Effectiveness of a bivalent mRNA vaccine dose against symptomatic SARS-CoV-2 infection among U.S. Healthcare personnel, September 2022-May 2023

BACKGROUND

Bivalent mRNA vaccines were recommended since September 2022. However, coverage with a recent vaccine dose has been limited, and there are few robust estimates of bivalent VE against symptomatic SARS-CoV-2 infection (COVID-19). We estimated VE of a bivalent mRNA vaccine dose against COVID-19 among eligible U.S. healthcare personnel who had previously received monovalent mRNA vaccine doses.

METHODS

We conducted a case-control study in 22 U.S. states, and enrolled healthcare personnel with COVID-19 (case-participants) or without COVID-19 (control-participants) during September 2022-May 2023. Participants were considered eligible for a bivalent mRNA dose if they had received 2-4 monovalent (ancestral-strain) mRNA vaccine doses, and were ≥67 days after the most recent vaccine dose. We estimated VE of a bivalent mRNA dose using conditional logistic regression, accounting for matching by region and four-week calendar period. We adjusted estimates for age group, sex, race and ethnicity, educational level, underlying health conditions, community COVID-19 exposure, prior SARS-CoV-2 infection, and days since the last monovalent mRNA dose.

RESULTS

Among 3,647 healthcare personnel, 1,528 were included as case-participants and 2,119 as control-participants. Participants received their last monovalent mRNA dose a median of 404 days previously; 1,234 (33.8%) also received a bivalent mRNA dose a median of 93 days previously. Overall, VE of a bivalent dose was 34.1% (95% CI, 22.6%-43.9%) against COVID-19 and was similar by product, days since last monovalent dose, number of prior doses, age group, and presence of underlying health conditions. However, VE declined from 54.8% (95% CI, 40.7%-65.6%) after 7-59 days to 21.6% (95% CI 5.6%-34.9%) after ≥60 days.

CONCLUSIONS

Bivalent mRNA COVID-19 vaccines initially conferred approximately 55% protection against COVID-19 among U.S. healthcare personnel. However, protection waned after two months. These findings indicate moderate initial protection against symptomatic SARS-CoV-2 infection by remaining up-to-date with COVID-19 vaccines.

Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial

BACKGROUND

Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP.

METHODS

This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat.

DISCUSSION

The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.

Effectiveness of a Messenger RNA Vaccine Booster Dose Against Coronavirus Disease 2019 Among US Healthcare Personnel, October 2021-July 2022

Background

Protection against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) can limit transmission and the risk of post-COVID conditions, and is particularly important among healthcare personnel. However, lower vaccine effectiveness (VE) has been reported since predominance of the Omicron SARS-CoV-2 variant.

Methods

We evaluated the VE of a monovalent messenger RNA (mRNA) booster dose against COVID-19 from October 2021 to June 2022 among US healthcare personnel. After matching case-participants with COVID-19 to control-participants by 2-week period and site, we used conditional logistic regression to estimate the VE of a booster dose compared with completing only 2 mRNA doses >150 days previously, adjusted for multiple covariates.

Results

Among 3279 case-participants and 3998 control-participants who had completed 2 mRNA doses, we estimated that the VE of a booster dose against COVID-19 declined from 86% (95% confidence interval, 81%-90%) during Delta predominance to 65% (58%-70%) during Omicron predominance. During Omicron predominance, VE declined from 73% (95% confidence interval, 67%-79%) 14-60 days after the booster dose, to 32% (4%-52%) ≥120 days after a booster dose. We found that VE was similar by age group, presence of underlying health conditions, and pregnancy status on the test date, as well as among immunocompromised participants.

Conclusions

A booster dose conferred substantial protection against COVID-19 among healthcare personnel. However, VE was lower during Omicron predominance, and waning effectiveness was observed 4 months after booster dose receipt during this period. Our findings support recommendations to stay up to date on recommended doses of COVID-19 vaccines for all those eligible.

Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort

OBJECTIVE

To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days.

SUMMARY BACKGROUND DATA

The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes.

METHODS

We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations.

RESULTS

The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret.

CONCLUSIONS

Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02800785.

