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Research Analysis: Check and Inject program is safe and cost effective

King County, Washington successfully introduced hand-drawn epinephrine to EMTs for severe allergic reactions and anaphylaxis

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EMTs administered epinephrine 422 times from July 2014 to December 2016.

Photo/Andrew Latimer

Inspired by the rising costs of epinephrine auto-injectors, King County Emergency Medical Services decided to implement a “Check and Inject” program in 2014. Recently published research in Prehospital Emergency Care has shown that this switch was not only safe for patients but saved the region at least $1 million over a three-year period. This research was also presented at the 2018 National Association of EMS Physicians Annual Meeting.

Starting in April 2014, 3,500 EMTs across King County were trained to administer intramuscular epinephrine from specially made kits. Training included an in-person practical session in which the EMTs demonstrated competence to an instructor.

Once the program was live, any use of the Check and Inject kits resulted in a special alert to the preexisting quality improvement team. Every case was then independently reviewed by two physicians for clinical appropriateness.

EMTs administered epinephrine 422 times from July 2014 to December 2016. Of those cases, 11 records were missing. Thus, 411 cases were included in the final analyses. The original protocols were followed 89.3 percent of the time. However, the physician review provided additional context.

In 86 percent of the cases, administration was clinically indicated and the protocol was followed. In an additional 9 percent of cases, administration was clinically indicated, but the protocol was not followed. See Table 2 for the full breakdown.

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Photo courtesy of Andrew Latimer

Memorable quotes about the Check and Inject kits program

Here are five memorable quotes from the program test:

“While [epinephrine auto-injectors] require minimal training, [their] rising costs have created a significant financial burden for EMS agencies.”

“The Check and Inject protocol was designed to balance inclusivity with prudence in patient selection.”

“In the King County EMS system, we conservatively estimate a cost-savings of roughly $335,000 annually in transitioning to the Check and Inject program from [epinephrine auto-injectors].”

“A review of the paramedic reports did not reveal information that would indicate that EMT epinephrine was inappropriate, though the paramedic report would potentially be biased by EMT presentation of the case and the goal to work collectively as a team to provide consistent care.”

“The study was conducted in a mature EMS system in a metropolitan county that undertook initial and ongoing specific training and monitoring.”

Key takeaways on the Check and Inject program

Here are the key takeaways for EMS leaders:

1. EMTs can correctly draw-up and administer medications

For these 411 cases, EMTs used good judgement and followed a novel protocol as it was designed in nearly 90 percent of the cases. More than 3500 EMTs were trained, meaning that only 1-in-3 EMTs helped treat a patient within this study, and few would have cared for more than a single patient.

2. State policy dictates the plausibility of such a program

There are currently 13 states with training programs that allow EMTs to inject epinephrine. The remaining 37 states will require a policy change in order to create similar programs.

3. Cost savings add up over time

The total cost to supply every responding vehicle in the region with the Check and Inject kits was pennies compared to supplying an equal level of epinephrine auto-injector coverage. This is in large part because the actual medication is only $9 per vial. Compare this to the $600 price tag attached to an EpiPen.

Additional resources on Check and Inject

Here are additional EMS1 resources on Check and Inject:

Editorial disclosure: Dr. Counts was not involved with the research discussed in this article; however, given her position within the University of Washington, she regularly works with many of the authors.

Catherine R. Counts, PHD, MHA, is a health services researcher with Seattle Medic One in the Division of Emergency Medicine at the University of Washington School of Medicine. She received both her PhD and MHA from Tulane University School of Public Health and Tropical Medicine.

Dr. Counts has research interests in domestic healthcare policy, quality, patient safety, organizational theory and culture, and pre-hospital emergency medicine. She is a member of the National Association of EMS Physicians and AcademyHealth. In her free time she trains Bruno, her USAR canine.

Connect with her on Twitter, Facebook, or her website, or reach out via email at ccounts@tulane.edu.