Pharmacist impact on the time to post-intubation sedation in the Emergency Department
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Publication Date
2025
Keywords
oregon, oaa 2025, ppmc, psvmc
Disciplines
Emergency Medicine | Medical Education | Pharmacy and Pharmaceutical Sciences
Abstract
Abstract: Providence Portland Medical Center (PPMC) is a 483-bed community teaching hospital with approximately 50,600 annual emergency department (ED) visits and an average of 150 ED visits per day. Rapid sequence intubation (RSI) is an airway management technique that is commonly performed in the ED and involves administration of an induction agent followed by a neuromuscular blocking agent (NMBA). Emerging evidence suggests that approximately 2.6% of patients who undergo RSI in the ED experience awareness with paralysis (AWP), a devastating recollection of sensory perceptions while under the influence of a NMBA. Given the significant psychological sequalae associated with AWP, timely post-intubation sedation is essential. PPMC’s current staffing model has an ED pharmacist available daily between the hours of 1200 and 2230. While on duty, the ED pharmacist is responsible for medication management during the RSI procedure, as well as the management of post intubation sedation. The objective of this study is to evaluate the impact of having an ED pharmacist at the bedside during an RSI procedure on the time to initiation of post-intubation sedation in the ED. This is an IRB-approved retrospective cohort study of adults 18 years of age or older who presented to the PPMC ED between January 1, 2020 and October 31, 2024 and received a dose of either rocuronium or vecuronium in the ED for RSI. The primary outcome is the mean time to post-intubation sedation following RSI in the ED, with and without an ED pharmacist present at bedside. Key secondary outcomes include frequency of post-intubation sedation, time to and frequency of adequate post-intubation sedation, ED length of stay, and mean doses of RSI and sedative medications. Overall, 196 patients were included in the analysis. There were 107 patients who underwent RSI with an ED pharmacist present, and 89 patients with an ED pharmacist absent. Both cohorts had similar baseline characteristics. The mean time to sedation was 12 minutes with an ED pharmacist present and 20 minutes with an ED pharmacist absent (p = 0.009). When an ED pharmacist was present compared to when an ED pharmacist was absent, patients more frequently re-ceived post-intubation sedation (90.7% vs 87.8%), more frequently received adequate post-intubation sedation (75.9% vs 62.9%), and had faster mean times to adequate sedation (20 minutes vs 39 minutes). There were no significant differences between mean doses of RSI medications aside from the pharmacist present group receiving a higher mean cumulative propofol dose (3148.6 mcg/kg vs 2004.0 mcg/kg). ED LOS was not significantly different between groups. In conclusion, a bedside ED pharmacist assisting with medication management during RSI procedures significantly decreased the time to the provision of post-intubation sedation. Patients were also more likely to receive post-intubation sedation in the ED and achieved a higher frequency of adequate sedation.
Specialty/Research Institute
Graduate Medical Education
Specialty/Research Institute
Pharmacy
Specialty/Research Institute
Emergency Medicine