UpdatED: The emergency medicine pharmacotherapy literature of 2022

The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2022. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors, with disagreements adjudicated by a third author. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 4 guidelines, and 3 meta-analyses covering topics including anticoagulant reversal, tenecteplase in acute ischemic stroke, guideline updates for heart failure and aortic aneurysm, magnesium in atrial fibrillation, sedation in mechanically ventilated patients and pain management strategies in the Emergency Department (ED), and tranexamic acid use in epistaxis and GI bleed.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study

STUDY OBJECTIVE

To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs).

METHODS

Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence.

RESULTS

A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86).

CONCLUSION

Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study

OBJECTIVES

In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.

DESIGN

An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.

SETTING

The ED of three academic medical centers.

PATIENTS

Mechanically ventilated adult patients that received neuromuscular blockers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).

CONCLUSIONS

AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Opioid and benzodiazepine use in the emergency department and the recognition of delirium within the first 24 hours of hospitalization

OBJECTIVE

Delirium is a common and serious brain dysfunction. The objective of our study was to test the hypothesis that opioids and benzodiazepines exposure in the emergency department (ED) is associated with delirium.

METHODS

This was a retrospective cohort study, including patients aged 65 years and older who were hospitalized from ED at an academic medical center from 2014 to 2017. Medication administration records were used to identify opioids and benzodiazepines given during the ED stay. Nurses used the Delirium Observation Screening Scale (DOSS) twice daily to assess delirium during hospitalization. The outcome was a positive DOSS within 1 day of ED encounter. We used logistic regression to predict the outcome of positive delirium screening by opioids and benzodiazepines.

RESULTS

A total of 7927 ED encounters that resulted in hospitalization were included in the analysis. We identified 2008 visits (25.3%) with a positive delirium screen. A total of 3304 (41.7%) received opioids, and 1801 (22.7%) received benzodiazepines. In this cohort, opioids were not associated with an increased odds of delirium (OR 1.00, 95% CI 0.87-1.15). Benzodiazepines were associated with increased odds of delirium (OR 1.37, 95% CI 1.13-1.65), as were benzodiazepines combined with opioids (OR 1.61, 95% CI 1.33-1.97).

CONCLUSION

In this study, the use of benzodiazepines was associated with a risk of delirium. The use of opioids did not increase the risk of delirium. Our findings imply that judicious pain management with opioids in the ED might not increase the risk of delirium.

Transfer boarding delays care more in low-volume rural emergency departments: A cohort study

PURPOSE

Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals.

METHODS

A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas.

FINDINGS

A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs.

CONCLUSIONS

Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.

Effectiveness of mRNA Covid-19 Vaccine among U.S. Health Care Personnel

BACKGROUND

The prioritization of U.S. health care personnel for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (Covid-19), allowed for the evaluation of the effectiveness of these new vaccines in a real-world setting.

METHODS

We conducted a test-negative case-control study involving health care personnel across 25 U.S. states. Cases were defined on the basis of a positive polymerase-chain-reaction (PCR) or antigen-based test for SARS-CoV-2 and at least one Covid-19-like symptom. Controls were defined on the basis of a negative PCR test for SARS-CoV-2, regardless of symptoms, and were matched to cases according to the week of the test date and site. Using conditional logistic regression with adjustment for age, race and ethnic group, underlying conditions, and exposures to persons with Covid-19, we estimated vaccine effectiveness for partial vaccination (assessed 14 days after receipt of the first dose through 6 days after receipt of the second dose) and complete vaccination (assessed ≥7 days after receipt of the second dose).

RESULTS

The study included 1482 case participants and 3449 control participants. Vaccine effectiveness for partial vaccination was 77.6% (95% confidence interval [CI], 70.9 to 82.7) with the BNT162b2 vaccine (Pfizer-BioNTech) and 88.9% (95% CI, 78.7 to 94.2) with the mRNA-1273 vaccine (Moderna); for complete vaccination, vaccine effectiveness was 88.8% (95% CI, 84.6 to 91.8) and 96.3% (95% CI, 91.3 to 98.4), respectively. Vaccine effectiveness was similar in subgroups defined according to age (<50 years or ≥50 years), race and ethnic group, presence of underlying conditions, and level of patient contact. Estimates of vaccine effectiveness were lower during weeks 9 through 14 than during weeks 3 through 8 after receipt of the second dose, but confidence intervals overlapped widely.

