scholarly journals LO26: Are ED physicians contributing to the opioid epidemic?

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S16
Author(s):  
G. Mok ◽  
H. Newton ◽  
L. Thurgur ◽  
I. Stiell
Keyword(s):  
Tertiary Care ◽  
Primary Outcome Measure ◽  
Care Hospital ◽  
Opioid Epidemic ◽  
Opioid Use ◽  
Total Dosage ◽  
Opioid Prescription ◽  
Prescription Practices ◽  
Median Dosage ◽  
Potential Abuse

Introduction: There is an opioid epidemic which has seen an increased mortality rate of 200% related to opioid use over the past decade. Prescription practices amongst ED physicians may be contributing to this problem. Our objective was to analyze ED physician prescription practices for patients discharged from the ED with acute fractures. Methods: We conducted a health records review of ED patients seen at two campuses of a tertiary care hospital with total annual census of 160,000 visits. We evaluated a consecutive sample of patients with acute fractures (January 1 2016–April 15 2016) seen and discharged by ED physicians. Patients admitted to hospital or discharged by consultant services were excluded. The primary outcome measure was the proportion of patients discharged with an opioid prescription. We collected data using a screening list, review of electronic records, and interobserver agreement for measures. We calculated simple descriptive statistics and estimated 4 months would be required to enroll 250 patients receiving opioid prescriptions. Results: We enrolled 816 patients, with 442 females (54.2%), median CTAS score of 3, and median pain score at triage of 6/10. The most common fractures were wrist/hand (35.2%) and foot excluding ankle (14.8%). An ED pain directive was used at triage for 21.2% and 281 patients (34.4%) received an opioid during ED stay, with tramadol (21.2%) being the most common. Overall, 250 patients (30.6%) were discharged with the following opioid prescriptions and median total dosages: hydromorphone (N = 114, median dosage 23mg, range 1–120mg), tramadol (N = 86, 1000mg, 200–2000mg), oxycodone (N = 33, 100mg, 10–170mg), codeine (N = 20, 600mg, 360–1200mg), and morphine (N = 9, 100mg, 25–200mg). Of patients prescribed hydromorphone, 61 (53.5%) were prescribed > 20mg. Overall, 35 patients (4.3%) had a pain related ED visit <1 month after discharge, of which 14 (40%) received an opioid prescription on initial discharge, and 12 (34.2%) received an opioid prescription upon subsequent discharge. Conclusion: Amongst patients presenting to the ED with acute fractures, the majority were not discharged home with an opioid prescription from ED physicians. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Despite only a minority of patients receiving opioid prescriptions, there were very few return to ED visits. To limit potential abuse, we recommend standardization of opioid prescribing in the ED, with attention to limiting the total dosage given.

scholarly journals Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures

CJEM ◽  
2020 ◽  
Vol 22 (4) ◽  
pp. 486-493
Author(s):  
Garrick Mok ◽  
Hailey Newton ◽  
Lisa Thurgur ◽  
Marie-Joe Nemnom ◽  
Ian G. Stiell
Keyword(s):  
Emergency Department ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Prescription Data ◽  
Care Hospital ◽  
Total Dosage ◽  
Opioid Prescription ◽  
Prescription Practices ◽  
Ed Visits

ABSTRACTBackgroundOpioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.MethodsWe conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016–April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.ResultsWe enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1–120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15–36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88–10.35)] had a significantly higher likelihood of opioid prescriptions.ConclusionsThe majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.

Vestibular Rehabilitation: Useful but not Universally so

2003 ◽  
Vol 128 (2) ◽  
pp. 240-250 ◽  
Author(s):  
E. Krebs David ◽  
M. Gill-Body Kathleen ◽  
W. Parker Stephen ◽  
V. Ramirez Jose ◽  
Wernick-Robinson Mara
Keyword(s):  
Tertiary Care ◽  
Vestibular Rehabilitation ◽  
Primary Outcome Measure ◽  
Gait Velocity ◽  
Care Hospital ◽  
Double Blind ◽  
Large Tertiary Care ◽  
Group A ◽  
Group B ◽  
Few Data

OBJECTIVE: Although vestibular rehabilitation (VR) is gaining popularity, few data support its utility in improving locomotor stability, and no good predictors exist of whom will benefit most. STUDY DESIGN AND SETTING: A double-blind, placebo-controlled randomized trial of vestibular rehabilitation was conducted at a large tertiary care hospital on 124 patients (59 ± 18 years old) with unilateral (n = 51) or bilateral (n = 73) vestibular hypofunction, of whom 86 completed a 12-week intervention. Of these 86, 27 returned for long-term (1-year) follow-up testing. The primary outcome measure was locomotor stability. RESULTS: Group A (6 weeks of VR) significantly ( P < 0.01) increased their gait velocity and stability compared with group B (6 weeks of strengthening exercise), but there was a smaller difference ( P = 0.05) between groups at 12 weeks, when both had had VR; there were no group differences at 1 year. Of the 86 who completed the intervention, 52 (61%) had clear locomotor gains. CONCLUSION AND SIGNIFICANCE: VR is helpful for most patients in providing locomotor stability, but further work is needed to determine the factors that prevent VR from being effective for all patients with vestibulopathy.

