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Boley S, Sidebottom A, Stenzel A, Watson D. Racial Disparities in Opioid Administration Practices Among Undifferentiated Abdominal Pain Patients in the Emergency Department. J Racial Ethn Health Disparities 2024; 11:416-424. [PMID: 36795292 DOI: 10.1007/s40615-023-01529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVES The purpose of this study was to examine racial disparities in opioid prescribing practices for patients presenting to the emergency department (ED) with a common chief complaint of abdominal pain. METHODS Treatment outcomes were compared for non-Hispanic White (NH White), non-Hispanic Black (NH Black), and Hispanic patients seen over 12 months in three emergency departments in the Minneapolis/St. Paul metropolitan area. Multivariable logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI) to measure the associations between race/ethnicity and outcomes of opioid administration during ED visits and discharge opioid prescriptions. RESULTS A total of 7309 encounters were included in the analysis. NH Black (n = 1988) and Hispanic patients (n = 602) were more likely than NH White patients (n = 4179) to be in the 18-39 age group (p < 0. 001). NH Black patients were more likely to report public insurance than NH White or Hispanic patients (p < 0.001). After adjusting for confounders, patients who identified as NH Black (OR: 0.64, 95% CI: 0.56-0.74) or Hispanic (OR: 0.78, 95% CI: 0.61-0.98) were less likely to be given opioids during their ED encounter when compared to NH White patients. Similarly, NH Black patients (OR: 0.62, 95% CI: 0.52-0.75) and Hispanic patients (OR: 0.66, 95% CI: 0.49-0.88) were less likely to receive a discharge opioid prescription. CONCLUSIONS These results confirm that racial disparities exist in the ED opioid administration within the department as well as at discharge. Future studies should continue to examine systemic racism as well as interventions to alleviate these health inequities.
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Affiliation(s)
- Sean Boley
- Emergency Care Consultants, Minneapolis, MN, USA.
| | | | - Ashley Stenzel
- Care Delivery Research, Allina Health, Minneapolis, MN, USA
| | - David Watson
- Research Institute, Children's Minnesota, Minneapolis, MN, USA
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Mitra B, Roman C, Wu B, Luckhoff C, Goubrial D, Amos T, Bannon-Murphy H, Huynh R, Dooley M, Smit DV, Cameron PA. Restriction of oxycodone in the emergency department (ROXY-ED): A randomised controlled trial. Br J Pain 2023; 17:491-500. [PMID: 38107754 PMCID: PMC10722107 DOI: 10.1177/20494637231189031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Background The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). Methods An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18-75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. Results There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p < .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71-2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39-0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86-1.02). Conclusions Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Cristina Roman
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Bertha Wu
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Carl Luckhoff
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Diana Goubrial
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Timothy Amos
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Ronald Huynh
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael Dooley
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - De Villiers Smit
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter A. Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Crowley AP, Sun C, Yan XS, Navathe A, Liao JM, Patel MS, Pagnotti D, Shen Z, Delgado MK. Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med 2023; 30:809-818. [PMID: 36876410 DOI: 10.1111/acem.14717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.
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Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Amol Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David Pagnotti
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zijun Shen
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Larson MJ, Bauer MR, Moresco N, Huntington N, Ritter G, Paul-Kagiri R, Hyppolite R, Richard P. Variation in prescribing of opioids for emergency department encounters: A cohort study in the Military Health System. J Eval Clin Pract 2022; 28:1157-1167. [PMID: 35666601 PMCID: PMC10281196 DOI: 10.1111/jep.13702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES: Emergency department (ED) clinicians account for approximately 13% of all opioid prescriptions to opioid-naïve patients and variability in the rates of prescribing have been noted among individual clinicians and different EDs. This study elucidates the amount of variability within a unified health system (the U.S. Military Health System [MHS]) with the expectation that understanding the sources of variability will enable health system leaders to improve the quality of decision making. METHODS The design was a retrospective cohort study examining variation in opioid prescribing within EDs of the US MHS. Participants were Army soldiers who returned from a deployment and received care between October 2009 and September 2016. The exposure was ED encounters at a military treatment facility. Key measures were the proportion of ED encounters with an opioid prescription fill; total opioid dose of the fill (morphine milligram equivalent, MME); and total opioid days-supply of the fill. RESULTS The mean proportion of ED encounters with an opioid fill across providers was 19.7% (SD 8.8%), median proportion was 18.6%, and the distribution was close to symmetric with the 75th percentile provider prescribing opioids in 24.6% of their ED encounters and the 25th percentile provider prescribing in 13.4% of their encounters. The provider-level mean opioid dose per encounter was 113.1 MME (SD 56.0) with the 75th percentile (130.1) 50% higher than the 25th percentile (87.4). The mean opioid supply per encounter was 6.8 days (SD 3.9) with more than a twofold ratio between the 75th percentile (8.3) and the 25th (4.1). Using a series of multilevel regression models to examine opioid fills associated with ED encounters and their dose levels, the variation among providers within facilities was much larger in magnitude than the variation among facilities. CONCLUSION Among ED encounters of Army soldiers at military treatment facilities, there was substantial variation among providers in prescribing opioid prescriptions that were not explained by patient case-mix. These results suggest that programmes and protocols to address less than optimal prescribing in the ED should be initiated to improve the quality of care.