CONCLUSIONS

The BNT162b2 and mRNA-1273 vaccines were highly effective under real-world conditions in preventing symptomatic Covid-19 in health care personnel, including those at risk for severe Covid-19 and those in racial and ethnic groups that have been disproportionately affected by the pandemic. (Funded by the Centers for Disease Control and Prevention.).

1426. Empiric Antimicrobial Prescribing for Urinary Tract Infections in Patients Discharged from the Emergency Department

Background

Urinary tract infections (UTIs) are commonly treated infections in the emergency department (ED), accounting for 3 million visits annually and 15% of outpatient antibiotic prescriptions. The purpose of this study was to characterize empiric and definitive antimicrobial therapy for treatment of UTIs in a nationally representative sample of ED patients.

Methods

This was a multicenter, retrospective cohort study utilizing the Emergency Medicine PHARMacy Research NETwork (EMPHARM-NET), a network of 15 geographically diverse EDs. Patients ≥18 years presenting to and discharged home from the ED with primary diagnosis code of cystitis, pyelonephritis, or UTI from 2018-2020 were included. We describe empiric intravenous (IV) and oral antibiotics used for the treatment of UTI in patients seen and discharged from the ED.

Results

Of the 3779 ED patients treated for UTI, most were discharged from the ED (n=2483, 66%). Most patients were female (76.3%) and common comorbidities were hypertension (47.8%) and diabetes (26.5%). Most patients had uncomplicated (39.4%) or complicated (40.9%) cystitis. 1134 (45.6%) had a positive urine culture, most commonly E. coli (63%) and K. pneumoniae (13%). The most common antibiotics administered in the ED were ceftriaxone (19.7%), nitrofurantoin (6.2%), cephalexin (5.8%), and sulfamethoxazole/trimethoprim (SMX/TMP, 4.8%). The most common antibiotics prescribed at discharge where cephalexin (33.9%), nitrofurantoin (20.6%), SMX/TMP (12%), ciprofloxacin (8.2%), and cefdinir (8%). The mean length of treatment was 7.1 days (standard deviation 2.5 days). Overall, 454 patients returned to the ED within 30 days. The odds of returning to the ED within 30 days was higher in those that did not have appropriate empiric antibiotics based on susceptibilities (OR 1.37, 95% confidence interval 1.06, 1.78).

Conclusion

This multicenter, retrospective cohort study describes ED patients discharged from the ED after UTI diagnosis. Patients presented most commonly for cystitis. Nearly half of discharged patients were culture positive. Antimicrobial selection varied; IV ceftriaxone and oral cephalexin were most commonly empirically utilized to treated patients with UTI. Inappropriate antimicrobial selection increased odds of a return ED visit within 30 days.

Disclosures

Megan A. Rech, PharmD, MS, BCCCP, FCCM, Spero (Research Grant or Support) Brett Faine, PharmD, Spero Therapeutics (Research Grant or Support) David A. Talan, MD, AbbVie (Consultant)GSK (Consultant)SPERO Therapeutics (Grant/Research Support)

1419. High Prevalence of Fluoroquinolone-Resistant Urinary Tract Infection Among US Emergency Department Patients Diagnosed with UTI, 2018-2020

Background

Uropathogen resistance, Fluoroquinolone-resistance (FQR) and Extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. We sought to determine recent resistance prevalence from a geographically diverse sample of US Emergency Departments (ED).

Methods

We conducted a multi-center, observational cohort study utilizing a network of 15 geographically diverse US EDs. Patients ≥ 18 years of age with the primary international classification of diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or urinary tract infection (UTI) and were discharged home from the ED from 2018-2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with fluoroquinolone (FQ)-resistant Escherichia coli.