scholarly journals Chronic Pain in the Emergency Department: A Pilot Interdisciplinary Program Demonstrates Improvements in Disability, Psychosocial Function, and Healthcare Utilization

2018 ◽  
Vol 2018 ◽  
pp. 1-10 ◽  
Author(s):  
Joshua A. Rash ◽  
Patricia A. Poulin ◽  
Yaadwinder Shergill ◽  
Heather Romanow ◽  
Jeffrey Freeman ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chronic Pain ◽  
Pain Catastrophizing ◽  
Tertiary Care ◽  
Care Plan ◽  
Care Hospital ◽  
Opioid Use ◽  
Care Plans ◽  
Individualized Care ◽  
Ed Visits

Objective. To evaluate the feasibility of an individualized interdisciplinary chronic pain care plan as an intervention to reduce emergency department (ED) visits and improve clinical outcomes among patients who frequented the ED with concerns related to chronic pain. Methods. A prospective cohort design was used in an urban tertiary care hospital. As a pilot program, fourteen patients with chronic pain who frequented the ED (i.e., >12 ED visits within the last year, of which ≥50% were for chronic pain) received a rapid interdisciplinary assessment and individualized care plan that was uploaded to an electronic medical record system (EMR) accessible to the ED and patient’s primary care provider. Patients were assessed at baseline and every three months over a 12-month period. Primary outcomes were self-reported pain and function assessed using psychometrically valid scales. Results. Nine patients completed 12-month follow-up. Missing data and attrition were handled using multiple imputation. Patients who received the intervention reported clinically significant improvements in pain, function, ED visits, symptoms of depression, pain catastrophizing, sleep, health-related quality of life, and risk of future aberrant opioid use. Discussion. Individualized care plans uploaded to an EMR may be worth implementing in hospital EDs for high frequency visitors with chronic pain.

Can the implementation of the Opioid Start Talking form impact the amount of opioid use in patients after ankle fracture repair?

2021 ◽  
Vol 17 (5) ◽  
pp. 397-404
Author(s):  
Benjamin Best, DO ◽  
Alan Afsari, MD ◽  
Rajan Sharma, DO ◽  
James T. Layson, DO ◽  
Marek Denisiuk, DO
Keyword(s):  
Ankle Fracture ◽  
Final Analysis ◽  
Fracture Repair ◽  
Ankle Fractures ◽  
P Value ◽  
Prescription Database ◽  
Opioid Epidemic ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Significant Difference

Objective: As part of 2018 legislation aimed at fighting the opioid epidemic, the Michigan Department of Health and Human Services (MDHHS) published the “Opioid Start Talking” (OST) Form on June 1, 2018. We examined if the implementation of the OST form led to an identifiable decrease in patient opioid use. Specifically, we examined the opioid prescription quantities in patients who sustained ankle fractures that required open reduction internal fixation (ORIF).Design: Retrospective. Hospital medical records and Michigan Automated Prescription Database (MAPS) were analyzed for similar ankle fracture patients operated on by two surgeons prior to and after the initiation of the OST form. Records allowed us to track opioid filling through MAPS for 120 days after surgery in two groups: preimplementation (PRE) and post-implementation (POST) OST groups. The gathered data were analyzed by the investigators along with a staff statistician.Setting: Single-institution orthopedic practice.Patients, participants: Seventy eight patientsMain outcome measure: Average morphine milligram equivalent (MME) per patient encounter.Results: Seventy eight patients were included in the final analysis after applying the exclusion criteria. There were 38 patients in the pre-OST form period and 40 in the post-OST form period groups. The pre-OST and post-OST groups were well matched between the two surgeons. There was no evidence of a statistically significant difference found in the median MME between patients from the pre-period group to the post-period group (median 59 vs 50, P = 0.61). In regard to the injury pattern, the bimalleolar MME median was 50 (38 = 25th percentile, 67 = 75th percentile; min-max 0-175) and the trimalleolar median MME was 63 (39 =25% percentile, 81 = 75th percentile; min-max 0-249) with a P value of 0.20.Conclusions: Overall, the administration of the OST form to patients with ankle fractures did not result in a decrease in MMEs prescribed within 120 days of surgery. Although it is a start in the battle against the opioid epidemic, further evaluation of the effectiveness of the OST form is necessary.