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Affiliation(s)
- Mary Jo Larson
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Mark R. Bauer
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Natalie Moresco
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Nick Huntington
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Grant Ritter
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | | | - Regine Hyppolite
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Patrick Richard
- Uniformed Services University of the Health Sciences, Bethesda, MD
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Van Schaik G, Self WH, Hennessy C, Ward MJ. Potentially avoidable interfacility transfers following reduced emergency department volumes due to COVID-19 "Safer-at-Home" orders. Am J Emerg Med 2022; 61:68-73. [PMID: 36057211 PMCID: PMC9389782 DOI: 10.1016/j.ajem.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We sought to assess if a state-wide lockdown implemented due to COVID-19 was associated with increased odds of being a potentially avoidable transfer (PAT). METHODS We conducted a retrospective observational analysis using hospital administrative data of interfacility ED-to-ED transfers to a single, quaternary care adult ED after "Safer at Home" orders were issued March 23rd, 2020 in [Blinded for submission]. Using the PAT classification to identify transfers rapidly discharged from the ED or hospital and may not require in-person care, we used a multivariable logistic regression model to examine the association of the lockdown order with odds of a transfer being a PAT. We compared the period January 1, 2018 to March 23, 2020 with March 24, 2020 to September 30, 2020, adjusting for seasonality, patient, and situational factors. RESULTS There were 20,978 ED-to-ED transfers from during this period that were eligible and 4806 (23%) that met PAT criteria. While the first month post-lockdown saw a decrease in PATs (28%), this was not sustained. In the multivariable model there was a significant seasonal effect; May through September had the highest number of transfers as well as PATs. After adjusting for seasonality, the lockdown was not associated with PATs (adjusted odds ratio [aOR] 0.99, 95% CI 0.2, 5.2) and PATs decreased over time. CONCLUSIONS We did not find an effect of the COVID-19 lockdown on PATs though there was a considerable seasonal effect and an overall downward trend in PATs over time.
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Affiliation(s)
- Graham Van Schaik
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America; VA Tennessee Valley Healthcare System, United States of America; Department of Biomedical Informatics, Vanderbilt University Medical Center, United States of America; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America.
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Navathe AS, Liao JM, Yan XS, Delgado MK, Isenberg WM, Landa HM, Bond BL, Small DS, Rareshide CAL, Shen Z, Pepe RS, Refai F, Lei VJ, Volpp KG, Patel MS. The Effect Of Clinician Feedback Interventions On Opioid Prescribing. Health Aff (Millwood) 2022; 41:424-433. [PMID: 35254932 DOI: 10.1377/hlthaff.2021.01407] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians' prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician's outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (-0.8) and for the combination of peer comparison and individual audit feedback (-1.2). This decrease was sustained during follow-up. There were no significant changes for individual audit feedback alone, and no interventions changed the proportion of encounters with an opioid prescription.
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Affiliation(s)
- Amol S Navathe
- Amol S. Navathe , Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Liao
- Joshua M. Liao, University of Washington, Seattle, Washington, and University of Pennsylvania
| | - Xiaowei S Yan
- Xiaowei S. Yan, Sutter Health, Walnut Creek, California
| | | | | | | | - Barbara L Bond
- Barbara L. Bond, Sutter Health, Castro Valley, California
| | | | | | - Zijun Shen
- Zijun Shen, Sutter Health, San Francisco
| | | | | | | | | | - Mitesh S Patel
- Mitesh S. Patel, Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania
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Kang H, Zhang P, Lee S, Shen S, Dunham E. Racial disparities in opioid administration and prescribing in the emergency department for pain. Am J Emerg Med 2022; 55:167-173. [DOI: 10.1016/j.ajem.2022.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 10/19/2022] Open
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Oskvarek JJ, Aldeen A, Shawbell J, Venkat A, Zocchi MS, Pines JM. Opioid Prescription Reduction After Implementation of a Feedback Program in a National Emergency Department Group. Ann Emerg Med 2022; 79:420-432. [DOI: 10.1016/j.annemergmed.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
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Gwam CU, Emara AK, Chughtai N, Javed S, Luo TD, Wang KY, Chughtai M, O'Gara T, Plate JF. Trends and risk factors for opioid administration for non-emergent lower back pain. World J Orthop 2021; 12:700-709. [PMID: 34631453 PMCID: PMC8472449 DOI: 10.5312/wjo.v12.i9.700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/08/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint.
