Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Cross-over Trial.

BACKGROUND: The opioid crisis presents many challenges for family practice providers in rural communities who treat patients with chronic non-cancer pain (CNCP). Unfortunately, evidence for effective opioid reduction strategies is sparse. We evaluated the effects of implementing a comprehensive opioid reduction protocol on overall opioid prescribing among patients with chronic non-cancer pain in our rural family medicine clinics. METHODS: We compared mean daily milligrams morphine equivalent (MME) prescribed to patients with CNCP in our rural family medicine clinic (n = 93) with another matched clinic (n =93) after implementation of our comprehensive protocol. We also compared mean daily MME prescribed to our patients with CNCP before and after implementation of the protocol. In a subsequent cross over phase, we examined the effects of the protocol when applied to the original control group patients. RESULTS: Mean daily MME in the intervention clinic (29.77) was significantly lower than the control clinic (93.2) after the intervention (t = 6.03; P < .00). Mean daily MME in the intervention group was significantly lower after implementation of the protocol (29.77) than before the protocol (MME 80.34) (t = 5.889; P < .00). After crossover, the mean daily MME was significantly lower (14.34) in the original control group than prior to the cross over intervention (85.68); (t = 8.19; P = .00). DISCUSSION: Our comprehensive opioid reduction protocol led to significant reductions in opioid prescribing in our rural family medicine clinics. Future studies should include important qualitative outcome measures such as patient function.

Pediatric DNAR orders in the perioperative period.

Do not attempt resuscitation (DNAR) orders are a formal expression of the intention to refrain from resuscitation. Since their inception in 1974, such orders have become widely accepted within the hospital setting. However, their acceptance in theatres where anesthesia may cause cardiovascular instability, outcomes from cardiac arrest are improved and when there is a cross-over of techniques between anesthetic practice and resuscitation, has been more problematic. In order to ascertain the opinions on DNAR orders in the perioperative period, a questionnaire was sent to all consultant members of the Association of Paediatric Anaesthetists of Great Britain and Ireland, which asked about DNAR orders, resuscitation under anesthesia and included a number of case studies. Of the 280 respondents, 160 (57.1%) agreed that an anesthetist could alter the order in the perioperative period with 41 (14.6%) stating that they would always suspend such an order. Most anesthetists agreed that they would discuss DNAR orders during their preoperative assessment but could not agree as to which interventions constituted normal anesthetic practice as opposed to resuscitation. At present, there is variation in practice between pediatric anesthetists over suspension of DNAR orders in the perioperative period and no specific guidelines to refer to. We suggest that guidelines be produced and that these should take into account the work that has already taken place and guidelines published by other anesthetic communities.

A feasibility study of signed consent for the collection of patient identifiable information for a national paediatric clinical audit database.

OBJECTIVES: To investigate the feasibility of obtaining signed consent for submission of patient identifiable data to a national clinical audit database and to identify factors influencing the consent process and its success. DESIGN: Feasibility study. SETTING: Seven paediatric intensive care units in England. PARTICIPANTS: Parents/guardians of patients, or patients aged 12-16 years old, approached consecutively over three months for signed consent for submission of patient identifiable data to the national clinical audit database the Paediatric Intensive Care Audit Network (PICANet). MAIN OUTCOME MEASURES: The numbers and proportions of admissions for which signed consent was given, refused, or not obtained (form not returned or form partially completed but not signed), by age, sex, level of deprivation, ethnicity (South Asian or not), paediatric index of mortality score, length of hospital stay (days in paediatric intensive care). RESULTS: One unit did not start and one did not fully implement the protocol, so analysis excluded these two units. Consent was obtained for 182 of 422 admissions (43%) (range by unit 9% to 84%). Most (101/182; 55%) consents were taken by staff nurses. One refusal (0.2%) was received. Consent rates were significantly better for children who were more severely ill on admission and for hospital stays of six days or more, and significantly poorer for children aged 10-14 years. Long hospital stays and children aged 10-14 years remained significant in a stepwise regression model of the factors that were significant in the univariate model. CONCLUSION: Systematically obtaining individual signed consent for sharing patient identifiable information with an externally located clinical audit database is difficult. Obtaining such consent is unlikely to be successful unless additional resources are specifically allocated to training, staff time, and administrative support.

Bereavement in paediatric intensive care.

The death of a child is a very sad event in anyone's life. It also affects all staff in paediatric intensive care units in different ways at different times. The publication of standards of bereavement care in paediatric intensive care hopes to be able to assist medical and nursing staff to understand and feel more confident in this emotionally difficult area of medicine. The aim of this article is to summarize some of the major points made in the document.