Integration of Pharmacy Student Interns into a Naloxone Telephone Outreach Service.

Opioid overdose remains a significant public health issue in the United States and is the leading cause of accidental death. Naloxone has become increasingly accessible, with greater emphasis placed by health systems and pharmacies on distribution of the safety tool. While the utility of pharmacists in advancing this work is clear, there is limited research on the success of integrating pharmacy students into a naloxone outreach program. The purpose of this project was to implement and evaluate the success of integrating pharmacy student interns into a naloxone telephone outreach service for Veteran patients at risk for opioid overdose. A telephone outreach protocol was developed and reviewed by Clinical Pharmacist Practitioners (CPPs) at the site. Pharmacy student interns were trained to complete naloxone outreach calls, which were supervised by a CPP. In the first three months, 160 patients were identified for outreach based on prescription opioid risk factors. Of the 118 reached by telephone, 92 (78.0%) accepted naloxone and 26 (22.0%) declined. In total, 150 (93.8%) patients received naloxone education via either telephone discussion or letter. Integrating supervised pharmacy student interns into a naloxone telephone outreach service was feasible for interns and CPPs and resulted in a high naloxone acceptance rate.

Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice.

OBJECTIVES: This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences. METHODS: We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis. RESULTS: Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale. CONCLUSIONS: A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.

Improving Care Delivery: Location Timestamps to Enhance Process Measurement of a Clinical Workflow.

Traditional quality improvement (QI) strategies to describe workflow processes rely primarily upon qualitative methods or human-driven observations. These methods may be limited in scope and accuracy when applied to time-based workflow processes. This study sought to evaluate the utility of integrating objective time measurements to augment traditional QI strategies using procedural sedation workflow in a pediatric emergency department as an archetype. METHODS: We applied the FOCUS-Plan-Do-Check-Act framework to reduce the time from arrival to sedation for long-bone fractures. First, we added supplementary framework-defining steps to repeat the Clarifying and Understanding steps. We then extracted objective time-based data from an electronic health record (EHR) system and a real-time locating system (RTLS). We then compared and contrasted the findings of traditional surveys with analyses of timed steps within the sedation workflow. RESULTS: When identifying the source of delays, traditional survey techniques yielded ambiguous and even conflicting results based on clinical roles. The timestamps supported 5 measurable clinical role of subworkflows. By measuring the time to completion for 54 sedation cases, workflow patterns and significant bottlenecks were identified. CONCLUSIONS: Analyzing the time to complete individual tasks provided a more nuanced description of workflow delays and clarity when traditional survey results conflicted. Augmenting traditional QI process maps with EHR and RTLS timestamps better explained workflow bottlenecks, informing the QI team when selecting targets for subsequent Plan-Do-Check-Act work.

Adherence with an Acute Agitation Algorithm and Subsequent Restraint Use.

Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition.

OBJECTIVES: To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS: Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS: Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS: About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department.

ABSTRACT: Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

Naloxone acceptance by outpatient veterans: A risk-prioritized telephone outreach event.

BACKGROUND: Opioid overdose is a major public health concern in the United States. Naloxone education and distribution can decrease the risk of overdose deaths. A previous study showed that a longitudinal, multi-attempt telephone intervention by a single pharmacy resident was effective for distributing naloxone to a high-risk veteran population. OBJECTIVES: The purpose of this project was to investigate whether a team-based, single-attempt telephone outreach event is effective for distributing naloxone to at-risk outpatient veterans. METHODS: The Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) tool was used to identify patients with risk class ≥4. Pharmacy trainees contacted 164 patients and offered naloxone. The primary outcome was the proportion of patients with RIOSORD risk class ≥4 who had naloxone before versus after the intervention. RESULTS: The proportion of patients with RIOSORD class ≥4 who had a naloxone kit before and after the event was 0.28 and 0.63, respectively (difference = 0.35, p < 1 × 10-6). Per-protocol analysis showed that of 164 patients contacted, 67% were reached (n = 109) and 80 patients accepted naloxone, corresponding to a 73% acceptance rate for those reached. CONCLUSIONS: A team-based telephone outreach event is an effective method for distributing naloxone to at-risk outpatient veterans.

