Overnight Pharmacist Coverage and Time to Postintubation Sedation in the Emergency Department

Failure to sedate intubated patients is associated with serious complications. The presence of an emergency medicine pharmacist (EMP) is associated with a decrease in time to sedative administration in patients following rapid sequence intubation (RSI) in the emergency department (ED). However, EMP coverage in prior work has been inconsistent and excluded overnight hours. We sought to evaluate time to sedation following RSI in the ED stratified by presence of an overnight EMP.

This was a retrospective cohort study of adult and pediatric patients in an urban ED from March 2022 to March 2023. On September 26, 2022, we expanded EMP services to include overnight coverage. In this analysis, we included patients who underwent RSI with rocuronium or succinylcholine between midnight and 6:30 AM, excluding those with pre-hospital advanced airway placement, or lack of post-intubation sedation within 30 minutes of paralytic receipt. Data were extracted from the electronic health record by an informaticist followed by manual chart review by a single abstractor. The primary outcome was time from the paralytic agent to the first sedative. The secondary outcome was ED resuscitation room length of stay (LOS).

A total of 363 patients received a paralytic, and 282 were included in the analysis (pre-EMP expansion, N = 156; post-EMP expansion, N = 126). The median time to first sedative in the pre-EMP expansion group was 7 (IQR 5-10) vs. 6 minutes (IQR 4-9) in the post-EMP expansion group (P = 0.024) for a median difference of 1 minute (95% CI, 0-2). Rocuronium was the most common paralytic across both groups (85.3% vs. 65.9%, respectively). The medical intensive care unit was the most common admitting service (67.3% vs. 71.4%), followed by trauma surgery (26.3% vs. 14.3%). ED resuscitation room LOS was similar between groups.

In this small preliminary sample size, overnight EMP coverage was not associated with a difference in time to first sedative following RSI in the ED. Despite previous studies suggesting up to 7.4% of patients experience awareness with paralysis following RSI in the ED, post-intubation sedation was initiated rapidly in this study across both groups. Future study directions will include a larger sample size as well as subgroup analyses based on age, paralytic agent, induction agent, and admitting service.