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Dufendach KR, Lehmann CU, Spooner SA. Special Requirements of Electronic Health Record Systems in Pediatrics: Clinical Report. Pediatrics 2024; 154:e2024068509. [PMID: 39308324 DOI: 10.1542/peds.2024-068509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 07/26/2024] [Accepted: 07/26/2024] [Indexed: 10/02/2024] Open
Abstract
Pediatricians' use of electronic health record (EHR) systems has become nearly ubiquitous in the United States, yet many systems lack full functionality to deliver effective and efficient pediatric care. This clinical report seeks to provide a compendium of core pediatric functionality of importance to child health care providers that may serve as the focus for EHR developers and clinicians as they evaluate their EHR needs. Also reviewed are important but less critical functions, any of which might be of importance in a specific pediatric context. The major areas described here are immunization management, growth and development, social drivers of health tracking, decision support for orders, patient identification, data normalization, privacy, and system functionality standards in pediatric contexts.
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Affiliation(s)
- Kevin R Dufendach
- Divisions of Neonatology and
- Biomedical Informatics, University of Cincinnati, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christoph U Lehmann
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - S Andrew Spooner
- Biomedical Informatics, University of Cincinnati, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Guilcher SJT, Cimino SR, Tadrous M, McCarthy LM, Riad J, Tricco AC, Hagens S, Lien J, Tharmalingam S, Gomes T. Experiences and Outcomes of Using e-Prescribing for Opioids: Rapid Scoping Review. J Med Internet Res 2023; 25:e49173. [PMID: 38153776 PMCID: PMC10784986 DOI: 10.2196/49173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/31/2023] [Accepted: 11/01/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND e-Prescribing is designed to assist in facilitating safe and appropriate prescriptions for patients. Currently, it is unknown to what extent e-prescribing for opioids influences experiences and outcomes. To address this gap, a rapid scoping review was conducted. OBJECTIVE This rapid scoping review aims to (1) explore how e-prescribing has been used clinically; (2) examine the effects of e-prescribing on clinical outcomes, the patient or clinician experience, service delivery, and policy; and (3) identify current gaps in the present literature to inform future studies and recommendations. METHODS A rapid scoping review was conducted following the guidance of the JBI 2020 scoping review methodology and the World Health Organization guide to rapid reviews. A comprehensive literature search was completed by an expert librarian from inception until November 16, 2022. Three databases were electronically searched: MEDLINE (Ovid), Embase (Ovid), and Scopus (Elsevier). The search criteria were as follows: (1) e-prescribing programs targeted to the use or misuse of opioids, including those that were complemented or accompanied by clinically focused initiatives, and (2) a primary research study of experimental, quasi-experimental, observational, qualitative, or mixed methods design. An additional criterion of an ambulatory component of e-prescribing (eg, e-prescribing occurred upon discharge from acute care) was added at the full-text stage. No language limitations or filters were applied. All articles were double screened by trained reviewers. Gray literature was manually searched by a single reviewer. Data were synthesized using a descriptive approach. RESULTS Upon completing screening, 34 articles met the inclusion criteria: 32 (94%) peer-reviewed studies and 2 (6%) gray literature documents (1 thesis study and 1 report). All 33 studies had a quantitative component, with most highlighting e-prescribing from acute care settings to community settings (n=12, 36%). Only 1 (3%) of the 34 articles provided evidence on e-prescribing in a primary care setting. Minimal prescriber, pharmacist, and clinical population characteristics were reported. The main outcomes identified were related to opioid prescribing rates, alerts (eg, adverse drug events and drug-drug interactions), the quantity and duration of opioid prescriptions, the adoption of e-prescribing technology, attitudes toward e-prescribing, and potential challenges with the implementation of e-prescribing into clinical practice. e-Prescribing, including key features such as alerts and dose order sets, may reduce prescribing errors. CONCLUSIONS This rapid scoping review highlights initial promising results with e-prescribing and opioid therapy management. It is important that future work explores the experience of prescribers, pharmacists, and patients using e-prescribing for opioid therapy management with an emphasis on prescribers in the community and primary care. Developing a common set of quality indicators for e-prescribing of opioids will help build a stronger evidence base. Understanding implementation considerations will be of importance as the technology is integrated into clinical practice and health systems.
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Affiliation(s)
- Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie R Cimino
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Jessica Riad
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Andrea C Tricco
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | | | | | | | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
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Rickey L, Auger K, Britto MT, Rodgers I, Field S, Odom A, Lehr M, Cronin A, Walsh KE. Measurement of Ambulatory Medication Errors in Children: A Scoping Review. Pediatrics 2023; 152:e2023061281. [PMID: 37986581 DOI: 10.1542/peds.2023-061281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability. METHODS We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type. RESULTS We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability. CONCLUSIONS Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.