AIM To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED
METHODS Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The “year” variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05.
RESULTS Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast.
CONCLUSION From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.
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Affiliation(s)
- Chukwuweike U Gwam
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Ahmed K Emara
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Noor Chughtai
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Sameer Javed
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - T David Luo
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Kevin Y Wang
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Morad Chughtai
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Tadhg O'Gara
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Johannes F Plate
- Department of Orthopaedic Surgery, University of Pittsburgh, 5200 Centre Avenue, Suite 415, Pittsburgh, PA 15232, USA
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Bakhoum N, Gerhart C, Schremp E, Jeffrey AD, Anders S, France D, Ward MJ. A Time and Motion Analysis of Nursing Workload and Electronic Health Record Use in the Emergency Department. J Emerg Nurs 2021; 47:733-741. [PMID: 33888334 PMCID: PMC11216543 DOI: 10.1016/j.jen.2021.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/06/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The use of an electronic health record may create unanticipated consequences for emergency care delivery. We sought to describe emergency department nursing task distribution and the use of the electronic health record. METHODS This was a prospective observational study of nurses in the emergency department using a time-and-motion methodology. Three trained research assistants conducted 1:1 observations between March and September 2019. Nurse tasks were classified into 6 established categories: electronic health record, direct/indirect patient care, communication, personal time, and other. Nurses' perceived workload was assessed using the National Aeronautics and Space Administration (NASA) Task Load Index. RESULTS Twenty-three observations were conducted over 46 hours. Overall, nurses spent 27% of their time on electronic health record tasks, 25% on direct patient care, 17% on personal time, 15% on indirect patient care, and 6% on communication. During morning (7 am-12 pm) and afternoon shifts (12 pm-3 pm), the use of the health record was the most commonly performed task, whereas indirect patient care was the task most performed during evening shifts (3 pm-12 pm). Using the National Aeronautics and Space Administration (NASA) Task Load Index, nurses reported an increase in mental demand and effort during afternoon shifts compared with morning shifts. DISCUSSION We observed that emergency nurses spent more time using the electronic health record as compared to other tasks. Increased usability of the electronic health record, particularly during high occupancy periods, may be a target for improvement.
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Affiliation(s)
| | | | - Emma Schremp
- Center for Research and Innovation in Systems Safety, Vanderbilt Medical Center, Nashville, TN
| | - Ashley D. Jeffrey
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Shilo Anders
- Center for Research and Innovation in Systems Safety, Vanderbilt Medical Center, Nashville, TN
| | - Daniel France
- Center for Research and Innovation in Systems Safety, Vanderbilt Medical Center, Nashville, TN
| | - Michael J. Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN
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Lee JB, Ghanem G, Saadat S, Yanuck J, Yeung B, Chakravarthy B, Nelson A, Shah S. Positive Toxicology Results Are Not Associated with Emergency Physicians' Opioid Prescribing Behavior. West J Emerg Med 2021; 22:1067-1075. [PMID: 34546882 PMCID: PMC8463062 DOI: 10.5811/westjem.2021.5.52378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/21/2021] [Indexed: 11/12/2022] Open
Abstract
Introduction Given the general lack of literature on opioid and naloxone prescribing guidelines for patients with substance use disorder, we aimed to explore how a physician’s behavior and prescribing habits are altered by knowledge of the patient’s concomitant use of psychotropic compounds as evident on urine and serum toxicology screens. Methods We conducted a retrospective chart review study at a tertiary, academic, Level I trauma center between November 2017–October 2018 that included 358 patients who were discharged from the emergency department (ED) with a diagnosis of fracture, dislocation, or amputation and received an opioid prescription upon discharge. We extracted urine and serum toxicology results, number and amount of prescription opioids upon discharge, and the presence of a naloxone script. Results The study population was divided into five subgroups that included the following: negative urine and serum toxicology screen; depressants; stimulants; mixed; and no toxicology screens. When comparing the 103 patients in which toxicology screens were obtained to the 255 patients without toxicology screens, we found no statistically significant differences in the total prescribed morphine milligram equivalent (75.0 and 75.0, respectively) or in the number of pills prescribed (15.0 and 13.5, respectively). Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. Conclusion Our study found no association between positive urine toxicology results for psychotropically active substances and the rates of opioid prescribing within a single-center, academic ED. Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. More research on the associations between illicit drug use, opioids, and naloxone prescriptions is necessary to help establish guidelines for high-risk patients.
