Pain Management After Cesarean Delivery Among Women with Opioid Use Disorder: Results from a Retrospective Pregnancy Cohort in a Rural Region of the Midwest.

Background: Increasing numbers of pregnant women are being treated with buprenorphine for opioid use disorder (OUD), which can interfere with effectiveness of other opioids used for pain relief, making perioperative guidance for patients requiring cesarean delivery unclear. Methods: Using a retrospective cohort design, we abstracted 8 years of medical records (2013-2020) from a hospital in rural Michigan. We compared analgesic use (as a proxy for pain) and hospital length of stay (LOS) between groups of women with OUD whose buprenorphine treatment was (1) discontinued before cesarean delivery (discontinuation) versus (2) continued throughout the perioperative period (maintenance). We used t-tests and Fisher's Exact tests for comparison of continuous and categorical variables, respectively. Results: Maternal characteristics reflected the local population (87% non-Hispanic White; 9% American Indian). Of 12,179 mothers giving birth during the study timeframe, 87 met all inclusion criteria (2.4% with diagnosed OUD; 38% of those delivered by cesarean; 76% of those received prenatal buprenorphine treatment). Using the first 2 days of the hospital stay as the standard time window for comparison, there were no differences in perioperative opioid analgesic use (mean ± standard deviation [SD] = 141.6 ± 205.4 vs. 134.0 ± 136.3 morphine milligram equivalents, p = 0.89) or LOS (mean ± SD = 2.9 ± 0.9 vs. 3.3 ± 1.0 days, p = 0.14) between discontinuation (n = 17) versus maintenance (n = 70). There was a lower use of acetaminophen in the discontinuation group (mean ± SD = 3,842.6 ± 2,108.1 vs. 4,938.2 ± 2,008.4 mg, p = 0.0489). Conclusion: This study provides empirical evidence supporting continued buprenorphine treatment for women with OUD throughout the perioperative period of a cesarean delivery in a rural setting, although replication with larger sample sizes would provide more confidence in the results.

Building on a safety culture with transparency by participating in a mentored quality-improvement program for insulin pen safety.

PURPOSE: The experience at a medium-sized regional medical center participating in the ASHP MENTORED QUALITY IMPROVEMENT IMPACT PROGRAM℠ (MQIIP) on Insulin Pen Safety in Hospitals is described. SUMMARY: With the support of top hospital leaders, Munson Medical Center (MMC) applied in June 2014 to participate in the MQIIP to complement its ongoing risk assessment related to the use of pen devices for insulin administration. Nurse knowledge deficits, problems with insulin pen storage and labeling, and improper insulin injection practices identified in baseline assessments for the MQIIP were the basis for process improvements, including new policies and procedures, an electronic alert and education for nurses, and individualized communication with pharmacy and nursing personnel about insulin pen safety. The experiences of other hospitals helped us identify solutions to safety issues and formulate communication strategies for improving insulin pen safety in our hospital. Awareness of the importance of insulin pen safety increased in all staff. Implementing these process improvements during the five-month intervention period resulted in increases in nurse knowledge and improvements in insulin pen storage, labeling, and injection practices, although problems persisted. Additional plans have been made to further enhance the safety of insulin use at MMC. CONCLUSION: The ASHP MQIIP on Insulin Pen Safety in Hospitals provided a structured and supportive approach to identifying and addressing insulin pen safety issues at MMC. The insight gained through participation enabled us to devise strategies to communicate with staff about safety issues and improve the safety of insulin pen use in the institution.