Outcomes of Combined Opioids and Benzodiazepines Consumption in Elderly Trauma: A Retrospective Cohort Study.

BACKGROUND: Acute substance intoxication is associated with traumatic injury and worse hospital outcomes. The objective of this study was to evaluate the association between simultaneous opioids and benzodiazepines (OB) use and hospital outcomes in elderly trauma patients. METHODS: We performed a retrospective analysis using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 database. We included trauma patients (age ≥ 65 years) examined by urine toxicology within 24 hours of presentation. The primary outcome was in-hospital mortality. Secondary outcomes included hospital and ICU lengths of stay (HLOS AND ICULOS), in-hospital complications (eg, ventilator-associated pneumonia), unplanned intubation, and duration of mechanical ventilation. Patients were stratified being both positive for opioids and benzodiazepines (OB+) or not (OB-) based on having positive or negative drug screen for both drugs, respectively. A 1:1 propensity score matching was performed controlling for demographics (eg, age and sex), comorbidities (eg, alcoholism), and injury characteristics. RESULTS: Of 77,311 tested patients, 849 OB+ were matched to OB- patients. Compared to OB- group, OB+ patients were more likely to have unplanned intubation (26 [3.1%] vs 8 [0.9%], P = 0.002) and had prolonged HLOS (≥2 days: 683 [84.0%] vs 625 [77.8%], P = 0.002). There were no differences in all other outcomes (P > 0.05). CONCLUSIONS: The OB intake is associated with higher incidence of unplanned intubation and longer HLOS in elderly trauma patients. Early identification of elderly trauma patient with OB+ can help provide necessary pharmacologic and behavioral interventions to treat their substance use and potentially improve outcomes.

Nurse Performance Metrics: A Scoping Review.

OBJECTIVE: The purposes of this scoping review are: 1) to identify instances in the literature that describe measuring individual nurse performance and 2) characterize those metrics. BACKGROUND: The impact of nurses on patient outcomes has been demonstrated at the unit or hospital level, with nurses measured in aggregate. There is an opportunity to evaluate individual nurse performance by creating metrics that capture it. METHODS: A scoping review based on the framework published by the Joanna Briggs Institute was performed. RESULTS: Researchers identified 12 articles. Three themes were trended: the emerging nature of these metrics in the literature, variability in their applications, and performance implications. CONCLUSIONS: Individual nurse performance metrics is an emerging body of research with variability in the types of metrics developed. There is an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics and to use them to support nursing practice and patient care.

One-way-street revisited: Streamlined admission of critically-ill trauma patients.

INTRODUCTION: Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding. MATERIALS & METHODS: This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing. RESULTS: A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018). CONCLUSION: This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.

A multidisciplinary approach to decreasing length of stay in acute care surgery patients.

AIM: To decrease hospital length of stay in acute care surgery patients. DESIGN: An observational cohort quality improvement project at a single tertiary referral centre. METHODS: A multidisciplinary team of physicians, nurses, case managers, and physical and occupational therapists was created to identify patients at risk for prolonged length of stay and implement weekly multidisciplinary rounding, with a systematic method of tracking progress in real time. The main outcome measure was hospital length of stay. The observed/expected ratios for length of stay 2 years before (2012-2014) and after (2014-2016) the intervention were compared. RESULTS: A total of 6,120 patients was analysed. Early identification and action on barriers to discharge created a significant decrease in risk-adjusted acute care surgery patient days per year (96 days) with limited added cost (1-2 hr per week). Patients discharged to home with or without services benefited most. CONCLUSION: Decreasing length of stay in acute care surgery patients is possible without adding a significant burden to healthcare providers. IMPACT: We describe a comprehensive, multidisciplinary initiative to decrease the length of stay of acute care surgery patients. Institutions can use existing resources in a sustainable manner to create a significant decrease in patient days per year with limited added cost. REGISTRATION: https://osf.io/zfc3t.

Variation of Opioid Prescribing Patterns among Patients undergoing Similar Surgery on the Same Acute Care Surgery Service of the Same Institution: Time for Standardization?

BACKGROUND: Diversion of unused prescription opioids is a major contributor to the current United States opioid epidemic. We aimed to study the variation of opioid prescribing in emergency surgery. METHODS: Between October 2016 and March 2017, all patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, or inguinal hernia repair in the acute care surgery service of 1 academic center were included. For each patient, we systematically reviewed the electronic medical record and the prescribing pharmacy platform to identify: (1) history of opioid abuse, (2) opioid intake 3 months preoperatively, (3) number of opioid pills prescribed, (4) prescription of nonopioid pain medications (eg, acetaminophen, ibuprofen), and (5) the need for opioid prescription refills. The mean and range of opioid pills prescribed, as well as their oral morphine equivalent, were calculated. RESULTS: A total of 255 patients were included (43.5% laparoscopic appendectomy, 44.3% laparoscopic cholecystectomy, and 12.1% inguinal hernia repair). The mean age was 47.5 years, 52.1% were female, 11.4% had a history of opioid use, and 92.5% received opioid prescriptions upon hospital discharge. Only 70.9% of patients were instructed to use nonopioid pain medications. The mean and range of opioid pills prescribed were 17.4; 0-56 (laparoscopic appendectomy), 17.1; 0-75 (laparoscopic cholecystectomy), and 20.9; 0-50 (inguinal hernia repair), while the range of prescribed oral morphine equivalent was 0-600 mg for laparoscopic appendectomy/laparoscopic cholecystectomy and 0-375 mg for inguinal hernia repair. No patients required any opioid medication refills. CONCLUSION: Even within the same surgical service, wide variation of opioid prescription was observed. Guidelines that standardize pain management may help prevent opioid overprescribing.