Results

Among 3,779 patients who met inclusion criteria, median age was 62.9 years (IQR: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (40.9%) and uncomplicated cystitis (39.4%). Six hundred and forty-five (17%) patients reported receiving antimicrobials in the previous 90-days. E. coli was the most common pathogen (62.9%), followed by Klebsiella pneumoniae (13%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 4.4%, ranging from 2.3% to 8.6% by site. Previous IV or oral antimicrobial use in the last 90-days and complicated vs. uncomplicated UTI were associated with FQ-resistant E. coli (OR 1.69, 95% CI: 1.33-2.14, and OR 1.60, 95% CI: 1.26-2.02, respectively). Of the most prescribed oral antibiotics upon patients discharged from the ED, E. coli resistance to nitrofurantoin and cephalexin was 1.8% and 0.9%, respectively.

Conclusion

FQ-resistant E. coli is widely prevalent and ESBL-mediated resistance appears to be emerging across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments.

Disclosures

Brett Faine, PharmD, Spero Therapeutics (Research Grant or Support) Megan A. Rech, PharmD, MS, BCCCP, FCCM, Spero (Research Grant or Support) David A. Talan, MD, AbbVie (Consultant)GSK (Consultant)SPERO Therapeutics (Grant/Research Support)

Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.

The "double eights mask brace" improves the fit and protection of a basic surgical mask amidst COVID-19 pandemic

STUDY OBJECTIVE

The COVID-19 pandemic has resulted in widespread shortages of personal protective equipment, including N95 respirators. Although basic surgical facemasks are more commonly available, their efficacy is limited due primarily to their poor face seal. This pilot study examined the impact of a rubber band mask brace on a basic surgical mask, as determined by quantitative fit testing.

METHODS

Subjects wearing a basic surgical facemask and the rubber band mask brace underwent quantitative fit testing using machinery designed to certify N95 mask fit. Subjects were tested with the brace anchored behind their ears, with a paperclip behind the head, and on the side knobs of their face shields. The primary outcome measure was whether the subject passed the quantitative fit test at or above the Occupational Safety and Health Administration (OSHA)-verified standard for N95 masks.

RESULTS

Subjects (n = 11) were 54.5% female, with a median height of 70 inches (interquartile range [IQR] = 68-74), weight of 170 pounds (IQR = 145-215), and body mass index (BMI) of 24.6 (IQR = 22.2-27.2), and encompassing 5 distinct N95 mask fit types. We found that 45%, 100%, and 100% of subjects passed the quantitative fit test when the brace was anchored behind the ears, with a paperclip and on a face shield, respectively.

CONCLUSION

Of the 11 subjects included in the analysis, across a range of body habitus and N95 mask fit types, all passed the quantitative fit test when the mask brace was anchored on either face shield or with a paperclip. This data suggests that although the brace does not create an N95 equivalent in terms of filtration, it would offer improved protection from airborne viruses when worn with a basic surgical mask.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study)

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

1675. Epidemiology of Urinary Tract Infections in the United States, 2009 - 2018

Background

Urinary tract infections (UTIs) are one of the most common bacterial infections. There is a lack of large epidemiologic studies evaluating the etiologies of UTIs in the United States. This study aimed to determine the prevalence of different UTI-causing organisms and their antimicrobial susceptibility profiles among patients being treated in a hospital setting.

Methods

We used the Premier Healthcare Database. Patients with a primary diagnosis code of cystitis, pyelonephritis, or urinary tract infection and had a urine culture from 2009- 2018 were included in the study. Both inpatients and patients who were only treated in the emergency department (ED) were included. We calculated descriptive statistics for uropathogens and their susceptibilities. Multi-drug-resistant pathogens are defined as pathogens resistant to 3 or more antibiotics. Resistance patterns are also described for specific drug classes, like resistance to fluoroquinolones. We also evaluated antibiotic use in this patient population and how antibiotic use varied during the hospitalization.

Results

There were 640,285 individuals who met the inclusion criteria. Females make up 82% of the study population and 45% were age 65 or older. The most common uropathogen was Escherichia Coli (64.9%) followed by Klebsiella pneumoniae (8.3%), and Proteus mirabilis (5.7%). 22.2% of patients were infected with a multi-drug-resistant pathogen. We found that E. Coli was multi-drug resistant 23.8% of the time; Klebsiella pneumoniae was multi-drug resistant 7.4%; and Proteus mirabilis was multi-drug resistant 2.8%. The most common antibiotics prescribed were ceftriaxone, levofloxacin, and ciprofloxacin. Among patients that were prescribed ceftriaxone, 31.7% of them switched to a different antibiotic during their hospitalization. Patients that were prescribed levofloxacin and ciprofloxacin switched to a different antibiotic 42.8% and 41.5% of the time, respectively.

