Introduction Deaths have increased, and prescription medications are involved in a significant percentage of deaths. Emergency department (ED) changes to managing acute pain and prescription drug monitoring programs (PDMPs) can impact the potential for abuse. Methods We analyzed the impact of a series of quality improvement initiatives on the opioid prescribing habits of emergency department physicians and advanced practice providers. We compared historical prescribing patterns with those after three interventions: 1) the implementation of a PDMP, 2) clinician education on alternatives to opioids (ALTOs), and 3) electronic health record (EHR) process changes. Results There was a 61.8% decrease in the percentage of opioid-eligible ED discharges that received a prescription for an opioid from 19.4% during the baseline period to 7.4% during the final intervention period. Among these discharges, the cumulative effect of the interventions resulted in a 17.3% decrease in the amount of morphine milligram equivalents (MME) prescribed per discharge from a mean of 104.9 MME/discharge during the baseline period to 86.8 MME/discharge. In addition, the average amount of MME prescribed per discharge became aligned with recommended guidelines over the intervention periods. Conclusions Initiating a PDMP and instituting an aggressive ALTO program along with EHR-modified process flows have cumulative benefits in decreasing MME prescribed in an acute ED setting.

Background Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed. Methods A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients. The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke. Discussion Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

Objectives Out‐of‐hospital cardiac arrest (OHCA) afflicts >350,000 people annually in the United States. While postarrest coronary angiography (CAG) with percutaneous coronary intervention (PCI) has been associated with improved survival in observational cohorts, substantial uncertainty exists regarding patient selection for postarrest CAG. We tested the hypothesis that symptoms consistent with acute coronary syndrome (ACS), including chest discomfort, prior to OHCAs are associated with significant coronary lesions identified on postarrest CAG. Methods We conducted a multicenter retrospective cohort study among eight regional hospitals. Adult patients who experienced atraumatic OHCA with successful initial resuscitation and subsequent CAG between January 2015 and December 2019 were included. We collected data on prehospital documentation of potential ACS symptoms prior to OHCA as well as clinical factors readily available during postarrest care. The primary outcome in multivariable regression modeling was the presence of significant coronary lesions (defined as >50% stenosis of left main or >75% stenosis of other coronary arteries). Results Four‐hundred patients were included. Median (interquartile range) age was 59 (51–69) years; 31% were female. At least one significant stenosis was found in 62%, of whom 71% received PCI. Clinical factors independently associated with a significant lesion included a history of myocardial infarction (adjusted odds ratio [aOR] = 6.5, [95% confidence interval {CI} = 1.3 to 32.4], p = 0.02), prearrest chest discomfort (aOR = 4.8 [95% CI = 2.1 to 11.8], p ≤ 0.001), ST‐segment elevations (aOR = 3.2 [95% CI = 1.7 to 6.3], p < 0.001), and an initial shockable rhythm (aOR = 1.9 [95% CI = 1.0 to 3.4], p = 0.05). Conclusions Among survivors of OHCA receiving CAG, history of prearrest chest discomfort was significantly and independently associated with significant coronary artery lesions on postarrest CAG. This suggests that we may be able to use prearrest symptoms to better risk stratify patients following OHCA to decide who will benefit from invasive angiography.

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Background Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are both important treatments for large‐vessel occlusion stroke. However, it is still unclear how the timing of IVT, EVT, and the need for transfer of a patient to an endovascular stroke center for EVT affect outcomes. In this investigation, we study the interaction between IVT, rapidity to EVT, and need for transfer among patients with large‐vessel occlusion stroke. Methods This investigation is an analysis of the OPUS‐REACH (Optimizing the Use Prehospital Stroke Systems of Care–Reacting to Changing Paradigms) registry of patients with large‐vessel occlusion stroke from 9 endovascular centers in the United States. Using the database, we extracted baseline characteristics of patients, whether the patient received IVT, and time intervals in the patients’ care. Patient demographics and characteristics were compared between 2 groups using the χ 2 test for categorical variables and 2‐sample t ‐tests or Wilcoxon rank‐sum tests for continuous variables. Multivariable logistic regression was performed to determine the adjusted associations of the variables with 90‐day dichotomized modified Rankin Scale outcome. Results A total of 1171 patients were included in the final analysis, and 38.9% had good functional outcome at 90 days. Male sex and lower initial National Institutes of Health Stroke Scale score were nonmodifiable factors associated with good clinical outcomes. We saw no differences in outcome whether a patient underwent primary or secondary transport. On multiple variable analysis, the receipt of IVT was the only modifiable factor associated with good outcomes. We found no overall effect of time from last known well to EVT on 90‐day outcomes unless the patient received IVT. Conclusions In this investigation, receipt of IVT was independently associated with improved outcomes at 90 days with an odds ratio of 1.51. Neither shorter time from last known well to EVT nor direct transport to an endovascular stroke center versus transfer to an endovascular stroke center was associated with improved outcomes. We therefore conclude that prehospital algorithms must account for the timely administration of IVT over time to EVT.