The impact of the 2007 graduated driver licensing law in Massachusetts on the rate of citations and licensing in teenage drivers.

OBJECTIVE: We recently demonstrated that the 2007 Massachusetts Graduated Driving Licensing (GDL) law decreased the rate of motor vehicle crashes in teenage drivers. To better understand this decrease, we sought to examine the law's impact on the issuance of driving licenses and traffic citations to teenage drivers. METHODS: Citation and license data were obtained from the Massachusetts Department of Transportation. Census data were obtained from the Census Data Center. Two study periods were defined: pre-GDL (2002-2006) and post-GDL (2007-2012). Two populations were defined: the study population (aged 16-17) and the control population (aged 25-29). The rates of licenses per population were compared pre- vs. post-GDL for the study group. The numbers of total, state, and local citations per population were compared pre- vs. post-GDL for both populations. A sensitivity analysis was performed for the rates of citations using licenses issued as a denominator. RESULTS: While licenses per population obtained by the study group decreased over the entire period, there was no change in the rate of decrease per year pre- vs. post-GDL (2.0% vs. 1.4%; p=0.6392). In the study population, total, state, and local citations decreased post-GDL (17.8% vs. 8.1%, p<0.0001; 3.7% vs. 2.2%, p<0.0001; 14.1% vs. 5.8%, p<0.0001, respectively). In the control group, total and state citations did not change (26.7% vs. 23.9%, p=0.3606; 9.2% vs. 10.2%, p=0.3404, respectively), and local citations decreased (17.5% vs. 13.7%, p=0.0389). The rates of decrease per year for total, state, and local citations were significantly greater in the study population compared with control (p<0.0001, p=0.0002, p<0.0001, respectively). CONCLUSIONS: The 2007 GDL law in Massachusetts was associated with fewer traffic citations without a change in the rate of licenses issued to teenagers. These findings suggest that 2007 GDL may be improving driving habits as opposed to motivating teenagers to delay the issuing of licenses.

"One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay.

Emergency department (ED) overcrowding remains a significant problem in many hospitals, and results in multiple negative effects on patient care outcomes and operational metrics. We sought to test whether implementing a quality improvement project could decrease ED LOS for trauma patients requiring an ICU admission from the ED, specifically by directly admitting critically ill trauma patients from the ED CT scanner to an ICU bed. This was a retrospective study comparing patients during the intervention period (2013-2014) to historical controls (2011-2013). Critically ill trauma patients requiring a CT scan, but not the operating room (OR) or Interventional Radiology (IR), were directly admitted from the CT scanner to the ICU, termed the "One-way street (OWS)". Controls from the 2011-2013 Trauma Registry were matched 1:1 based on the following criteria: Injury Severity Score; mechanism of injury; and age. Only patients who required emergent trauma consult were included. Our primary outcome was ED LOS, defined in minutes. Our secondary outcomes were ICU LOS, hospital LOS and mortality. Paired t test or Wilcoxon signed rank test were used for continuous univariate analysis and Chi square for categorical variables. Logistic regression and linear regressions were used for categorical and continuous multivariable analysis, respectively. 110 patients were enrolled in this study, with 55 in the OWS group and 55 matched controls. Matched controls had lower APACHE II score (12 vs. 15, p = 0.03) and a higher GCS (14 vs. 6, p = 0.04). ED LOS was 229 min shorter in the OWS group (82 vs. 311 min, p < 0.0001). The time between CT performed and ICU disposition decreased by 230 min in the OWS arm (30 vs. 300 min, p < 0.001). There was no difference in ED arrival to CT time between groups. Following multivariable analysis, mortality was primarily predicted by the APACHE II score (OR 1.29, p < 0.001), and not ISS, mechanism of injury, or age. After controlling for APACHE II score, there was no difference in mortality between the two cohorts (OR = 0.49, p = 0.28). Expedited admission of critically ill trauma patients immediately following CT imaging significantly reduced ED LOS by 3.82 h (229 min), without a change in ICU LOS, hospital LOS, or mortality. Further studies are needed to assess the impact of expedited admission on morbidity and mortality.