Conclusion

E. Coli showed significant multidrug resistance in this population of UTI patients that were hospitalized or treated within the ED, and antibiotic switching is common.

Disclosures

All Authors: No reported disclosures

Emergent Warfarin Reversal With Fixed-Dose 4-Factor Prothrombin Complex Concentrate

BACKGROUND

Four-factor prothrombin complex concentrate (4FPCC) is used for emergent warfarin reversal, but dosing remains controversial. Following approval, further studies have evaluated a variety of fixed-dose regimens. The studies utilized lower doses as compared with package insert dosing and provided data in regard to efficacy, safety, and cost savings. Further data are needed, however, to determine which fixed-dose regimen provides optimal efficacy and safety for emergent warfarin reversal.

OBJECTIVES

The purpose of this study is to evaluate the efficacy, safety, and cost-savings of a fixed-dose 4FPCC protocol.

METHODS

This multicentered, retrospective chart review of adult patients requiring 4FPCC for emergent warfarin reversal utilized a fixed-dose regimen of 1500 units. The 2 primary outcomes were the proportion of patients who achieved a post-4FPCC international normalized ratio (INR) of ≤1.5 and ≤2. Secondary outcomes included thrombotic events within 7 days of 4FPCC administration and survival to discharge. A cost analysis was also performed to identify potential cost savings.

RESULTS

Of the 64 patients included, 44 (68.8%) achieved a post-4FPCC INR ≤1.5, and 61 (95.3%) achieved a post-4FPCC INR ≤2.0. No thrombotic events were reported; 55 (85.9%) patients survived to hospital discharge. More than $1000 was saved per patient via utilization of the fixed-dose protocol.

CONCLUSION AND RELEVANCE

A fixed-dose of 1500 units of 4FPCC successfully achieved a target INR of ≤1.5 in the majority of patients and resulted in no thrombotic events. This study adds to the data evaluating alternative 4FPCC dosing regimens in comparison to package insert recommended dosing.

Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study

Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

Abstract TP247: Impact of Helicopter Emergency Medical Services Flights on Recombinant Tissue Plasminogen Activator (rtpa) Integrity

Introduction: Inter-hospital transfer of ischemic stroke patients by Helicopter Emergency Medical Services (HEMS) is common in rural states. The administration of recombinant tissue plasminogen activator (rtPA) is often initiated at the outside hospital and continues during HEMS (drip and ship). Due to the unstable nature of rtPA after reconstitution in conjunction with strong, low frequency vibrations present during HEMS, there is potential for the physical integrity and thrombolytic activity of rtPA to be compromised during inter-hospital transfer.

Hypothesis: Air ambulance transfer alters the antigen integrity of rtPA in ischemic stroke patients.

Methods: Prospective cohort study of acute ischemic stroke patients receiving rtPA during air ambulance transfer to a comprehensive stroke center (CSC) (intervention group) compared to patients who presented directly to our CSC Emergency Department (control group). The duration of each flight was recorded to control for degree of exposure. To access the structural integrity and thrombolytic activity of rtPA, small residual samples (<0.5 mL) were taken from each patient’s vial after the infusion was completed. The structural integrity of rtPA antigen was evaluated with a specific rtPA protein ELISA.

Results: Thirteen patients received rtPA and were transferred to our CSC via our air ambulance service. The mean flight time was 30.6±5.5 minutes. The mean concentration of rtPA in the control sample was 1.035±0.42 mg/mL. The mean difference in the concentration of the rtPA in the intervention group compared to the control group was 1.59±1.28 mg/mL.

Conclusions: HEMS transfer appears to increase rtPA antigen concentrations possibly due to degradation. Future analysis will examine whether alteration in integrity of rtPA affects the thrombolytic activity.

Urinary Squamous Epithelial Cells Do Not Accurately Predict Urine Culture Contamination, but May Predict Urinalysis Performance in Predicting Bacteriuria

OBJECTIVES

The presence of squamous epithelial cells (SECs) has been advocated to identify urinary contamination despite a paucity of evidence supporting this practice. We sought to determine the value of using quantitative SECs as a predictor of urinalysis contamination.

