Correlates of Staff Acceptability of a Novel Telemedicine-Delivered Medications for Opioid Use Disorder Program in a Rural Detention Center.

Opioid overdose death is significantly increased immediately following incarceration. Evidence-based medications are underutilized in rural jails and detention centers. We have reported our efforts to address this gap through telemedicine-based medications for opioid use disorder treatment (tele-MOUD) for incarcerated patients. Staff acceptance and perceptions are critically important factors in the assurance of program validation. We assessed tele-MOUD acceptability and perceptions of effectiveness and stigma in one detention center. Overall, we found that jail staff's general acceptability of the program was rather low, as was perceived effectiveness of MOUD, while stigmatizing beliefs were present. Furthermore, tele-MOUD acceptability was positively correlated with perceptions of MOUD effectiveness and negatively correlated with stigmatizing notions of MOUD (p's < 0.001). Findings suggest the need for educational interventions. Future research investigating the potential moderating effects of training on staff acceptability of jail-based tele-MOUD will support the implementation and sustainability of these life-saving programs.

Impact of an Educational Intervention to Improve Physician Adherence to Bronchiolitis Clinical Practice Guidelines: A Pre-Post Intervention Study.

Bronchiolitis is the leading cause of infant hospitalizations in the United States. Despite clinical practice guidelines discouraging the utilization of non-evidence-based therapies, there continues to be wide variation in care and resource utilization. A pre-post physician focused educational intervention was conducted with the aims to reduce the use of non-evidence-based medical therapies, including bronchodilators, among patients admitted for bronchiolitis. Among patients meeting inclusion criteria (pre: n = 45; post: n = 47), bronchodilator use decreased by 50% ( P < .001). Antibiotic use increased by 9% ( P < .02), although results remained within published acceptable utilization rates of less than 19%. There were no statistical differences in chest X-ray, respiratory viral panel, and steroid use. There were no differences in number of pediatric intensive care unit transfers, 30-day readmission rates, and mean length of stay. The findings demonstrate that a physician-focused educational intervention highlighting American Academy of Pediatrics clinical practice guidelines resulted in reduced utilization of bronchodilators.

Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings.

BACKGROUND: The United States is facing an epidemic of opioid use and misuse leading to historically high rates of overdose. Community-based overdose education and naloxone distribution has effectively trained lay bystanders to recognize signs of overdose and administer naloxone for reversal. There has been a movement to encourage physicians to prescribe naloxone to all patients at risk of overdose; however, the rate of physician prescribing remains low. This study aims to describe resident knowledge of overdose risk assessment, naloxone prescribing practices, attitudes related to naloxone, and barriers to overdose prevention and naloxone prescription. METHODS: The HOPE (Hospital-based Overdose Prevention and Education) Initiative is an educational campaign to teach internal medicine residents to assess overdose risk, provide risk reduction counseling, and prescribe naloxone. As part of a needs assessment, internal medicine residents at an academic medical center in Baltimore, Maryland, were surveyed in 2015. Data were collected anonymously using Qualtrics. RESULTS: Ninety-seven residents participated. Residents were overwhelmingly aware of naloxone (80%) and endorsed a willingness to prescribe (90%). Yet despite a high proportion of residents reporting patients in their panels at increased overdose risk (79%), few had prescribed naloxone (15%). Residents were willing to discuss overdose prevention strategies, although only a minority reported doing so (47%). The most common barriers to naloxone prescribing were related to knowledge gaps in how to prescribe and how to assess risk of overdose and identify candidates for naloxone (52% reporting low confidence in ability to identify patients who are at risk). CONCLUSIONS: Medicine residents are aware of naloxone and willing to prescribe it to at-risk patients. Due to decreased applied knowledge and limited self-efficacy, few residents have prescribed naloxone in the past. In order to improve rates of physician prescribing, initiatives must help physicians better assess risk of overdose and improve prescribing self-efficacy.

Outcomes following thoracoabdominal resection of neuroblastoma.

OBJECTIVE: To evaluate the intraoperative and postoperative care of children following thoracoabdominal resection of neuroblastoma. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit (PICU) of major pediatric cancer center. PATIENTS: Eighty-eight patients undergoing thoracoabdominal resection of neuroblastoma over a 6-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical data were collected, including: length of PICU stay (LOS-P), duration of mechanical ventilation (MVD), mean arterial blood pressure, central venous pressure (CVP), fluid management, pressor use, and mortality. Twenty-one patients required inotropic/vasopressors support pressors following surgery. Patients who received pressors had longer operative times (p < .05) and received less intraoperative fluid (p < .05), but had the same estimated blood loss and urine output as nonpressor (NP) patients. Among the patients who received pressors, the MVD was 57 hrs, compared with 24 hrs in the NP group (p < .01). The LOS-P was 118 hours in the pressors group, vs. 69 hrs in the NP group (p < .01). The mean arterial blood pressure was lower and the CVP was higher in the pressors group compared with the NP group, and pressors patients received significantly more fluid postoperatively (p < .01). When pressors were initiated at a low CVP (<8), MVD was 39 hrs compared with 71 hrs when pressors were started at a higher CVP (p = .08). LOS-P was only slightly shorter in the low CVP group, 112 hrs vs. 123 hours (p = NS). The PICU mortality rate was 0%. CONCLUSIONS: Patients who received pressors had longer operative times and received less intraoperative fluid. Subsequently, they required more postoperative fluid, which is likely the result of hemodynamic instability leading to longer MVD and LOS-P. A prospective study evaluating operative fluid management and optimal time for initiation of pressors, in addition to the role of catecholamines and cytokines in this unique postoperative patient population is indicated.