The impact of public health interventions on critical illness in the pediatric emergency department during the SARS-CoV-2 pandemic.

Study objective: The impact of public health interventions during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on critical illness in children has not been studied. We seek to determine the impact of SARS-CoV-2 related public health interventions on emergency healthcare utilization and frequency of critical illness in children. Methods: This was an interrupted time series analysis conducted at a single tertiary pediatric emergency department (PED). All patients evaluated by a provider from December 31 through May 14 of 6 consecutive years (2015-2020) were included. Total patient visits (ED and urgent care), shock trauma suite (STS) volume, and measures of critical illness were compared between the SARS-CoV-2 period (December 31, 2019 to May 14, 2020) and the same period for the previous 5 years combined. A segmented regression model was used to explore differences in the 3 outcomes between the study and control period. Results: Total visits, STS volume, and volume of critical illness were all significantly lower during the SARS-CoV-2 period. During the height of public health interventions, per day there were 151 fewer total visits and 7 fewer patients evaluated in the STS. The odds of having a 24-hour period without a single critical patient were >5 times higher. Trends appeared to start before the statewide shelter-in-place order and lasted for at least 8 weeks. Conclusions: In a metropolitan area without significant SARS-CoV-2 seeding, the pandemic was associated with a marked reduction in PED visits for critical pediatric illness.

Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial.

Importance: Timely analgesia is critical for children with injuries presenting to the emergency department, yet pain control efforts are often inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Opioids are historically used for significant pain from traumatic injuries but have concerning adverse effects. Intranasal ketamine may provide an effective alternative. Objective: To determine whether intranasal ketamine is noninferior to intranasal fentanyl for pain reduction in children presenting with acute extremity injuries. Design, Setting, and Participants: The Pain Reduction With Intranasal Medications for Extremity Injuries (PRIME) trial was a double-blind, randomized, active-control, noninferiority trial in a pediatric, tertiary, level 1 trauma center. Participants were children aged 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries between March 2016 and February 2017. Analyses were intention to treat and began in May 2017. Interventions: Intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 µg/kg). Main Outcomes and Measures: The primary outcome was reduction in visual analog scale pain score 30 minutes after intervention. The noninferiority margin for this outcome was 10. Results: Of 90 children enrolled, 45 (50%) were allocated to ketamine (mean [SD] age, 11.8 [2.6] years; 26 boys [59%]) and 45 (50%) to fentanyl (mean [SD] age, 12.2 [2.3] years; 31 boys [74%]). Thirty minutes after medication, the mean visual analog scale reduction was 30.6 mm (95% CI, 25.4-35.8) for ketamine and 31.9 mm (95% CI, 26.6-37.2) for fentanyl. Ketamine was noninferior to fentanyl for pain reduction based on a 1-sided test of group difference less than the noninferiority margin, as the CIs crossed 0 but did not cross the prespecified noninferiority margin (difference in mean pain reduction between groups, 1.3; 90% CI, -6.2 to 8.7). The risk of adverse events was higher in the ketamine group (relative risk, 2.5; 95% CI, 1.5-4.0), but all events were minor and transient. Rescue analgesia was similar between groups (relative risk, 0.89; 95% CI, 0.5-1.6). Conclusions and Relevance: Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk. Trial Registration: ClinicalTrials.gov Identifier: NCT02778880.

Utilizing risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) scores to prioritize offer of rescue naloxone in an outpatient veteran population: A telephone-based project.