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Affiliation(s)
- Lisa Rickey
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Katherine Auger
- Division of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria T Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Isabelle Rodgers
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Shayna Field
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alayna Odom
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Madison Lehr
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Kathleen E Walsh
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Einhorn LM, Zhao C, Goldstein BA, Raman SR, Cheng J. Impact of state legislation and institutional protocols on opioid prescribing practices following pediatric tonsillectomy. Laryngoscope Investig Otolaryngol 2023; 8:775-785. [PMID: 37342116 PMCID: PMC10278102 DOI: 10.1002/lio2.1074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/22/2023] Open
Abstract
Objectives Tonsillectomy is a common pediatric surgery, and pain is an important consideration in recovery. Due to the opioid epidemic, individual states, medical societies, and institutions have all taken steps to limit postoperative opioids, yet few studies have examined the effect of these interventions on pediatric otolaryngology practices. The primary aim of this study was to characterize opioid prescribing practices following North Carolina state opioid legislation and targeted institutional changes. Methods This single center retrospective cohort study included 1552 pediatric tonsillectomy patient records from 2014 to 2021. The primary outcome was number of oxycodone doses per prescription. This outcome was assessed over three time periods: (1) Before 2018 North Carolina opioid legislation. (2) Following legislation, before institutional changes. (3) After institutional opioid-specific protocols. Results The mean (± standard deviation) number of doses per prescription in Periods 1, 2, and 3 was: 58 ± 53, range 4-493; 28 ± 36, range 3-488; and 23 ± 17, range 1-139, respectively. In the adjusted model, Periods 2 and 3 had lower doses by -41% (95% CI -49%, -32%) and -40% (95% CI -55%, -19%) compared to Period 1. After 2018 North Carolina legislation, dosage decreased by -9% (95% CI -13%, -5%) per year. Despite interventions, ongoing variability in prescription regimens remained in all periods. Conclusion Legislative and institution specific opioid interventions was associated with a 40% decrease in oxycodone doses per prescription following pediatric tonsillectomy. While variability in opioid practices decreased post-interventions, it was not eliminated. Level of evidence 3.
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Affiliation(s)
- Lisa M. Einhorn
- Division of Pediatric Anesthesiology, Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Congwen Zhao
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Benjamin A. Goldstein
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Sudha R. Raman
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Jeffrey Cheng
- Division of Pediatric Otolaryngology, Department of Otolaryngology – Head and Neck Surgery and Communication SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
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Hageman IC, Tien MY, Trajanovska M, Palmer GM, Corlette SJ, King SK. Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice. J Pediatr Surg 2022; 57:1249-1257. [PMID: 35397872 DOI: 10.1016/j.jpedsurg.2022.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia. MATERIAL/METHOD A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records. RESULTS Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge. CONCLUSION There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.
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Affiliation(s)
- Isabel C Hageman
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Faculty of Medicine, Utrecht University, Utrecht, the Netherland.
| | - Melissa Y Tien
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Misel Trajanovska
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Greta M Palmer
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sebastian J Corlette
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sebastian K King
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
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Risk factors associated with recent opioid-related hospitalizations in children: a nationwide analysis. Pediatr Surg Int 2022; 38:843-851. [PMID: 35239012 DOI: 10.1007/s00383-022-05088-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Identifying at-risk children can provide a crucial opportunity for preventative measures to avoid opioid addiction. This study sought to determine at-risk pediatric patients that were previously hospitalized due to other causes prior to their opioid-related admission. METHODS The Nationwide Readmissions Database (2010-2014) was queried for children 1-18 years old with an opioid-related hospitalization. Previous admissions (up to 1 year prior) and associated diagnoses were compared. Results were weighted for national estimates. RESULTS 51,349 opioid-related hospitalizations were identified with an overall in-hospital mortality of 0.8%. Seventeen percent had a previous admission during the same calendar year of which 44% had > 1 and 11% had ≥ 5 prior admissions. Only 4% of prior admissions occurred at a different hospital. Males and females were equally represented, and 82% were ≥ 13 years old. Only 16% of previously admitted patients underwent a major surgical procedure during a previous hospitalization. The most common concomitant diagnoses for patients with prior hospitalizations were drug abuse (37%), chronic pulmonary disease (18%), and depression (10%). CONCLUSION Opioid-related hospitalizations often occur among children with multiple recent admissions, usually to the same hospital. Most patients do not have a history of cancer or recent surgery to account for their opioid use.
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DePhillips M, Watts J, Sample J, Dowd MD. Use of Outpatient Opioids Prescribed From a Pediatric Acute Care Setting. Pediatr Emerg Care 2022; 38:e1298-e1303. [PMID: 35470302 DOI: 10.1097/pec.0000000000002731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Deaths due to prescription opioid overdoses are at record high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy, but little is known about how much is needed to adequately treat acutely painful conditions for outpatients. The purpose of this study was to quantify the usage of opioids prescribed from the pediatric emergency departments of a Midwestern tertiary care children's hospital system. METHODS This was a prospective descriptive study in which patients aged 0 to 17 years seen in 2 pediatric emergency departments who received a prescription for an outpatient opioid were enrolled. The main outcome was opioid doses used at home, which was obtained via phone follow-up. Additional information, including patient demographics, location, prescriber specialty, diagnosis, and opioid name and amount prescribed, was obtained via chart review. RESULTS A total of 295 patients were enrolled, with 281 completing the study (95%). The median numbers of opioid doses prescribed and used were 12 and 2 doses, respectively, with 9 doses in excess. Patients with lower extremity fractures used more opioids than other diagnoses, with a median of 8 doses. The majority of families reported keeping extra doses at home. CONCLUSIONS Prescribed opioid doses exceeded used doses by a factor of 6. Lower extremity fractures required more doses than other acutely painful conditions. We should consider limiting doses prescribed to decrease excess opioids available for misuse and abuse.
