2025 Southeastern Residency Conference

Title: Antidote Assessment in a Community Health System

Authors: Madison Owen, Rachel Rumbarger, Jon Oriet, Jonathan Worley

Objective: Identify antidote management trends to improve patient safety and outcomes.

Self Assessment Question: Which of the following is a key factor in improving patient outcomes related to antidote management?

Background: Antidotes are essential in the management patients with toxic exposures, as delays or unavailability can significantly increase morbidity and mortality. However, global deficiencies in antidote stocking arise due to infrequent use, limited education, inadequate awareness, supply chain interruptions, and constrained hospital resources. Expert consensus guidelines for antidote stocking in hospitals were updated in 2018 to address these challenges. Cone Health initially evaluated its antidote PAR (Periodic Automatic Replenishment) levels in 2018, based on these guidelines. Since then, changes in drug availability, the introduction of new antidotes, system expansions, and a lack of routine oversight necessitated a 2024 review. This review identified misalignments with updated guidelines, leading to system-wide inventory adjustments at emergency care locations. Changes were driven by guideline recommendations, usage patterns, waste considerations, and cost-effectiveness, leading to adjustments in PAR levels for 18 antidotes across multiple closely located sites. This study aimed to evaluate current antidote practices and assess whether recent inventory changes improved alignment with guidelines and patient care.

Methods: This was a multi-center, IRB-approved, retrospective study that evaluated patients who received a select antidote for a toxicological emergency at four hospitals and two free-standing emergency departments​ within Cone Health. Exclusion criteria included incomplete medical records, antidote use outside of toxicological emergencies, or patients treated in non-emergency settings. Utilizing the 2018 Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care and the in-house hospital vulnerability assessment updates and antidote indication and dosing updates, the inventory PAR levels for antidotes at Cone Health were updated, resulting in modifications to the PAR levels for digoxin immune fab, glucagon, and 16 other antidotes. A pre-post intervention design was used, with pre-intervention data collected from March 2018 through March 2024 and post-intervention data from April 2024 through February 2025. The primary objective was to assess the composite appropriateness of antidote utilization based on guideline recommendations, including dose accuracy and time to administration. Secondary objectives included evaluating individual metrics for dose and administration timing and determining the adequacy of current antidote inventory. Descriptive statistics were utilized for analysis.

Results: A total of 231 patients met inclusion criteria, with 128 in the pre-intervention group and 103 in the post-intervention group. Following antidote inventory adjustments, adherence to guideline-recommended dosing improved, with no cases of suboptimal dosing in the post-intervention group. For the composite primary outcome, optimal timing was achieved in 70% (90/128) of cases and optimal dosing in 97% (124/128) in the pre-intervention group, compared to 71% (73/103) and 100% (103/103), respectively, in the post-intervention group. Despite modifications to PAR levels, including increases for some antidotes, no instances of stock depletion leading to treatment delays were observed. Inventory adequacy was maintained across all emergency care sites.

Conclusion: Optimizing antidote inventory based on updated guideline recommendations improved adherence to dosing accuracy and administration time without compromising availability. The modest reduction in administration time suggests improved efficiency, though further enhancements could positively impact patient outcomes. These findings underscore the importance of routine antidote inventory assessments in improving patient safety and resource management. Future research should focus on prospective antidote utilization evaluation, identifying opportunities for optimization through order set utilization, and cost-effectiveness analysis to refine stocking strategies further.