Background Studies have documented inconsistent emergency anaphylaxis care and low compliance with published guidelines. Objective To evaluate anaphylaxis management before and after implementation of an emergency department (ED) anaphylaxis order set and introduction of epinephrine auto-injectors and to measure the effect on anaphylaxis guideline adherence. Methods A cohort study was conducted from April 29, 2008-August 9, 2012. Adult ED patients diagnosed with anaphylaxis were included. ED management, disposition, self-injectable epinephrine prescriptions, allergy follow-up and incidence of biphasic reactions were evaluated. Results The study included 202 patients. Median age of patients was 45.3 years (IQR 31.3 – 56.4); 139 (69%) were female. Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs. 33%, OR 2.05, 95%CI 1.04- 4.04) and admitted to ED observation unit (EDOU) (65% vs. 44%, OR 2.38, 95%CI 1.23-4.60) and less likely to be dismissed home directly from ED (16% vs. 29%, OR: 0.47, 95%CI 0.22- 1.00). Eleven patients (5%) had a biphasic reaction. Of these, five (46%) had the biphasic reaction in EDOU; one patient was admitted to intensive care unit (ICU). Six patients (55%) had reactions within 6 hours of initial symptom resolution of whom two were admitted to ICU. Conclusion Significantly greater proportions of anaphylaxis patients received epinephrine and were admitted to EDOU after introduction of epinephrine auto-injectors and order set implementation. Slightly over half of the biphasic reactions occurred within recommended observation time of 4-6 hours. These data suggest that the multifaceted approach to changing anaphylaxis management described here improved guideline adherence.

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for these low frequency but high stakes events. Engagement of all emergency department personnel can be very challenging due to a variety of barriers. This article describes the use of an in situ simulation training model as a component of active shooter education in one emergency department. The educational tool was intentionally developed to be multidisciplinary in planning and involvement, to avoid interference with patient care and to be completed in the true footprint of the work space of the participants. Feedback from the participants was overwhelmingly positive both in terms of added value and avoidance of creating secondary emotional or psychological stress. The specific barriers and methods to overcome implementation are outlined. Although the approach was used in only one department, the approach and lessons learned can be applied to other emergency departments in their planning and preparation. (Disaster Med Public Health Preparedness. 2018;page 1 of 8).

IntroductionCompassion fatigue (CF) is the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering. Emergency care providers are at an increased risk of CF secondary to their first responder roles and exposure to traumatic events. We aimed to investigate the current state of compassion fatigue among emergency medicine (EM) resident physicians, including an assessment of contributing factors.MethodsWe distributed a validated electronic questionnaire consisting of the Professional Quality of Life Scale with subscales for the three components of CF (compassion satisfaction, burnout and secondary traumatic stress), with each category scored independently. We collected data pertaining to day- versus night-shift distribution, hourly workload and child dependents. We included residents in EM, neurology, orthopedics, family medicine, pediatrics, obstetrics, and general surgery.ResultsWe surveyed 255 residents, with a response rate of 75%. Of the 188 resident respondents, 18% worked a majority of their clinical shifts overnight, and 32% had child dependents. Burnout scores for residents who worked greater than 80 hours per week, or primarily worked overnight shifts, were higher than residents who worked less than 80 hours (mean score 25.0 vs 21.5; p=0.013), or did not work overnight (mean score 23.5 vs 21.3; p=0.022). EM residents had similar scores in all three components of CF when compared to other specialties. Secondary traumatic stress scores for residents who worked greater than 80 hours were higher than residents who worked less than 80 hours (mean score 22.2 vs 19.5; p=0.048), and those with child dependents had higher secondary traumatic stress than those without children (mean score 21.0 vs 19.1; p=0.012).ConclusionCF scores in EM residents are similar to residents in other surgical and medical specialties. Residents working primarily night shifts and those working more than 80 hours per week appear to be at high risk of developing compassion fatigue. Residents with children are more likely to experience secondary traumatic stress.

IntroductionEpinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery.MethodsThis observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by healthcare providers at an academic ED. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED healthcare providers.ResultsOf 217 ED healthcare providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably for time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (p<0.001 for all comparisons). However, manual injection use was rated more favorably for risk of provider self-injury and patient cost (p<0.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector.ConclusionED healthcare providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED.

The time to successful ETI was not significantly different between VL and DL. Video laryngoscopy had a greater perceived ease of use, but DL was perceived to be more feasible for use in actual HazMat situations. These findings suggest that both DL and VL are reasonable modalities for use in HazMat situations, and the choice of modality could be based on the clinical situation and provider experience.