Real-world data of the use and experience of caplacizumab for the treatment of acquired thrombotic thrombocytopenic purpura: Case series

PurposeCaplacizumab was licensed for acquired thrombotic thrombocytopenic purpura (aTTP) based on prospective controlled trials. Real-world evidence is crucial in rare diseases. We aim to describe a patient population with aTTP, receiving caplacizumab in a real-world setting, reporting their outcomes, including safety and tolerability, and contrasting them with a historical cohort from our center.MethodsWe describe data collected retrospectively from 2012 to 2022 for 16 patients with aTTP (8 received caplacizumab and 8 the historical standard-of-care). Patients' characteristics and outcomes were compared between groups.ResultsPatients’ demographic and baseline characteristics were similar in both groups. Caplacizumab led to a rapid normalization of the platelet count of 3.5 (IQR, 2–6) versus 16 (IQR, 9.5–23.5) days in the historical cohort: (p = .002). The median number of plasma exchanges and the length of days requiring them, between the caplacizumab group versus the historical cohort, was 6 (IQR, 6–10) versus 19.5 (IQR, 12.5–29.5) plasma exchanges (p = .006); and 9 (IQR, 8.5–13.5) versus 22 (15–31) days (p = .049), respectively. There were no refractory cases in the caplacizumab group in comparison with 37.5 % in the historical cohort. None of patients treated with caplacizumab experienced a recurrence after 1081 (IQR, 511–3125) days of follow-up. Safety was in line with data reported in clinical trials, with mild adverse events (mostly grade≤2).ConclusionWe provided real-world evidence in the treatment of aTTP, confirming the results obtained in clinical trials. Caplacizumab reduced the time to platelet count recovery and the number and length of plasma exchanges.     

Gender differences in funding among grant recipients in emergency medicine: A multicenter analysis

ObjectiveTo describe differences in funded grants between male and female faculty in two academic emergency departments.MethodsThis was a retrospective analysis of grant funding at two academic emergency departments from January 2012-September 2018. We queried the grants department databases at each institution and obtained records of all funded grants for emergency medicine (EM) faculty. We extracted the following information for each award: gender of the principal investigator (PI), PI academic rank, grant mechanism (government, institutional, industry, organizational), and percent effort. Differences by gender were compared using Chi-square or Fisher’s exact test and Wilcoxon-rank sum.ResultsOne-hundred and thirty grants were awarded to EM faculty at the two institutions during the study period. Of the funded grants, 35 (27%) of recipients were female. Among grant recipients, females held lower academic ranking than males (p-value < 0.001): Instructor (49% vs 51%), Assistant Professor (36% vs 64%), Associate Professor (9% vs 91%), and Professor (0% vs 100%), respectively. Organizational grants were dispersed equally between funded faculty, but females received a fewer government, industry, and institutional grants (p-value = 0.007). Female grant recipients were awarded a higher median percent of effort compared to males (14% [IQR: 3–51] vs 8% [IQR: 1–15], respectively, p-value = 0.023).ConclusionIn this multicenter analysis, gender discrepancies exist among funded grants of EM faculty. Male recipients had higher academic ranking than their female counterparts. Female recipients were less likely to have government, institutional, and industry grants but received a greater percent effort on funding that was awarded.     

Pharmacogenomic response of low dose haloperidol in critically ill adults with delirium

PurposeTo characterize the pharmacogenomic response of low-dose haloperidol for delirium treatment in critically ill adults.Materials and methodsSingle-center, pilot study of a convenience sample of ICU adults with delirium treated with low-dose IV haloperidol. Patients were evaluated for delirium with the ICDSC every 8 h. Serum haloperidol concentrations were collected on ICU days 2–6, CYP2D6 and CYP3A4 genotypes were characterized and patients were categorized as extensive (EM), intermediate (IM) or poor metabolizers (PM).ResultsThe 22 patients (median age 67 [IQR 48,77] years; median APACHE III 81[IQR 54,181]; CYP2D6 [EM = 12, IM = 7, PM = 3], CYP3A [EM = 18, IM = 4]) received a median [IQR] daily haloperidol dose of 3.0 [2.4, 4.5] mg. After adjusting for age, SOFA, and ICU day, neither an association between CYP2D6 (IM p = .67/PM p = .25) or CYP3A4 (IM p = .44) metabolizer status and serum haloperidol concentrations was found. After adjusting for age, SOFA, and ICU day, neither an association between daily haloperidol dose (p = .77) or ICDSC score (p = .13) and serum haloperidol concentrations was found. No patient experienced QTc interval prolongation (≥500 ms).ConclusionsThis pilot study, the first to evaluate the pharmacogenomic response of low-dose haloperidol when used to treat delirium in the ICU, suggests CYP2D6/CYP3A4 metabolizer status does not affect the serum haloperidol concentrations.     

