Implementation of order sets for opioid alternatives in community hospital emergency departments

How Can We Get to Equitable and Effective Postpartum Pain Control?

Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.

Clinician Acceptance of Order Sets for Pain Management: A Survey in Two Urban Hospitals

BACKGROUND

Order sets are a clinical decision support (CDS) tool in computerized provider order entry systems. Order set use has been associated with improved quality of care. Particularly related to opioids and pain management, order sets have been shown to standardize and reduce the prescription of opioids. However, clinician-level barriers often limit the uptake of this CDS modality.

OBJECTIVE

To identify the barriers to order sets adoption, we surveyed clinicians on their training, knowledge, and perceptions related to order sets for pain management.

METHODS

We distributed a cross-sectional survey between October 2020 and April 2021 to clinicians eligible to place orders at two campuses of a major academic medical center. Survey questions were adapted from the widely used framework of Unified Theory of Acceptance and Use of Technology. We hypothesize that performance expectancy (PE) and facilitating conditions (FC) are associated with order set use. Survey responses were analyzed using logistic regression.

RESULTS

The intention to use order sets for pain management was associated with PE to existing order sets, social influence (SI) by leadership and peers, and FC for electronic health record (EHR) training and function integration. Intention to use did not significantly differ by gender or clinician role. Moderate differences were observed in the perception of the effort of, and FC for, order set use across gender and roles of clinicians, particularly emergency medicine and internal medicine departments.

CONCLUSION

This study attempts to identify barriers to the adoption of order sets for pain management and suggests future directions in designing and implementing CDS systems that can improve order sets adoption by clinicians. Study findings imply the importance of order set effectiveness, peer influence, and EHR integration in determining the acceptability of the order sets.

The Impact of the Parenteral Opioid Medication Shortages on Opioid Utilization Practices in the Emergency Department of Two University Hospitals

INTRODUCTION

Both opioid and non-opioid analgesics are commonly utilized in treating acute and chronic pain in the emergency department (ED). Opioid stewardship efforts have focused on judicious opioid use and opioid alternatives as first-line analgesics. Parenteral opioid formulations have been impacted by periodic shortages creating the opportunity for a natural experiment to observe how emergency clinician prescribing behavior may be impacted. We investigated the change in analgesic practice related to a period of parenteral opioid shortage at two large urban, academic medical centers.

METHODS

A retrospective review of pharmacy administration data from two academic urban EDs was performed looking at time periods before, during, and after resolution of the parenteral opioid shortage. The data were analyzed by medication, dose, time, number of doses, and oral morphine milligram equivalents (MME) administered per patient.

RESULTS

The percentage of patients who received any opioid among ED visits decreased during the shortage period and did not return to pre-shortage levels after the shortage ended: 11.5% pre, 8.5% during (p=0.01), 7.2% post (NS; p=0.18). The number of doses of either oral or IV opioid doses administered during the shortage decreased significantly: 8.7% pre, 5.6% during (p=0.02) for PO, and 13.7% pre, 9.0% during (p=0.004) for IV, and neither changed during recovery from the shortage. The percentage of patients receiving non-opioid analgesics rose from 30.5% before to 45.8% (p=0.004) after the shortage. Among patients who received opioids, the MME per patient did not change across the time periods: 11.5% before, 11.2% during, 12.7% post.

CONCLUSIONS

A period of restricted opioid use due to parenteral opioid shortages led to less opioid use overall and fewer patients treated with opioids, yet no significant change in opioid MME administered per patient requiring opioids. Overall, the shift in opioid prescribing during the parenteral opioid shortage appeared to be sustained in the post-shortage period.