METHODS

Retrospective cross-sectional study of adults (≥18 years old) presenting to a tertiary academic medical center who had urinalysis with microscopy and urine culture performed. Patients with missing or implausible demographic data were excluded (2.5% of total sample). The primary analysis aimed to determine an SEC threshold that predicted urine culture contamination using receiver operating characteristics (ROC) curve analysis. The a priori secondary analysis explored how demographic variables (age, sex, body mass index) may modify the SEC test performance and whether SECs impacted traditional urinalysis indicators of bacteriuria.

RESULTS

A total of 19,328 records were included. ROC curve analysis demonstrated that SEC count was a poor predictor of urine culture contamination (area under the ROC curve = 0.680, 95% confidence interval [CI] = 0.671 to 0.689). In secondary analysis, the positive likelihood ratio (LR+) of predicting bacteriuria via urinalysis among noncontaminated specimens was 4.98 (95% CI = 4.59 to 5.40) in the absence of SECs, but the LR+ fell to 2.35 (95% CI = 2.17 to 2.54) for samples with more than 8 SECs/low-powered field (lpf). In an independent validation cohort, urinalysis samples with fewer than 8 SECs/lpf predicted bacteriuria better (sensitivity = 75%, specificity = 84%) than samples with more than 8 SECs/lpf (sensitivity = 86%, specificity = 70%; diagnostic odds ratio = 17.5 [14.9 to 20.7] vs. 8.7 [7.3 to 10.5]).

CONCLUSIONS

Squamous epithelial cells are a poor predictor of urine culture contamination, but may predict poor predictive performance of traditional urinalysis measures.

Discordance Between Patient and Clinician Experiences and Priorities in Rural Interhospital Transfer: A Mixed Methods Study

PURPOSE

Rural emergency department (ED) patients require interhospital transfer for definitive care at nearly 6 times the national rate, yet transfer decision-making is variable. The goal of this study was to understand patient experiences, preferences, and decision-making in the rural interhospital transfer process, and to measure the concordance between patient opinions and provider perceptions.

METHODS

Ours is a mixed methods study of patients transferred to a 711-bed Midwestern academic medical center and the emergency physicians in community hospitals. Qualitative interviews were conducted by a single research assistant with admitted patients transferred from an ED, and a corresponding survey was distributed to community emergency physicians. Standardized scenarios were posed to both groups to understand transfer priorities.

FINDINGS

Seventy-nine patients and 40 physicians participated in this study. Patients and physicians cited proximity to home, medical expertise, a personal relationship with a health care provider, health insurance, privacy concerns, and patient choice as the primary factors that influenced patient transfer priorities. Compared with patient respondents, physicians overestimated the patient-perceived importance of proximity to home (P = .015) and being cared for by a personal physician (P = .049), but they underestimated the value of receiving treatment in a comprehensive medical center (P = .002). In standardized scenarios, physicians agreed with patients in transfer preferences for conditions requiring neurosurgical consultation, but they underestimated patients' desire for transfer for pneumonia requiring mechanical ventilation.

CONCLUSION

Patients and physicians recognize similar factors that influence patient preferences in interhospital ED transfer, but physicians may overestimate the value of nonmedical influences on decision-making priorities.

Importance of Decision Support Implementation in Emergency Department Vancomycin Dosing

Introduction

The emergency department (ED) plays a critical role in the management of life-threatening infection. Prior data suggest that ED vancomycin dosing is frequently inappropriate. The objective is to assess the impact of an electronic medical record (EMR) intervention designed to improve vancomycin dosing accuracy, on vancomycin dosing and clinical outcomes in critically ill ED patients.

Methods

Retrospective before-after cohort study of all patients (n=278) treated with vancomycin in a 60,000-visit Midwestern academic ED (March 2008 and April 2011) and admitted to an intensive care unit. The primary outcome was the proportion of vancomycin doses defined as “appropriate” based on recorded actual body weight. We also evaluated secondary outcomes of mortality and length of stay.