Pessary offer documentation in women undergoing surgery for pelvic organ prolapse at a tertiary care hospital

2020 ◽  
Vol 29 (15) ◽  
pp. 870-873
Author(s):  
Zubaida Masood ◽  
Rahila Imtiaz ◽  
Samia Husain ◽  
Sonia Husain ◽  
Rubina Izhar
Keyword(s):  
Pelvic Organ Prolapse ◽  
Primary Outcome ◽  
Tertiary Care ◽  
Pelvic Organ ◽  
Primary Outcome Measure ◽  
Pelvic Surgery ◽  
Care Hospital ◽  
Concomitant Surgery ◽  
History Of ◽  
Age Range

Background: Women report similar functional outcomes after pessary treatment or surgery for pelvic organ prolapse (POP). Aims: To assess the documentation of pessary counselling in women who underwent surgery for POP. Methods: This was a retrospective cohort study conducted on women who underwent hysterectomy for prolapse. The primary outcome measure was documentation regarding offer of pessary. ‘Pessary offer’ was defined as documentation that clearly stated that the care provider offered pessary to the patient. Findings: Over the study period, 81 hysterectomies took place for POP; pessary offer was documented for only 19 (23.5%) case records. Characteristics significantly associated with pessary offer were history of chronic cough (P=0.031), previous pelvic surgery (P<0.001), no secondary indication for surgery (P=0.012), concomitant surgery performed other than hysterectomy (P=0.046), age range (P<0.001) and BMI range (P<0.001). Conclusion: Pessary offer was documented in less than quarter of cases. This denotes a need to strengthen documentation of offer, counselling for pessary, or both of these.

scholarly journals Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital

CJEM ◽  
2009 ◽  
Vol 11 (01) ◽  
pp. 23-28 ◽  
Author(s):  
Jocelyn Gravel ◽  
Sergio Manzano ◽  
Michael Arsenault
Keyword(s):  
Hospital Admission ◽  
Strong Association ◽  
Tertiary Care ◽  
Pediatric Intensive Care ◽  
Pediatric Emergency ◽  
Primary Outcome Measure ◽  
Care Hospital ◽  
Level 3 ◽  
Dichotomous Outcomes ◽  
Triage Level

ABSTRACTObjective:We evaluated the validity of the Canadian Paediatric Triage and Acuity Scale (Paed-CTAS) for children visiting a pediatric emergency department (ED).Methods:This was a retrospective study evaluating all children who presented to a pediatric university-affiliated ED during a 1-year period. Data were retrieved from the ED database. Information regarding triage and disposition was registered in an ED database by a clerk following patient management. In the absence of a gold standard for triage, admission to hospital, admission to pediatric intensive care unit (PICU) and length of stay (LOS) in the ED were used as surrogate markers of severity. The primary outcome measure was the correlation between triage level (from 1 to 5) and admission to hospital. The correlation between triage level and dichotomous outcomes was evaluated by aχ2test and an analysis of variance (ANOVA) was used to evaluate the association between triage level and ED LOS.Results:Over the 1-year period, 58 529 patients were triaged in the ED. The proportion admitted to hospital was 63% for resuscitation (level 1), 37% for emergent (level 2), 14% for urgent (level 3), 2% for semiurgent (level 4) and 1% for nonurgent (level 5) (p&lt; 0.001). There was also a good correlation between triage levels and LOS and admission to PICU (bothp&lt; 0.001).Conclusion:This computerized version of PaedCTAS demonstrates a strong association with admission to hospital, admission to PICU and LOS in the ED. These results suggest that PaedCTAS is a valid tool for triage of children in a pediatric ED.

scholarly journals Practices regarding prescription and dispensing of drugs in a tertiary care hospital in rural West Bengal, India

2017 ◽  
Vol 6 (11) ◽  
pp. 2712
Author(s):  
Alapan Bandyopadhyay ◽  
Debdut Dhar ◽  
Abhijit Mukherjee ◽  
Sharmistha Bhattacherjee ◽  
Samir Dasgupta
Keyword(s):  
West Bengal ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
International Standards ◽  
Care Hospital ◽  
Cross Sectional ◽  
Prescription Practices ◽  
Patient Interviews ◽  
Essential Drug List ◽  
Tertiary Healthcare