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Affiliation(s)
| | | | - Jennifer Sample
- Pharmacology, Toxicology, and Therapeutic Innovations, Children's Mercy Hospital, Kansas City, MO
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Donado C, Solodiuk JC, Mahan ST, Difazio RL, Heeney MM, Starmer AJ, Cravero JP, Berde CB, Greco CD. Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort. Hosp Pediatr 2022; 12:164-173. [PMID: 35059711 DOI: 10.1542/hpeds.2021-005990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation. METHODS We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions. RESULTS Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly. CONCLUSION We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.
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Affiliation(s)
- Carolina Donado
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | - Jean C Solodiuk
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | | | | | - Matthew M Heeney
- Pediatrics, Harvard Medical School, Boston, Massachusetts
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Amy J Starmer
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joseph P Cravero
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | - Charles B Berde
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
| | - Christine D Greco
- Departments of Anesthesiology, Critical Care and Pain Medicine and
- Departments of Anestheasia
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Tan L, Chen W, He B, Zhu J, Cen X, Feng H. A Survey of Prescription Errors in Paediatric Outpatients in Multi-Primary Care Settings: The Implementation of an Electronic Pre-Prescription System. Front Pediatr 2022; 10:880928. [PMID: 35757118 PMCID: PMC9218205 DOI: 10.3389/fped.2022.880928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prescription errors impact the safety and efficacy of therapy and are considered to have a higher impact on paediatric populations. Nevertheless, information in paediatrics is still lacking, particularly in primary care settings. There exists a need to investigate the prevalence and characteristics of prescription errors in paediatric outpatients to prevent such errors during the prescription stage. METHODS A cross-sectional study to evaluate paediatric prescription errors in multi-primary care settings was conducted between August 2019 and July 2021. Prescriptions documented within the electronic pre-prescription system were automatically reviewed by the system and then, potentially inappropriate prescriptions would be reconciled by remote pharmacists via a regional pharmacy information exchange network. The demographics of paediatric patients, prescription details, and types/rates of errors were assessed and used to identify associated factors for prescription using logistic regression. RESULTS A total of 39,754 outpatient paediatric prescriptions in 13 community health care centres were reviewed, among which 1,724 prescriptions (4.3%) were enrolled in the study as they met the inclusion criteria. Dose errors were the most prevalent (27%), with the predominance of underdosing (69%). They were followed by errors in selection without specified indications (24.5%), incompatibility (12.4%), and frequency errors (9.9%). Among critical errors were drug duplication (8.7%), contraindication (.9%), and drug interaction (.8%) that directly affect the drug's safety and efficacy. Notably, error rates were highest in medications for respiratory system drugs (50.5%), antibiotics (27.3%), and Chinese traditional medicine (12.3%). Results of logistic regression revealed that specific drug classification (antitussives, expectorants and mucolytic agents, anti-infective agents), patient age (<6 years), and prescriber specialty (paediatrics) related positively to errors. CONCLUSION Our study provides the prevalence and characteristics of prescription errors of paediatric outpatients in community settings based on an electronic pre-prescription system. Errors in dose calculations and medications commonly prescribed in primary care settings, such as respiratory system drugs, antibiotics, and Chinese traditional medicine, are certainly to be aware of. These results highlight an essential requirement to update the rules of prescriptions in the pre-prescription system to facilitate the delivery of excellent therapeutic outcomes.
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Affiliation(s)
- Lu Tan
- Department of Pharmacy, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Wenying Chen
- Department of Pharmacy, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Binghong He
- Department of Pharmacy, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Jiangwei Zhu
- Department of Pharmacy, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Xiaolin Cen
- Department of Pharmacy, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Huancun Feng
- Department of Pharmacy, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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Choufi S, Mounier S, Merlin E, Rochette E, Delorme J, Authier N, Chenaf C. Opioid Analgesic Prescription in French Children: A National Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:13316. [PMID: 34948923 PMCID: PMC8702064 DOI: 10.3390/ijerph182413316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/26/2022]
Abstract
Codeine use was restricted in 2013 and is currently contraindicated for children below the age of 12 years. We examined how the prescription of opioid analgesics in children in France evolved between 2012 and 2018. Our population-based study from the SNIIRAM database (National System of Health Insurance Inter-Regime Information) was designed to determine trends in opioid prescription from 2012 to 2018 in all French children. The number of children who received at least one opioid prescription gradually declined from 452,665 in 2012 (347.5 children per 10,000) to 169,338 in 2018 (130.3 children per 10,000). This decrease was especially marked for codeine (36 children per 10,000 in 2018 vs. 308.5 children per 10,000 in 2012), whereas the number of tramadol prescriptions increased by 171% in 2018 (94.6 children per 10,000). Despite the increase, strong opioids still formed only a small proportion of prescriptions (2.6 children per 10,000 given opioids in 2018). Overall opioid prescriptions in French children dramatically decreased between 2012 and 2018, probably owing to restrictions on the use of codeine. Codeine has been partly replaced by tramadol. Morphine is still probably underused. This suggests that opioids are being used less often for pain management in children.