基于深度学习人工智能骨龄测评系统临床应用

目的 观察基于深度学习的人工智能骨龄测评(BAA)系统临床应用及其对低年资儿科放射医师的辅助作用.方法 收集80名5?12岁儿童手腕骨X线正位片,对掌指骨进行骨龄测评,由高年资儿科放射医师借助BAA系统建立研究所用参考骨龄.根据中华-05法中的TW3-RUS标准,分别以BAA系统、低年资儿科放射医师及BAA系统辅助低年...     

Sepsis is frequent in initially non-critical hypotensive emergency department patients and is associated with increased mortality

ObjectiveHypotension, defined as a mean arterial pressure of maximum 70 mmHg, is associated with significant morbidity and mortality. The objective of this study was to determine in initially non-critical hypotensive adult patients the proportion of sepsis and if septic patients had different outcome and clinical factors than non-septic patients.MethodsThis retrospective observational study was conducted over a year on adult hypotensive emergency department patients initially considered by triage as non-critical. Patients were separated into three groups: hypotensive septic patients (HSP), hypotensive non-septic infected patients (HNSIP), and other hypotensive patients (OHP). Clinical scores, signs, length of stay (LOS), and mortality were compared using analysis of variance for continuous variables and chi-square analysis for categorical variables.ResultsThere were 136 (35.5%) septic patients, 37 (9.7%) with non-septic infection, and 210 (54.8%) with another cause of hypotension. Overall in-hospital mortality was 12.0% and total mortality was greater in HSP than in HNSIP (20.6% vs. 5.4%, p = 0.031) or OHP (20.6 vs. 7.6%, p < 0.001). LOS was greater for HSP when compared to HNSIP (median(IQR): 9(6–17) vs. 6(1?13), p = 0.004) and OHP (median(IQR): 9(6–17) vs. 3(1–8) days, p < 0.0001).ConclusionSepsis in a priori non-critical hypotensive adult patients, when compared with other causes of hypotension, is associated with significantly higher mortality and increased LOS. Patients that present to the emergency department and have a MAP of 70mmHg or less must be rigorously evaluated and have consistent follow-up.     

Cardiac Amyloidosis Without Increased Left Ventricular Wall Thickness

ObjectivesTo determine how often left ventricular wall thickness (LVWT) is normal and to assess the effect of LVWT on clinical outcomes of patients with immunoglobulin light chain (AL) cardiac amyloidosis.Patients and MethodsA total of 117 patients with systemic AL amyloidosis were retrospectively categorized from April 1, 1995, to September 15, 2012; group A included cardiac amyloidosis patients with an LVWT greater than 12 mm (45 patients); group B, cardiac amyloidosis patients with an LVWT of 12 mm or less (25 patients); and group C, no evidence of cardiac amyloidosis (47 patients). We compared echocardiographic parameters and survival rates among the 3 groups.ResultsNo differences were found between groups A and B in the following parameters: left ventricular ejection fraction (median, 56% [interquartile range (IQR), 46%-63%] vs 56% [IQR, 49%-63%], P=.76), left arterial volume index (median, 44.5 [IQR, 38.5-59.7] vs 43.9 [IQR, 33.8-57.1] mL/m², P=.79), eˈ (median, 0.04 [IQR, 0.03-0.05] vs 0.05 [IQR, 0.04-0.06] m/s, P=.10), and E/eˈ (early diastolic mitral inflow velocity (E)/eˈ) (median, 18.4 [IQR, 12.0-23.3] vs 18.0 [IQR, 13.6-25.0], P=.98). Patients in group C exhibited significantly different values for these parameters (median, 65% [IQR, 61%-69%], 23.4 [IQR, 18.0-29.0] mL/m², 0.08 [IQR, 0.06-0.09] m/s, and 8.8 [IQR, 7.2-10.5], respectively; all P<.001). The survival rates were statistically different, with median survival times of 422, 729, and 2080 days in groups A, B, and C, respectively (P=.002). Using multivariate Cox proportional hazards regression analysis, we found that age, an N-terminal pro–B-type natriuretic peptide level of 1800 pg/mL or greater, E/eˈ, and complete hematologic remission were significant predictors of survival.ConclusionsA third of patients with AL cardiac amyloidosis were diagnosed as having an LVWT of 12 mm or less. Because appropriate therapy can improve the survival of patients with AL cardiac amyloidosis, early detection by sensitive diagnostic methods should be pursued even when LVWT is not increased.     

