IMPORTANCE Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics.OBJECTIVE To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from

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Background Due to the emergence of community-associated strains, the prevalence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections has increased substantially in pediatric patients. A vancomycin AUC0–24/MIC index >400 best predicts treatment outcomes for invasive MRSA infection in adults. Data on whether recommended vancomycin doses in children achieve this break point are lacking. Objective This study aimed to assess the likelihood that currently recommended vancomycin doses in children achieve AUC0–24/MIC >400. Methods Vancomycin AUC0–24/MIC predictions were conducted across a range of dosages (40–70 mg/kg/d) using a Monte Carlo simulation (n = 5000). AUC0–24 was calculated as daily dose divided by vancomycin clearance, and daily dose was fixed for a given simulation. Three literature-reported estimates in children were used to define vancomycin clearance and its variance. For the MIC distribution of MRSA isolates, susceptibility data were obtained from the University of California, San Francisco Children’s Hospital, San Francisco, California (n = 180; 40% ≤0.5 mg/L; 59% = 1 mg/L; and 1% = 2 mg/L). Results Using the recommended empiric dosage of 40 mg/kg/d, 58% to 66% of children were predicted to achieve AUC0–24/MIC >400. Increasing the vancomycin dosage to 60 mg/kg/d substantially increased the likelihood (88%–98%) of achieving this pharmacodynamic target. On sensitivity analysis, a dosage of 40 mg/kg/d was more strongly influenced by small changes in MIC compared with 60 mg/kg/d. Conclusions Recommended empiric vancomycin dosing in children (40 mg/kg/d) was not predicted to consistently achieve the pharmacodynamic target of AUC0–24/MIC >400 for invasive MRSA infections. A vancomycin dosage of 60 mg/kg/d was predicted to optimize achievement of this target in children.

IntroductionEmergency department clinical pharmacists (EPh) serve a relatively new clinical role in emergency medicine. New EPh may still face barriers prior to working in the emergency department (ED), including staff acceptance. We aimed to assess staff perceptions of a university hospital EPh program 1 year after implementation.MethodsWe sent an electronic survey consisting of 7 multiple-choice questions, 17 5-point Likert-scale questions, and 1 free-text comment section to ED providers and nurses. The qualitatively validated survey assessed staff’s general perceptions of the EPh and their clinical work.ResultsWe received responses from 14 attending physicians, 34 emergency medicine residents, 5 mid-level providers, and 51 nurses (80% response rate). Overall, the ED staff strongly supported the presence of an EPh. All of the respondents consulted the EPh at least once in their previous 5 ED shifts. Most respondents (81%) felt the EPh’s availability for general consultation and aid during resuscitations served as the major contribution to medication and patient safety. The participants also expressed that they were more likely to consult a pharmacist when they were located in the ED, as opposed to having to call the main pharmacy.ConclusionThe EPh model of practice at our institution provides valuable perceived benefit to ED providers.

Optimal management of the critically ill patient in shock requires rapid identification of its etiology. We describe a successful application of an emergency physician performed bedside ultrasound in a patient presenting with shock and subsequent cardiac arrest. Pulmonary embolus was diagnosed using bedside echocardiogram and confirmed with CTA of the thorax. Further validation and real-time implementation of this low-cost modality could facilitate the decision to implement thrombolytics for unstable patients with massive pulmonary embolism who cannot undergo formal radiographic evaluation.