Introduction: Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED.

Methods: This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017–July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model.

Results: We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008).

Conclusion: Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.

Objective: Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).

Methods: We conducted a retrospective observational study from 2008–2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU.

Results: Of 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08).

Conclusion: In a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

Introduction: Despite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices.

Methods: We developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model. 

Results: The estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation. 

Conclusion: In this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.