Results

The EMR dose calculation tool was associated with an increase in mean vancomycin dose ([14.1±5.0] vs. [16.5±5.7] mg/kg, p<0.001) and a 10.3% absolute improvement in first-dose appropriateness (34.3% vs. 24.0%, p=0.07). After controlling for age, gender, methicillin-resistant staphylococcus aureus infection, and Acute Physiology and Chronic Health Evaluation II score, 28-day in-hospital mortality (odds ratio OR 1.72; 95% CI [0.76–3.88], p=0.12) was not affected.

Conclusion

A computerized decision-support tool is associated with an increase in mean vancomycin dose in critically ill ED patients, but not with a statistically significant increase in therapeutic vancomycin doses. The impact of decision-support tools should be further explored to optimize compliance with accepted antibiotic guidelines and to potentially affect clinical outcome.

Achieving regionalization through rural interhospital transfer

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.

Prehospital oral chlorhexidine does not reduce the rate of ventilator-associated pneumonia among critically ill trauma patients: A prospective concurrent-control study

PURPOSE

The purpose of the study was to test the hypothesis that prehospital oral chlorhexidine administered to intubated trauma patients will decrease the Clinical Pulmonary Infection Score (CPIS) during the first 2 days of hospitalization.

MATERIALS AND METHODS

Prospective interventional concurrent-control study of all intubated adult trauma patients transported by air ambulance to a 711-bed Midwestern academic trauma center over a 1-year period. Patients transported by 2 university-based helicopters were treated with oral chlorhexidine after intubation, and the control group was patients transported by other air transport services.

RESULTS

Sixty-seven patients were enrolled, of which 23 received chlorhexidine (9 patients allocated to the intervention were not treated). The change in CPIS score was no different between the intervention and control groups by intention to treat (1.06- vs 1.40-point reduction, P = .520), and no difference was observed in tracheal colonization (29.0% vs 36.7%, P = .586). No differences were observed in the rate of clinical pneumonia (8.7% vs 8.6%, P = .987) or mortality (P = .196) in the per-protocol chlorhexidine group.

CONCLUSIONS

The prehospital administration of oral chlorhexidine does not reduce the CPIS score over the first 48 hours of admission for intubated trauma patients. Further study should explore other prehospital strategies of reducing complications of critical illness.

News Flash: Old Mother Hubbard Reports the Cupboard is Bare… Time for the FDA to Let Droperidol Out of the (Black) Box

A quick way for a clinical pharmacist to eliminate himself or herself from “employee of the month” consideration is to mention the term medication shortage. Even with training geared toward maximizing resources, the cumulative disappearance of a plethora of medications for the treatment of nausea, vomiting, and/or primary headaches is almost too much for emergency medicine physicians to manage. With prochlorperazine, metoclopramide, promethazine, and ondansetron in increasingly short supply, it is time for the Food and Drug Administration to revisit droperidol's black box warning driven by Q Tc interval prolongation, given its questionable validity, and restore droperidol's place in the armamentarium of emergency medicine physicians.

Treating primary headaches in the ED: can droperidol regain its role?

OBJECTIVE

The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED).

METHODS

A report was generated from a pharmacy database to identify all adult patients who received low-dose droperidol in the ED over a 7-month period; a subsequent retrospective chart review was conducted. Low-dose droperidol was defined as a cumulative dose of ≤2 mg. Patients who received droperidol for any other reason than the treatment of a headache were excluded. Data were analyzed descriptively.

RESULTS

Seventy-three cases in which droperidol was administered for the treatment of a headache were identified over the 7-month period. Most doses (92%) administered were 1.25 mg or less. Fifty-three patients (73%) had complete resolution or significant improvement of headache symptoms as subjectively or objectively (eg, numerical pain scale) documented by the treating physician. Eight patients (11%) had minimal improvement in their headaches symptoms; 12 patients (16%) received no relief after the administration of droperidol. The average time to discharge from the ED was 94.8 ± 67.2 minutes. No cardiac arrhythmias were noted. Other adverse events included 2 cases of extrapyramidal side effects; one patient reported restlessness/anxiousness and the other patient had dystonia.

CONCLUSION

The administration of low-dose (≤2 mg) droperidol may be safe and effective for the treatment of primary headaches in the ED.