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Affiliation(s)
- Jonathan B Lee
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Ghadi Ghanem
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Soheil Saadat
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Justin Yanuck
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Brent Yeung
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| | - Bharath Chakravarthy
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Ariana Nelson
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
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Wentz AE, Wang RRC, Marshall BDL, Shireman TI, Liu T, Merchant RC. Variation in opioid analgesia administration and discharge prescribing for emergency department patients with suspected urolithiasis. Am J Emerg Med 2020; 38:2119-2124. [PMID: 33071098 PMCID: PMC7704692 DOI: 10.1016/j.ajem.2020.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Previous research has suggested caution about opioid analgesic usage in the emergency department (ED) setting and raised concerns about variations in prescription opioid analgesic usage, both across institutions and for whom they are prescribed. We examined opioid analgesic usage in ED patients with suspected urolithiasis across fifteen participating hospitals. METHODS This is a secondary analysis of a clinical trial including adult ED patients with suspected urolithiasis. In multilevel models accounting for clustering by hospital, we assessed demographic, clinical, state-level, and hospital-level factors associated with opioid analgesic administration during the ED visit and prescription at discharge. RESULTS Of 2352 participants, 67% received an opioid analgesic during the ED visit and 61% were prescribed one at discharge. Opioid analgesic usage varied greatly across hospitals, ranging from 46% to 88% (during visit) and 34% to 85% (at discharge). Hispanic patients were less likely than non-Hispanic white patients to receive opioid analgesics during the ED visit (OR 0.72, 95% CI 0.55-0.94). Patients with higher education (OR 1.29, 95% CI 1.05-1.59), health insurance coverage (OR 1.27, 95% CI 1.02-1.60), or receiving care in states with a prescription drug monitoring program (OR 1.64, 95% CI 1.06-2.53) were more likely to receive an opioid analgesic prescription at ED discharge. CONCLUSION We found marked hospital-level differences in opioid analgesic administration and prescribing, as well as associations with education, healthcare insurance, and race/ethnicity groups. These data might compel clinicians and hospitals to examine their opioid use practices to ensure it is congruent with accepted medical practice.
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Affiliation(s)
- Anna E Wentz
- Brown University School of Public Health, Department of Epidemiology, Box G-121-3, Providence, RI 02912, USA.
| | - Ralph R C Wang
- Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Brandon D L Marshall
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA.
| | - Theresa I Shireman
- Brown University School of Public Health, Health Services Policy & Practice, Providence, RI, USA.
| | - Tao Liu
- Brown University School of Public Health, Data & Statistics Core of Brown Alcohol Research Center on HIV (ARCH), Providence, RI, USA.
| | - Roland C Merchant
- Harvard Medical School, Brigham and Women's Hospital Department of Emergency Medicine, Boston, MA, USA.