Background: Irrational prescription practices are a distressing global problem, especially in the developing countries. A study was conducted to assess the patterns of prescribing and dispensing drugs in a tertiary healthcare centre serving a large rural population in the eastern India.Methods: A cross-sectional observational study was conducted from July-September 2016 in the general out-patient department and the institution pharmacy of a tertiary care hospital of West Bengal, India. Data were congregated by collection and review of individual prescriptions, measuring the time of interaction between patients and prescribers/dispensers, and conducting patient interviews at exit.Results: Analysis of the collected and tabulated data revealed that after average, 2.5 medicines were prescribed per prescription, with 95.26% being under their generic name. Of the drugs prescribed, 95.79% were from the essential drug list. The average consultation time was 150.0s (SD 62.3s) and average dispensing time was 81.5s (SD 51.2s). Of the drugs prescribed, 86.12% of drugs were actually dispensed from the institution pharmacy but none of the drugs were labeled. The percentage of prescriptions with an antibiotic was 47.83%, while injections were recorded on in 2.83% of the prescriptions. Percentage of patients who had knowledge of the dosage of the drugs prescribed to them was 91.67%.Conclusions: While the study found high percentages of drugs prescribed under generic names high percentage of drugs actually prescribed from the Institution Pharmacy, prescription of drugs from the Essential Drugs List, and a low number of injections per prescription conforming to WHO set standards, it also found a lack of drug labelling, high percentage of prescription of antibiotics to be indicators that do not conform with the WHO set international standards.

scholarly journals It Is Time to Implement Primary Prevention in the Workplace to Ameliorate the Ongoing U.S. Opioid Epidemic

2021 ◽  
pp. 104829112110398
Author(s):  
Aurora B. Le ◽  
Jonathan D. Rosen
Keyword(s):  
Primary Prevention ◽  
The United States ◽  
Evidence Base ◽  
Opioid Epidemic ◽  
Physical And Mental Health ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Health Crisis ◽  
Work Related ◽  
Negative Impacts

The United States’ opioid public health crisis continues having disastrous consequences on communities, including workers and employers. From May 2019 to May 2020, the largest number of drug overdose deaths was recorded over a twelve-month period. The “twindemics” of COVID-19 and opioids underscore the urgent need to address workers’ physical and mental health. Although much has been written about the negative impacts of the opioid epidemic on the workplace, few initiatives have focused on primary prevention, addressing work-related root causes of opioid use disorders (e.g., injury, stress) that may lead to prescription or illicit opioid use. We suggest primary prevention efforts to address the connection between workplace hazards and opioid misuse, dependence, and addiction such as examining patterns of work injury and stress with records of opioid prescription. Government funding should be expanded to support primary prevention and research efforts to strengthen the evidence-base to support workplace primary prevention endeavors.

scholarly journals Association between initial opioid prescription diagnosis type and subsequent chronic prescription opioid use in Rhode Island: a population-based cohort study

BMJ Open ◽  
2022 ◽  
Vol 12 (1) ◽  
pp. e050540
Author(s):  
Benjamin D Hallowell ◽  
Laura C Chambers ◽  
Luke Barre ◽  
Nancy Diao ◽  
Collette Onyejekwe ◽  
...  
Keyword(s):  
Cohort Study ◽  
Rhode Island ◽  
Population Based ◽  
Primary Outcome Measure ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Management Approaches ◽  
Opioid Users ◽  
Prescription Opioid Use

ObjectiveTo identify initial diagnoses associated with elevated risk of chronic prescription opioid use.DesignPopulation-based, retrospective cohort study.SettingState of Rhode Island.ParticipantsRhode Island residents with an initial opioid prescription dispensed between 1 April 2019 and 31 March 2020.Primary outcome measureSubsequent chronic prescription opioid use, defined as receiving 60 or more days’ supply of opioids in the 90 days following an initial opioid prescription.ResultsAmong the 87 055 patients with an initial opioid prescription, 3199 (3.7%) subsequently became chronic users. Patients who become chronic users tended to receive a longer days’ supply, greater quantity dispensed, but a lower morphine milligram equivalents on the initial opioid prescription. Patients prescribed an initial opioid prescription for diseases of the musculoskeletal system and connective tissue (adjusted OR (aOR): 5.9, 95% CI: 4.7 to 7.6), diseases of the nervous system (aOR: 6.3, 95% CI: 4.9 to 8.0) and neoplasms (aOR: 5.6, 95% CI: 4.2 to 7.5) had higher odds of subsequent chronic prescription opioid use, compared with a referent group that included all diagnosis types with fewer than 15 chronic opioid users, after adjusting for confounders.ConclusionsBy focusing interventions and prescribing guidelines on specific types of diagnoses that carry a high risk of chronic prescription opioid use and diagnoses that would benefit equally or more from alternative management approaches, states and healthcare organisations may more efficiently decrease inappropriate opioid prescribing while improving the quality of patient care.

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