BACKGROUND: Since 2014, the Department of Veterans Affairs (VA) has been working to address the ongoing opioid epidemic through opioid-education initiatives, the development of risk calculators, and other risk stratification tools. One primary focus of VA efforts has been the distribution of rescue naloxone kits to veterans at greatest risk of opioid-related adverse events. The purpose of this project was to identify primary care veterans at highest risk for serious opioid-related adverse events using the Risk Index for Overdose and Serious Opioid-Induced Respiratory Depression (RIOSORD) and offer rescue naloxone kits by telephone-based outreach. RIOSORD is a risk-stratification tool developed and validated within the veteran population. METHODS: Veterans identified at highest risk of overdose or opioid-related adverse effects were contacted by telephone or letter to offer to provide a rescue naloxone kit between November 1st, 2016 and February 1st, 2017. The primary outcome of the project was the percentage of patients contacted that agreed to a naloxone prescription. Secondary outcomes included comparative efficacy of phone versus letter contact and reasons for refusal of naloxone if the offer was declined. RESULTS: Of 41 veterans targeted by this project, most were successfully reached by telephone within three attempts (92.7%, n = 38). Approximately two-thirds of those reached by telephone agreed to a prescription for rescue naloxone (n = 26, 63.4%). The veterans that requested rescue naloxone selected the nasal formulation (n = 17) over the intramuscular auto-injector (n = 9). CONCLUSIONS: This project demonstrated that telephone-based outreach can be one method of distributing rescue naloxone to a high-risk patient population without requiring an in-person visit to a provider.

Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Variability exists in the evaluation of nonaccidental trauma (NAT) in the pediatric emergency department because of misconceptions and individual bias of clinicians. Further maltreatment, injury, and death can ensue if these children are not evaluated appropriately. The implementation of guidelines for NAT evaluation has been successful in decreasing differences in care as influenced by race and ethnicity of the patient and their family. Our Specific, Measurable, Achievable, Realistic, and Timely aim was to increase the percent of patients evaluated in the emergency department for NAT who receive guideline-adherent evaluation from 47% to 80% by December 31, 2016. METHODS: The team determined key drivers for the project and tested them by using multiple plan-do-study-act cycles. Interventions included construction of a best practice guideline, provider education, integration of the guideline into workflow, and order set construction to support guideline recommendations. Data were compiled from electronic medical records to identify patients <3 years of age evaluated in the pediatric emergency department for suspected NAT based on chart review. Adherence to guideline recommendations for age-specific evaluation (<6, 6-12, and >12-36 months) was tracked over time on statistical process control charts to evaluate the impact of the interventions. RESULTS: A total of 640 encounters had provider concern for NAT and were included in the analysis. Adherence to age-specific guideline recommendations improved from a baseline of 47% to 69%. CONCLUSIONS: With our improvement methodology, we successfully increased guideline-adherent evaluation for patients with provider concern for NAT. Education and electronic support at the point of care were key drivers for initial implementation.

Quality Improvement-Focused Departmental Grand Rounds Reports: A Strategy to Engage General Surgery Residents.

Background Many institutions are seeking ways to enhance their surgical trainees' quality improvement (QI) skills. Objective To educate trainees about the importance of lifelong performance improvement, chief residents at New York Presbyterian Hospital-Weill Cornell Medicine are members of a multidisciplinary QI team tasked with improving surgical outcomes. We describe the process and the results of this effort. Methods Our analysis used 2 data sources to assess complication rates: the National Surgical Quality Improvement Program (NSQIP) and ECOMP, our own internal complication database. Chief residents met with a multidisciplinary QI team to review complication rates from both data sources. Chief residents performed a case-by-case analysis of complications and a literature search in areas requiring improvement. Based on this information, chief residents met with the multidisciplinary team to select interventions for implementation, and delivered QI-focused grand rounds summarizing the QI process and new interventions. Results Since 2009, chief residents have presented 16 QI-focused grand rounds. Urinary tract infections (UTIs) and surgical site infections (SSIs) were the most frequently discussed. Interventions to improve UTIs and SSIs were introduced to the department of surgery through these reports in 2011 and 2012. During this time we saw improvement in outcomes as measured by NSQIP odds ratio. Conclusions Departmental grand rounds are a suitable forum to review NSQIP data and our internal, resident-collected data as a means to engage chief residents in QI improvement, and can serve as a model for other institutions to engage surgery residents in QI projects.