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Affiliation(s)
- Samira Choufi
- Pédiatrie, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France; (S.C.); (S.M.); (E.M.)
| | - Simon Mounier
- Pédiatrie, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France; (S.C.); (S.M.); (E.M.)
| | - Etienne Merlin
- Pédiatrie, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France; (S.C.); (S.M.); (E.M.)
- CIC 1405, Unité CRECHE, INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Emmanuelle Rochette
- Pédiatrie, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France; (S.C.); (S.M.); (E.M.)
- CIC 1405, Unité CRECHE, INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Jessica Delorme
- CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Université Clermont Auvergne, F-63003 Clermont-Ferrand, France; (J.D.); (N.A.); (C.C.)
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
| | - Nicolas Authier
- CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Université Clermont Auvergne, F-63003 Clermont-Ferrand, France; (J.D.); (N.A.); (C.C.)
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, F-63001 Clermont-Ferrand, France
| | - Chouki Chenaf
- CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Université Clermont Auvergne, F-63003 Clermont-Ferrand, France; (J.D.); (N.A.); (C.C.)
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, F-63001 Clermont-Ferrand, France
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11
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Kassem AB, Saeed H, El Bassiouny NA, Kamal M. Assessment and analysis of outpatient medication errors related to pediatric prescriptions. Saudi Pharm J 2021; 29:1090-1095. [PMID: 34703362 PMCID: PMC8523327 DOI: 10.1016/j.jsps.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 08/01/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Medication errors are the errors that impact the efficacy and safety of the therapy. The impact of medication errors is higher for certain subjects, such as pediatrics, who require more attention. Hence, the current study aimed to investigate the types and frequency of outpatient medication errors of pediatric subjects related to different prescription types. METHODS A cross-sectional study was carried in several community pharmacies to record the medication errors found in outpatient pediatric prescriptions by gathering data from the outpatient prescriptions besides direct counseling with the subjects and their parents. Many medical resources (disease and drug-related) were used for checking the different aspects of medication errors. The data collection process included a preprepared sheet containing several items representing the medication errors in addition to a counseling session. Data were expressed as percentages and compared through the Chi-square test for results of handwritten and computerized prescriptions. RESULTS 752 outpatient pediatric prescriptions were recruited in the study as they involve medication errors. Among the highest percentage of medication errors was the absence of essential data in the prescription, such as diagnosis, age, and weight. The duration of the therapy and contraindication for some of the prescribed medications were among the highest recorded errors. Among the critical errors were the drug interaction and drug duplication that directly affect the drug's efficacy and safety. There was a significant difference between computerized and handwritten prescriptions regarding the number of medication errors related to each type. CONCLUSION Medication errors related to outpatient pediatric prescriptions vary from one to another prescription with predominant errors that influence the therapy's safety or efficacy. The role of patient counseling and prescription checking is critical for improving patient therapy.
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Affiliation(s)
- Amira B. Kassem
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Noha A. El Bassiouny
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Marwa Kamal
- Clinical Pharmacy Department, Faculty of Pharmacy, Fayoum University, Fayoum, Egypt
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12
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Hassan MM, Rahman OF, Hussain ZB, Burgess SL, Yen YM, Kocher MS. Opioid overprescription in adolescents and young adults undergoing hip arthroscopy. J Hip Preserv Surg 2021; 8:75-82. [PMID: 34567603 PMCID: PMC8460166 DOI: 10.1093/jhps/hnab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/03/2021] [Indexed: 12/16/2022] Open
Abstract
Few studies have examined factors related to the increased consumption of opioids after hip arthroscopy in adolescents and young adults. This study sought to determine prescription patterns following hip arthroscopy in this population, and to determine clinical or surgical factors associated with increased post-operative opioid use. Daily post-operative opioid intake was obtained from pain-control logbooks of adolescents and young adults who underwent hip arthroscopy between January 2017 and 2020. Study outcomes were defined as the median total number of opioid tablets consumed, total days opioids were consumed, mean daily opioid consumption and the ratio of opioids prescribed post-operatively to consumed. Clinical and surgical factors were analyzed to determine any association with opioid consumption. Fifty-eight (20%) patients returned completed logbooks. Most patients (73%) were prescribed 30 oxycodone tablets. The median number of tablets consumed was 7 (range 0–41) over a median duration of 7 days (range 1–22). The median ratio of tablets consumed to prescribed was 20%. Increasing patient age at surgery was associated with increased total number of tablets consumed (r = 0.28, P = 0.04) and to the ratio of tablets consumed to prescribed (r = 0.30, P = 0.03). Patients who were prescribed more than 30 tablets consumed on average 7.8 more tablets than patients prescribed fewer (P = 0.003). Patients who underwent regional anesthesia consumed tablets for longer compared with those who did not (median, 10 versus 4 days; P = 0.03). After undergoing hip arthroscopy, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed.