Early recognition of sepsis through emergency medical services pre-hospital screening

BackgroundThe Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance.ObjectivesTo determine if pre-hospital sepsis screening improves 3-hour bundle compliance.MethodsProspective implementation of an EMS sepsis screening tool (June 2016–November 2016) was compared to a historical control (August 2015–March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components.ResultsOf 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2–8] vs. 2 [IQR 1–4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0–35] vs. 46 min [IQR 34–57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0–38] vs. 46 min [IQR 27.5–72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44–92] vs. 72 min [IQR 59.5–112], p = 0.26).ConclusionImplementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.     

Measuring nurses' perceptions of their work environment and linking with behaviour change theories and implementation strategies to support evidence based practice change

PurposeSurvey tools, such as the Alberta Context Tool, reliably measure context but researchers have no process to map context to clinician behaviour and develop strategies to support practice change. Therefore, we aimed to map the Alberta Context Tool to the Theoretical Domains Framework and the Behaviour Change Wheel.MethodThe multi-centre study used the Alberta Context Tool to collect data from a convenience sample of nurses working in two emergency departments. These findings were categorised as barriers and enablers, and then mapped to the Theoretical Domains Framework to examine for behavioural domains. Using the Behaviour Change Wheel functions, strategies were developed to target clinician behaviour change.ResultsSurvey response rate was 42% (n = 68). Nurses perceived a positive work environment in the dimensions of Social Capital (median 4.00, IQR 0.33), Culture (median 3.83, IQR 1.16) and Leadership (median 3.60, IQR 1.1). Low scoring dimensions included Formal Interactions (median 2.75, IQR 1.00); Time (median 2.60, IQR 1.00) Staffing (median 3.0, IQR 2.00) and Space (median 3.0, IQR 2.00). Enablers (n = 77) and barriers (n = 25) were identified in both sites. The Theoretical Domains Framework was mapped to Alberta Context Tool barriers and enablers. The behaviour change strengths included: social and professional role; beliefs about capability; goals; and emotions. Using the Behaviour Change Wheel functions, 67 strategies were developed to address barriers and enablers.ConclusionsThe Alberta Context Tool successfully measured two emergency environments identifying barriers and enablers. This approach enabled environment dimensions to be targeted with practical solutions to support evidence-based practice implementation.     

Plasma syndecan-1 is associated with fluid requirements and clinical outcomes in emergency department patients with sepsis

BackgroundDegradation of the endothelial glycocalyx is recognized as a major part of the pathophysiology of sepsis. Previous clinical studies, mostly conducted in intensive care settings, showed associations between glycocalyx shedding and clinical outcomes. We aimed to explore the association of plasma syndecan-1, a marker of glycocalyx degradation, with the subsequent fluid requirements and clinical outcomes of emergency department patients with sepsis.MethodsThis was a post hoc analysis of a randomized trial of fluid resuscitation in the emergency department. The study was conducted in the emergency department of an urban 1500-bed tertiary care center. The data of 95 adults who were diagnosed with sepsis-induced hypoperfusion and had undergone baseline syndecan-1 measurement were included. The syndecan-1 levels at baseline (T0) and hour 6 (T6) were studied to characterize their association with clinical outcomes, including subsequent fluid administration, organ failure outcomes and mortality.ResultsThe median syndecan-1 levels at T0 and T6 were 207 (IQR 135–438) and 207 (IQR 128–490) ng/ml, respectively. Syndecan-1 levels at T0 were correlated with baseline sequential organ failure assessment (SOFA) score (ρ = 0.35, p < 0.001). Syndecan-1 levels at both T0 and T6 were correlated with subsequent fluid administration over 24 and 72 h and associated with the diagnosis of septic shock, the maximum dose of vasopressors and the need for renal replacement therapy (p < 0.05). Higher syndecan-1 levels at T6 were associated with higher 90-day mortality (p = 0.03).ConclusionsIn the emergency department, syndecan-1 levels were associated with fluid requirements, sepsis severity, organ dysfunction, and mortality.     

