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.
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:
- Wash. EMTs using cheaper ‘Epi Kit’ instead of EpiPen
- Epinephrine: Drug Whys
- Should EMTs, EMRs be allowed to draw up epi?
- Beyond auto-injectors: New kit expands BLS treatment options for severe allergic reactions
- Is draw-up epinephrine the new norms for EMTs, EMRs?
- NY EMS agency drops EpiPens over rising costs
- When time is of the essence: Recognizing and treating anaphylaxis
- Mich. law: Firefighters can’t use EpiPens
- Over 400 NY agencies participating in EpiPen replacement program
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.