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Preoperative Opioid Prescription Is Associated With Major Complications in Patients With Crohn's Disease Undergoing Elective Ileocolic Resection. Dis Colon Rectum 2020; 63:1090-1101. [PMID: 32015287 DOI: 10.1097/dcr.0000000000001571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Opioid use has grown exponentially over the last decade. The effect of preoperative opioid prescription in patients with Crohn's disease undergoing surgery is unknown. OBJECTIVE The purpose of this study was to identify whether preoperative opioid prescription is associated with adverse postoperative outcomes in Crohn's disease. DESIGN This is a single-institution retrospective observational study. SETTINGS This study was performed at an academic tertiary care center. Details of preoperative opioid prescription were collected from the Kentucky All-Schedule Prescription Electronic Reporting database and the electronic databases of bordering states. PATIENTS Consecutive patients undergoing ileocolic resection for Crohn's disease from 2014 to 2018 were included. MAIN OUTCOME MEASURES The outcomes examined were major complications (Clavien-Dindo ≥3a), length of stay, and 30-day hospital readmission. RESULTS Fifty one of 118 patients were prescribed opioids within 6 months preoperatively (range, 0-33,760 morphine milligram equivalents). Patients with preoperative opioid prescription compared with no preoperative opioid prescription required more daily opioids during hospital admission (p = 0.024). Nineteen patients had a major postoperative complication (preoperative opioid prescription: 26% (13/51) vs no preoperative opioid prescription: 9% (6/67)). On multivariable analysis, preoperative opioid prescription (OR = 2.994 (95% CI, 1.024-8.751); p = 0.045) was a significant risk factor for a major complication. Preoperative opioid prescription was associated with increased length of stay (p < 0.001) and was a risk factor for readmission (OR = 2.978 (95% CI, 1.075-8.246); p = 0.036). Twenty-four patients were readmitted. Using a cutoff for higher opioid prescription of 300 morphine milligram equivalents within 6 months preoperation (eg, 60 tablets of hydrocodone/acetaminophen 5/325), preoperative opioid prescription remained a risk factor for major postoperative complications (OR = 3.148 (95% CI, 1.110-8.928); p = 0.031). LIMITATIONS This was a retrospective study and could not assess nonprescribed opioid use. CONCLUSIONS Preoperative opioid prescription was a significant risk factor for adverse outcomes in patients with Crohn's disease undergoing elective ileocolic resection. See Video Abstract at http://links.lww.com/DCR/B113. LA PRESCRIPCIÓN PREOPERATORIA DE OPIOIDES SE ASOCIA CON COMPLICACIONES MAYORES EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIÓN ILEOCÓLICA ELECTIVA: El uso de opioides ha crecido exponencialmente en la última década. Se desconoce el efecto de la prescripción preoperatoria de opioides en pacientes con enfermedad de Crohn sometidos a cirugía.Identificar si la prescripción preoperatoria de opioides está asociada con resultados postoperatorios adversos en la enfermedad de Crohn.Este es un estudio observacional retrospectivo de una sola institución.Este estudio se realizó en un centro académico de atención terciaria. Los detalles de la prescripción preoperatoria de opiáceos se recopilaron de la base de datos de "Kentucky All-Schedule Prescription Electronic Reporting" y de las bases de datos electrónicas de los estados fronterizos.Pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre 2014-2018.Los resultados examinados fueron complicaciones mayores (Clavien-Dindo ≥3a), duración de la estancia y el reingreso hospitalario de 30 días.A cincuenta y uno de 118 pacientes se le recetaron opioides dentro de los 6 meses preoperatorios (rango, 0 a 33,760 equivalentes de miligramos de morfina). Los pacientes con prescripción preoperatoria de opioides en comparación con ninguna prescripción preoperatoria de opioides requirieron más opioides diarios durante el ingreso hospitalario (p = 0,024). Diecinueve pacientes tuvieron una complicación postoperatoria importante (prescripción preoperatoria de opioides: 26% [13/51] frente a ninguna prescripción preoperatoria de opioides: 9% [6/67]). En el análisis multivariable, la prescripción de opioides preoperatorios (OR = 2.994, IC 95%: 1.024-8.751, p = 0.045) fueron factores de riesgo significativos para una complicación mayor. La prescripción preoperatoria de opioides se asoció con un aumento de la duración de la estadía (p <0.001) y fue un factor de riesgo para el reingreso (OR = 2.978, IC 95%: 1.075-8.246, p = 0.036). Veinticuatro pacientes fueron readmitidos. Utilizando un límite para una mayor prescripción de opioides de 300 miligramos equivalentes de morfina dentro de los 6 meses previos a la operación (p. Ej., 60 tabletas de hidrocodona / acetaminofén 5/325), la prescripción preoperatoria de opioides siguió siendo un factor de riesgo para complicaciones postoperatorias mayores (OR = 3.148 IC 95%: 1.110-8.928, p = 0.031).Este fue un estudio retrospectivo y no pudo evaluar el uso de opioides no prescritos.La prescripción preoperatoria de opioides fue un factor de riesgo significativo para los resultados adversos en pacientes con enfermedad de Crohn sometidos a resección ileocólica electiva. Consulte Video Resumen en http://links.lww.com/DCR/B113.
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Kettler E, Brennan J, Coyne CJ. The effects of a morphine shortage on emergency department pain control. Am J Emerg Med 2020; 43:229-234. [PMID: 32192896 DOI: 10.1016/j.ajem.2020.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE In 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition. METHODS This was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17-6/30/17 and our study period (without morphine) was 4/1/18-6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition. RESULTS We identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study -3.30, control -3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01). CONCLUSIONS Removing IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.
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Affiliation(s)
- Ellen Kettler
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Jesse Brennan
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Christopher J Coyne
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
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