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Affiliation(s)
- Mahad M Hassan
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Omar F Rahman
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 100 E 77th St, New York, NY 10075, USA
| | - Zaamin B Hussain
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Orthopaedic Surgery, Emory University School of Medicine, 1364 E Clifton Rd NE, Atlanta, GA 30322, USA
| | - Stephanie L Burgess
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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13
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Goodloe JB, Bailey EP, Luce LT, Corrigan CS, Dow MA, Barfield WR, Murphy RF. A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures. JOURNAL OF SURGICAL EDUCATION 2021; 78:1660-1665. [PMID: 33839079 DOI: 10.1016/j.jsurg.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/03/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set. DESIGN A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure. RESULTS There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)). CONCLUSIONS The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.
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Affiliation(s)
- J Brett Goodloe
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Evan P Bailey
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Lindsay T Luce
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Corinne S Corrigan
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Matthew A Dow
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - William R Barfield
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina
| | - Robert F Murphy
- Medical University of South Carolina Department of Orthopaedics and Physical Medicine, Charleston, South Carolina.
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Hunsberger JB, Monitto CL, Hsu A, Yenokyan G, Jelin E. Pediatric surgeon opioid prescribing behavior: A survey of the American Pediatric Surgery Association membership. J Pediatr Surg 2021; 56:875-882. [PMID: 33039104 DOI: 10.1016/j.jpedsurg.2020.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The opioid crisis has led to increasing numbers of overdose fatalities in teens and young adults. Surgery, as a common cause of acute pain in children, drives much of the opioid prescribing in pediatrics. Therefore, we sought to characterize opioid prescribing practices of pediatric surgeons by surveying members of the American Pediatric Surgery Association (APSA). STUDY DESIGN After receiving approval from our institutional review board, we sent an online survey to the entire APSA membership. The survey included four vignettes of common pediatric surgical procedures with questions regarding analgesic prescribing practices, the rationale for these practices, and knowledge about opioid risk mitigation. RESULTS Of 1127 APSA members contacted, 327 (29%) provided survey responses. For all vignettes, opioid prescribing was within standard ranges for 83% of respondents. Eighty-eight percent of respondents prescribed nonopioid pain medicine. Additionally, 25% reported routinely utilizing a prescription drug monitoring program, 64% did not tell patients how to dispose of opioids, and 37% did not know themselves how to dispose of leftover opioids. CONCLUSIONS Prescribing by APSA surgeons is largely within standard ranges, but improvement is needed, particularly regarding opioid disposal. Procedure-specific consensus guidelines for opioid prescribing and opioid risk mitigation strategies are warranted. LEVEL OF EVIDENCE Observational study, level III.
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Affiliation(s)
- Joann B Hunsberger
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287.
| | - Constance L Monitto
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287
| | - Aaron Hsu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287
| | - Gayane Yenokyan
- Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University, Baltimore, MD 21287
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15
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Rieder MJ, Jong G'. The use of oral opioids to control children's pain in the post-codeine era. Paediatr Child Health 2021; 26:120-127. [PMID: 33747307 DOI: 10.1093/pch/pxaa133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/06/2020] [Indexed: 11/14/2022] Open
Abstract
Pain is a common problem for children, and pain management comprises both pharmacologic and nonpharmacologic measures. For moderate to severe pain, oral opioids have been a popular choice for the last few decades. Codeine has historically been the best-known oral opioid for use in children. However, availability and use of codeine have sharply declined due to safety concerns. A variety of other opioids have been used in place of codeine, but data are limited regarding their efficacy and safety in children. While the same pathways metabolize oral oxycodone as codeine, oxycodone's pharmacokinetics varies widely. There are also limited data on the safety and efficacy of oral hydromorphone and tramadol use for children. Oral morphine is the opiate alternative to codeine for which there is the most evidence of safety and efficacy in children. Research is needed to investigate both other opioids and non-opioid approaches to guide evidence-based analgesic therapy and treatment for moderate-to-severe pain in children.
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Affiliation(s)
- Michael J Rieder
- Canadian Paediatric Society, Drug Therapy and Hazardous Substances Committee, Ottawa, Ontario
| | - Geert 't Jong
- Canadian Paediatric Society, Drug Therapy and Hazardous Substances Committee, Ottawa, Ontario
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16
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Rieder MJ, Jong G'. Les opioïdes par voie orale en remplacement de la codéine pour contrôler la douleur chez les enfants. Paediatr Child Health 2021; 26:120-127. [PMID: 33747308 DOI: 10.1093/pch/pxaa134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/06/2020] [Indexed: 11/14/2022] Open
Abstract
La douleur est un problème courant chez les enfants. Des mesures pharmacologiques et non pharmacologiques sont utilisées pour la prendre en charge. Depuis quelques décennies, les opioïdes par voie orale sont populaires pour soulager la douleur modérée à grave. La codéine a longtemps été l'opioïde par voie orale le plus connu pour les enfants. Pour des raisons de sécurité, elle est désormais nettement moins accessible et moins employée. Divers autres opioïdes la remplacent, mais les données sur leur efficacité et leur sécurité sont limitées chez les enfants. L'oxycodone par voie orale emprunte les mêmes voies métaboliques que la codéine, mais sa pharmacocinétique est très variable. Les données sur la sécurité et l'efficacité de l'hydromorphone et du tramadol par voie orale chez les enfants sont également limitées. Lorsqu'on y recourt au lieu de la codéine, la morphine par voie orale est l'opiacé dont la sécurité et l'efficacité sont les mieux démontrées chez les enfants. Des recherches devront être réalisées pour explorer d'autres approches relatives aux médicaments opioïdes et non opioïdes, afin d'orienter les traitements analgésiques fondés sur des données probantes qui soulageront la douleur modérée à grave chez les enfants.
