Michael A. Darracq

Background: Few studies have assessed the safety and efficacy of discharging emergency department patients with alcohol withdrawal after receiving parenteral phenobarbital. This study aimed to validate this practice and delineate the role of intramuscular phenobarbital for this indication. Methods: This single-center retrospective chart review included adult patients with non-severe alcohol withdrawal, as diagnosed by treating providers based on clinical judgment, who were managed in the emergency department’s low-acuity provider at triage zone, received parenteral phenobarbital, and were discharged within 12 h of arrival. The primary safety and efficacy endpoints were the percentages of patients who expired or re-presented to the emergency department for an alcohol-related diagnosis within seven days of the initial presentation, respectively. A subgroup analysis was performed to compare outcomes between those who only received intramuscular or intravenous phenobarbital. Results: Of the 192 patient encounters included, no deaths were reported. Twenty-one (10.9%) patients re-presented after the initial visit, received treatment, and were discharged home. One (0.52%) patient was admitted following re-presentation. The percentages of patients who re-presented in the intramuscular-only and intravenous-only groups were 8% and 13.5%, respectively (p = 0.25). The total and weight-based doses received were not significantly different between those who did and did not re-present in both the intramuscular-only and intravenous-only groups. The median length of stay in the intramuscular-only and intravenous-only groups was 3.97 h and 5.87 h, respectively (p < 0.001). Conclusions: Our findings suggest that patients presenting with non-severe alcohol withdrawal symptoms may be discharged from the emergency department following receipt of parenteral phenobarbital, without requiring additional outpatient alcohol withdrawal medications. Intramuscular phenobarbital appears to be a viable alternative route of administration and warrants further investigation.

Introduction: We sought to compare physician assistant (PA) and nurse practitioner (NP) practice in United States emergency departments (ED) based on ED visits as reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). Methods: We performed a retrospective, secondary analysis of the 2010 to 2017 NHAMCS with analysis of ED visits, patient demographics, and hospital characteristics. Results: Between 2010 to 2017, 21.0% (95% confidence interval, [CI] +/-3.1%) of ED visits were seen by either a PA/NP (with and without physician involvement) and 8.6% (+/-2.9%) were seen by PA/NP alone. We identified an increase for NP visits between 2014–2016 and found that PA/NP visits share many of the same characteristics. Conclusion: While emergency medicine has predominately been a specialty for PAs, the number of ED visits with NPs has been increasing over the past several years. While there are some differences, PAs/NPs share many similar practice characteristics in the ED.