. Reducing prescribed opioids reduces both patient use and risk of diversion. Modifications in surgical technique, administration of local anesthetics, and use of systemic nonopioid analgesics have all been successfully employed.
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