Language preference does not influence stroke patients' symptom recognition or emergency care time metrics

IntroductionOur objective was to determine whether acute ischemic stroke (AIS) patients' language preference is associated with differences in time from symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DTI), and door-to-needle (DTN) time.MethodsWe identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003–05/2014 for whom language preference was available. Data were abstracted from the institution's Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DTI, and 4) DTN time.ResultsOf 3190 AIS patients, 300 (9.4%) were non-English preferring (NEP). Comparing NEP to English preferring (EP) patients in unadjusted or adjusted analyses, time from symptom discovery to arrival and rate of EMS utilization were not significantly different (overall median time 157 min, IQR 55–420; EMS utilization: 65% vs. 61.3% p = 0.21). There was also no significant differences in DTI or in likelihood of guideline-recommended DTI ≤ 25 min (overall median 59 min, IQR 29–127; DTI ≤ 25 min 24.3% vs. 21.3% p = 0.29) or DTN time or in likelihood of guideline-recommended DTN ≤ 60 min (overall median 53 min, IQR 36–73; DTN ≤ 60 min 62.5% vs. 58.2% p = 0.60).ConclusionConsistent with prior reports examining disparities in care, a systems-based approach to acute stroke prevents differences in hospital-based metrics. Reassuringly, NEP and EP patients also had similar speed of symptom recognition and EMS utilization.     

Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly

ObjectiveTo determine the optimum practice for students to apply lumbar mobilisations with force parameters consistent with an experienced therapist.DesignThirty physiotherapy students attended three practice sessions over two weeks where they performed lumbar mobilisations on a fellow student. Students viewed feedback on their applied forces (measured using an instrumented treatment table) in real-time on a computer screen. Performance was tested before and after feedback at each practice session and at follow up sessions one week and three months later.Outcome measuresA greater accuracy in manual force application was defined as a smaller difference between each student-applied force parameter (mean peak force (N), force amplitude (N), and oscillation frequency (Hz)), and that previously applied by an expert. Test data from each session was analysed using Friedman's and Wilcoxon signed rank tests to determine student learning and retention.ResultsStudents were more accurate after feedback at Session 1 (median difference between student and expert force parameters 7.7 N, IQR 3.2–15.3) than before feedback (median 17.5, IQR 7.3–33.6, P < 0.001). Increased practice improved performance, with the greatest accuracy after feedback at Session 3 (median 7.0, IQR 3.5–11.9, P < 0.01). Retention however was poor, with performance at follow-up sessions no different to baseline.ConclusionsStudents apply more consistent and accurate mean peak force, force amplitude and oscillation frequency after practising with objective, concurrent feedback. Additional practice sessions further improve performance, however retention is poor.     

Diagnostic Performance of Ultrasound Computer-Aided Diagnosis Software Compared with That of Radiologists with Different Levels of Expertise for Thyroid Malignancy: A Multicenter Prospective Study