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Affiliation(s)
- Michael J Rieder
- Société canadienne de pédiatrie, comité de pharmacologie et des substances dangereuses, Ottawa (Ontario)
| | - Geert 't Jong
- Société canadienne de pédiatrie, comité de pharmacologie et des substances dangereuses, Ottawa (Ontario)
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17
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Pain Control and Medication Use in Children Following Closed Reduction and Percutaneous Pinning of Supracondylar Humerus Fractures: Are We Still Overprescribing Opioids? J Pediatr Orthop 2021; 40:543-548. [PMID: 33044375 DOI: 10.1097/bpo.0000000000001639] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this 2-part study is to determine opioid prescribing patterns and characterize actual opioid use and postoperative pain control in children following discharge after closed reduction and percutaneous pinning of a supracondylar humerus fracture. METHODS A retrospective study was conducted from 2014 to 2016 to determine pain medication prescribing patterns at a single level 1 trauma center. Next, a prospective, observational study was conducted from 2017 to 2018 to determine actual pain medication use and pain scores in the acute postoperative period. Data were collected through telephone surveys performed on postoperative day 1, 3, and 5. Pain scores were collected using a parental proxy numerical rating scale (0 to 10) and opioid use was recorded as the number of doses taken. RESULTS From 2014 to 2016, there were 126 patients who were prescribed a mean of 47 doses of opioid medication at discharge. From 2017 to 2018, telephone questionnaires were completed in 63 patients. There was no significant difference (P>0.05) in pain ratings or opioid use by fracture type (Gartland), age, or sex. Children required a mean of 4 doses of oxycodone postoperatively. There were 18 (28%) patients who did not require any oxycodone. On average, pain scores were highest on postoperative day 1 (average 5/10) and decreased to clinically unimportant levels (<1) by postoperative day 5. Acetaminophen and ibuprofen were utilized as first-line pain medications in only 25% and 9% of patients, respectively. Two of 3 patients who used >15 oxycodone doses experienced a minor postoperative complication. CONCLUSIONS Pediatric patients have been overprescribed opioids after operative treatment of supracondylar humerus fractures at our institution. Families who report pain scores >5 of 10 and/or persistent opioid use beyond postoperative day 5 warrant further clinical evaluation. Two of 3 pain outliers in this study experienced a minor postoperative complication. With appropriate parental counseling, satisfactory pain control can likely be achieved with acetaminophen and ibuprofen for most patients. If oxycodone is prescribed for breakthrough pain, then the authors recommend limiting to <6 doses. LEVEL OF EVIDENCE Level IV-observational, cohort study.
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Abstract
OBJECTIVE To describe variability in and consequences of opioid prescriptions following pediatric laparoscopic appendectomy. SUMMARY BACKGROUND DATA Postoperative opioid prescribing patterns may contribute to persistent opioid use in both adults and children. METHODS We included children <18 years enrolled as dependents in the Military Health System Data Repository who underwent uncomplicated laparoscopic appendectomy (2006-2014). For the primary outcome of days of opioids prescribed, we evaluated associations with discharging service, standardized to the distribution of baseline covariates. Secondary outcomes included refill, Emergency Department (ED) visit for constipation, and ED visit for pain. RESULTS Among 6732 children, 68% were prescribed opioids (range = 1-65 d, median = 4 d, IQR = 3-5 d). Patients discharged by general surgery services were prescribed 1.23 (95% CI = 1.06-1.42) excess days of opioids, compared with those discharged by pediatric surgery services. Risk of ED visit for constipation (n = 61, 1%) was increased with opioid prescription [1-3 d, risk ratio (RR) = 2.46, 95% CI = 1.31-5.78; 4-6 d, RR = 1.89, 95% CI = 0.83-4.67; 7-14 d, RR = 3.75, 95% CI = 1.38-9.44; >14 d, RR = 6.27, 95% CI = 1.23-19.68], compared with no opioid prescription. There was similar or increased risk of ED visit for pain (n = 319, 5%) with opioid prescription [1-3 d, RR = 1.00, 95% confidence interval (CI) = 0.74-1.32; 4-6 d, RR = 1.31, 95% CI = 0.99-1.73; 7-14 d, RR = 1.52, 95% CI = 1.00-2.18], compared with no opioid prescription. Likewise, need for refill (n = 157, 3%) was not associated with initial days of opioid prescribed (reference 1-3 d; 4-6 d, RR = 0.96, 95% CI = 0.68-1.35; 7-14 d, RR = 0.91, 95% CI = 0.49-1.46; and >14 d, RR = 1.22, 95% CI = 0.59-2.07). CONCLUSIONS There was substantial variation in opioid prescribing patterns. Opioid prescription duration increased risk of ED visits for constipation, but not for pain or refill.