The aim of the work described here was to evaluate the diagnostic performance of ultrasound thyroid computer-aided diagnosis (CAD) software. This multicenter prospective study included 494 patients (565 thyroid nodules) who underwent surgery or biopsy after ultrasonography at four hospitals from January 2019 to September 2019. The diagnostic performance metrics of different readers were calculated and compared with the pathologic results. The sensitivity of CAD was outstanding and was equivalent to that of a senior radiologist (90.51% vs. 88.47%, p > 0.05). The area under the curve of CAD was equivalent to that of a junior radiologist (0.748 vs. 0.739, p > 0.05). However, the specificity was only 49.63%, which was lower than those of the three radiologists (75.56%, 85.93% and 90.37% for the junior, intermediate and senior radiologists, respectively). The diagnostic performance of the junior radiologist was significantly improved with the aid of CAD (junior + CAD). The sensitivity and area under the curve of junior + CAD were improved from 72.20% to 89.93% and from 0.739 to 0.816, respectively (both p values <0.05), and the positive predictive value, negative predictive value and κ coefficient improved from 76.3% to 78.6%, 82.0% to 86.8% and 0.394 to 0.511, respectively. Though specificity slightly decreased from 75.56% to 73.33%, the difference was not statistically significant (p > 0.05). In general, the clinical application value of CAD is promising, and its instrumental value for junior radiologists is significant.     

Door-To-Triage Time in a Canadian Tertiary-Care Center

BackgroundThe interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional.ObjectiveWe sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada.MethodsData were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period. Demographic information, arrival time (door time), triage time, and Canadian Triage and Acuity Score (CTAS) were collected. DTT was compared across variables using Kruskal-Wallis one-way analysis of variance.ResultsSeven hundred and seventy-five patients were included in the study, representing 82.9% of ambulatory patients. DTT was variable (1–86 min) with a median of 12 min (interquartile range [IQR] 6–21 min). Patients in the 5^th percentile with the longest DTT waited a median of 54 min (IQR 48–63 min). DTT varied across days of the week (p < 0.01); the longest wait was on Monday (median 22 [IQR 11–43] min) and the shortest on Sunday (median 8 [IQR 5–12] min). There was no relationship between DTT and CTAS (p = 0.12).ConclusionsDTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.     

A suction laryngoscope facilitates intubation for physicians with occasional emergency medical service experience—A manikin study with severe simulated airway haemorrhage

Introduction

We developed a suction laryngoscope, which enables simultaneous suction and laryngoscopy in cases of airway haemorrhage and evaluated its potential benefits in physicians with varying emergency medical service experience.

Methods

Eighteen physicians with regular and 24 physicians with occasional emergency medical service experience intubated the trachea of a manikin with severe simulated airway haemorrhage using the suction laryngoscope and the Macintosh laryngoscope in random order.

Results

In physicians with regular emergency medical service experience, there was neither a difference in time needed for intubation [median (IQR, CI 95%)]: 34 (18, 30–46) vs. 34 (22, 30–52) s; P = 0.52, nor in the number of oesophageal intubations [0/18 (0%) vs. 3/18 (16.7%); P = NS] when using the suction vs. the Macintosh laryngoscope. In physicians with occasional emergency medical service experience, there was no difference in time needed for intubation [median (IQR, CI 95%)]: 42 (25, 41–57) vs. 45 (33, 41–65) s; P = 0.56, but the number of oesophageal intubations was significantly lower when using the suction laryngoscope [4/24 (16.7%) vs. 12/24 (50.0%); P = 0.04].

Conclusions

In a model of severe simulated airway haemorrhage, employing a suction laryngoscope significantly decreased the likelihood of oesophageal intubations in physicians with occasional emergency medical service experience.     

Patient blood management in critically ill children undergoing cardiac surgery: A cohort study