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Abstract
Management of acute pain in children is fundamental to our practice. Its myriad benefits include reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesic approach is now routinely used, informed and judicious use of opioid receptor agonists remains crucial in this treatment paradigm, as long as the benefits and risks are fully understood. Further, an ongoing public health response to the current opioid crisis is required to help prevent new cases of opioid addiction, identify opioid-addicted individuals, and ensure access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain.
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20
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Hush SE, Brady C, Soldanska M, Williams JK. Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty. Cleft Palate Craniofac J 2020; 57:1190-1196. [PMID: 32567352 DOI: 10.1177/1055665620932000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We have previously shown the efficacy of an enhanced recovery after surgery (ERAS) protocol in pediatric cleft palatoplasty for proof of concept (POC). We sought to validate the efficacy of ERAS when expanded to patients of variable age and complexity undergoing primary palatoplasty. MAIN OUTCOME MEASURE(S) Between April 2017 and December 2018, 100 patients were collected prospectively for the expanded assessment (ERAS2) and POC (ERAS1) and compared to historical controls both independently and in aggregate (ERAS(T)). We compared patient demographics, perioperative narcotic administration, length of stay (LOS), and rates of return to service (RTS). RESULTS Despite increased complexity, total narcotic usage (morphine equivalents normalized per weight) during each phase of care was significantly greater in controls when compared to ERAS1, ERAS2, or ERAST, respectively (intraoperative: 0.44 mg/kg vs 0.013 mg/kg vs 0.016 mg/kg vs 0.014 mg/kg; postanesthesia care unit: 0.061 mg/kg vs 0.006 mg/kg vs 0.007 mg/kg vs 0.007 mg/kg; postoperative: 0.389 mg/kg vs 0.009 mg/kg vs 0.026 mg/kg vs 0.017 mg/kg). ERAS1 and ERAS2 groups each demonstrated a decrease in LOS (-36.6%, -26.3%) when compared to controls. Overall, application of ERAS led to a 95.7% reduction in narcotic administration and a 31.7% decrease in LOS when compared to controls. The incidence of RTS was higher in ERAS2 (13.0%) when compared to ERAS1 (2.1%) or controls (2.4%), with the strongest independent predictor being a positive perioperative respiratory viral panel (PRVP). CONCLUSIONS Application of ERAS to palatoplasty patients of advanced age and complexity evidenced consistency with respect to decreased perioperative narcotic administration and shortened LOS. A positive PRVP was found to be an independent predictor of RTS even when ERAS was applied.
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Affiliation(s)
- Stefanie E Hush
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Colin Brady
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Magdalena Soldanska
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Joseph K Williams
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
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21
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Bilgutay AN, Hua H, Edmond M, Blum ES, Smith EA, Elmore JM, Scherz HC, Garcia-Roig M, Kirsch AJ, Cerwinka WH. Opioid utilization is minimal after outpatient pediatric urologic surgery. J Pediatr Urol 2020; 16:108.e1-108.e7. [PMID: 31784376 DOI: 10.1016/j.jpurol.2019.10.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution. MATERIALS AND METHODS After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use. RESULTS Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups. DISCUSSION AND CONCLUSIONS Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.
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Affiliation(s)
- Aylin N Bilgutay
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA.
| | - Hannah Hua
- Children's Healthcare of Atlanta, Atlanta, GA, Department of Statistics, Advanced Analytics Team, USA
| | - Mary Edmond
- Children's Healthcare of Atlanta, Atlanta, GA, Department of Statistics, Advanced Analytics Team, USA
| | - Emily S Blum
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA; Global Center for Medical Innovation, Atlanta, GA, USA
| | - Edwin A Smith
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA
| | - James M Elmore
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA
| | - Hal C Scherz
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA
| | - Michael Garcia-Roig
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA
| | - Wolfgang H Cerwinka
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Pediatric Urology, Emory University, Atlanta, GA, USA
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Implementation of a Modified Enhanced Recovery Protocol in Cleft Palate Repairs. J Craniofac Surg 2019; 30:2154-2158. [DOI: 10.1097/scs.0000000000005718] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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24
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Kahl LK, Stevens MW, Gielen AC, McDonald EM, Ryan L. Characteristics of opioid prescriptions for discharged pediatric emergency department patients with acute injuries. J Investig Med 2019; 67:1024-1027. [PMID: 31109930 DOI: 10.1136/jim-2019-001035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/24/2019] [Accepted: 04/10/2019] [Indexed: 11/03/2022]
Abstract
This study describes the characteristics of opioid prescriptions for pediatric patients discharged from the emergency department (ED) with acute injuries, including type, formulation, quantity dispensed, and associations with patient age group and prescriber level of training. This retrospective cohort study enrolled all acutely injured patients receiving opioid prescriptions at discharge from an urban academic pediatric ED in a 1-year period. Electronic medical records were reviewed to abstract clinical and prescription data and prescriber level of training. Descriptive statistics were used for analysis. We identified 254 patients with injuries who received opioid prescriptions at ED discharge during the study period (mean age 9.5 years, 65% male). The most common injury was fracture (71%). Oxycodone was the opioid most frequently prescribed (96.1%). Liquid formulations were prescribed in 51.6% of cases. The median number of doses prescribed per prescription was 12 (SD±9.1), with a range of 1-50. Residents wrote 72.9% of prescriptions and prescribed more doses than non-residents (15.5 vs 12.2, p=0.01). Post-graduate year 2 (PGY2) residents prescribed more doses than PGY1 or PGY3+ residents. Our data show wide variation in the number of opioid doses prescribed to acutely injured pediatric patients at ED discharge and frequent use of liquid formulation; both factors may place this population at risk for accidental ingestion. These findings also support the development of pediatric clinical guidelines to define appropriate quantities of opioids to prescribe, promote poisoning prevention strategies, and design post-graduate education for medical trainees about safe prescribing practices.