ObjectiveThe objective of this study was to audit current patient blood management practice in children throughout cardiac surgery and paediatric intensive care unit (PICU) admission.DesignThis was a prospective observational cohort study.SettingThis was a single-centre study in the cardiac operating room (OR) and PICU in a major tertiary children's hospital in Australia.PatientsChildren undergoing corrective cardiac surgery and requiring admission to PICU for postoperative recovery were included in the study.Measurements and main resultsFifty-six patients and 1779 blood sampling episodes were audited over a 7-month period. The median age was 9 months (interquartile range [IQR] = 1–102), with the majority (n = 30 [54%]) younger than 12 months. The median number of blood sampling episodes per patient per day was 6.6 (IQR = 5.8–8.0) in total, with a median of 5.0 (IQR = 4.0–7.5) episodes in the OR and 5.0 (IQR = 3.4–6.2) episodes per day throughout PICU admission. The most common reason for blood tests across both OR and PICU settings was arterial blood gas analysis (total median = 86%, IQR = 79–96). The overall median blood sampling volume per kg of bodyweight, patient, and day was 0.63 mL (IQR = 0.20–1.14) in total. Median blood loss for each patient was 3.5 mL/kg per patient per day (IQR = 1.7–5.6) with negligible amounts in the OR and a median of 3.6 mL/kg (IQR = 1.7–5.7) in the PICU. The median Cell Saver® transfusion volume was 9.9 mL/kg per patient per day (IQR = 4.0–19.1) in the OR. The overall median volume of other infusion products (albumin 4%, albumin 20%, packed red blood cells) received by each patient was 20.1 mL/kg (IQR = 10.7–36.4) per day. Sampling events and blood loss were positively associated with PICU stay.ConclusionsPatient blood management practices observed in this study largely conform to National Blood Authority guidelines. Further implementation projects and research are needed to accelerate implementation of known effective blood conservation strategies within paediatric critical care environments.     

The feasibility of bedside transvaginal ultrasonography in non-pregnant women in the emergency department

Study objectiveWe recorded data on the routine use of point-of-care transvaginal ultrasound (POC TVUS) for the evaluation of non-pregnant women with pelvic complaints in the Emergency Department (ED), and sought to determine how it altered the diagnostic impression and management.MethodsThis was a prospective observational study. Adult non-pregnant women with pelvic complaints undergoing POC TVUS were enrolled. Pre and post ultrasound, the treating physician completed a data collection form indicating the most likely cause of the patient’s pain, current treatment plan, and expected ultrasound findings. Immediately after the ultrasound, the treating physician completed another form to indicate details about the sonographic process and findings, and whether a radiologyperformed TVUS was planned.ResultsOf 113 women enrolled, 79% had both ovaries visualized and the POC TVUS led to changes in plan in 43% of patients, including 3 emergent/urgent interventions; 48% of patients had unexpected findings. Of the 25% who had an additional radiology exam, there were no instances of discordant findings when both ovaries were assessed to be normal on ED Ultrasound. The ultrasound added <10 minutes in 92% of patients. With an ED ultrasound only (n = 85), the median length of stay (LOS) was 282 (IQR 197–323) minutes, compared to 437 (IQR 367-500) minutes when a radiology ultrasound was required (n = 28) (median difference,170 minutes [95% CI 122-212 min]).ConclusionIn this study, emergency physicians were able to efficiently obtain and interpret POC TVUS images that changed assessment of non-pregnant women with pelvic pain without significantly increasing the ED length of stay.     

Pharmacist driven antibiotic redosing in the emergency department

Study objectiveDetermine whether an expanded emergency medicine (EM) pharmacist scope of practice reduces the frequency of major delays in subsequent antibiotic administration in patients boarded in the emergency department (ED).MethodsA pre-post, quasi-experimental study conducted from November 2019–March 2020 at a single-center tertiary academic medical center following the implementation of an expanded EM pharmacist scope of practice. Adult patients were included if they received an initial antibiotic dose in the ED and deemed to be high-risk. Subsequent antibiotic doses were reordered by EM pharmacists for up to 24-h after the initial order pending ED length of stay (LOS). The historical control group consisted of retrospective chart review of cases from the previous year.ResultsThe study identified that of the 181 participants enrolled, major delays in subsequent antibiotic administration occurred in 13% of the intervention group and 48% of the control group (p < 0.01). When compared to the control group, the intervention group had a significant decrease in the number of delays among antibiotics dosed at 6-h (39% vs 13%) and 8-h (60% vs 8%) intervals. For antibiotics dosed at 12-h intervals, no statistically significant difference was observed between the control and intervention groups respectively (19% vs 5%). A statistically significant lower incidence of in-hospital mortality was observed in the intervention group (3% vs 11%, p = 0.02). In the intervention group, 97% of patients received subsequent antibiotic doses while boarded in the ED, compared to 65% in the control group (<0.01).ConclusionExpanding EM pharmacist scope of practice was associated with a significant reduction in the frequency of major delays in subsequent antibiotic administration as well as a decreased incidence of hospital mortality.