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Affiliation(s)
- Lauren Krystine Kahl
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martha W Stevens
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrea C Gielen
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eileen M McDonald
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leticia Ryan
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Nelson SE, Adams AJ, Buczek MJ, Anthony CA, Shah AS. Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship. J Bone Joint Surg Am 2019; 101:119-126. [PMID: 30653041 DOI: 10.2106/jbjs.18.00657] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture. METHODS Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics. RESULTS Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex. CONCLUSIONS Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Susan E Nelson
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | - Alexander J Adams
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Buczek
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Apurva S Shah
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Bicket MC, Kattail D, Yaster M, Wu CL, Pronovost P. An analysis of errors, discrepancies, and variation in opioid prescriptions for adult outpatients at a teaching hospital. J Opioid Manag 2018; 13:51-57. [PMID: 28345746 PMCID: PMC5697796 DOI: 10.5055/jom.2017.0367] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine opioid-prescribing patterns and rate of three types of errors, discrepancies, and variation from ideal practice. DESIGN Retrospective review of opioid prescriptions processed at an outpatient pharmacy. SETTING Tertiary institutional medical center. PATIENTS We examined 510 consecutive opioid medication prescriptions for adult patients processed at an institutional outpatient pharmacy in June 2016 for patient, provider, and prescription characteristics. MAIN OUTCOME MEASURE(S) We analyzed prescriptions for deviation from best practice guidelines, lack of two patient identifiers, and noncompliance with Drug Enforcement Agency (DEA) rules. RESULTS Mean patient age (standard deviation) was 47.5 years (17.4). The most commonly prescribed opioid was oxycodone (71 percent), usually not combined with acetaminophen. Practitioners prescribed tablet formulation to 92 percent of the sample, averaging 57 (47) pills. We identified at least one error on 42 percent of prescriptions. Among all prescriptions, 9 percent deviated from best practice guidelines, 21 percent failed to include two patient identifiers and 41 percent were noncompliant with DEA rules. Errors occurred in 89 percent of handwritten prescriptions, 0 percent of electronic health record (EHR) computer-generated prescriptions, and 12 percent of non-EHR computer-generated prescriptions. Interrater reliability by κ was 0.993. CONCLUSIONS Inconsistencies in opioid prescribing remain common. Handwritten prescriptions continue to demonstrate higher associations of errors, discrepancies, and variation from ideal practice and government regulations. All computer-generated prescriptions adhered to best practice guidelines and contained two patient identifiers, and all EHR prescriptions were fully compliant with DEA rules.
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Affiliation(s)
- Mark C. Bicket
- Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Deepa Kattail
- Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Myron Yaster
- Professor, Department of Anesthesiology, University of Colorado-Anschutz Medical Campus, Aurora, CO USA
| | - Christopher L. Wu
- Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University
| | - Peter Pronovost
- Professor, Department of Anesthesiology and Critical Care Medicine, Department of Surgery, Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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27
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Yaster M. In Response. Anesth Analg 2018; 122:2064. [PMID: 27195647 DOI: 10.1213/ane.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Myron Yaster
- Departments of Anesthesiology/Critical Care Medicine, Pediatrics, and Neurosurgery, The Johns Hopkins University, Baltimore, Maryland,
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28
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Affiliation(s)
- Maxime Thibault
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Quebec, Canada,
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29
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Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge. Anesth Analg 2017; 125:2113-2122. [PMID: 29189368 DOI: 10.1213/ane.0000000000002586] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The epidemic of nonmedical use of prescription opioids has been fueled by the availability of legitimately prescribed unconsumed opioids. The aim of this study was to better understand the contribution of prescriptions written for pediatric patients to this problem by quantifying how much opioid is dispensed and consumed to manage pain after hospital discharge, and whether leftover opioid is appropriately disposed of. Our secondary aim was to explore the association of patient factors with opioid dispensing, consumption, and medication remaining on completion of therapy. METHODS Using a scripted 10-minute interview, parents of 343 pediatric inpatients (98% postoperative) treated at a university children's hospital were questioned within 48 hours and 10 to 14 days after discharge to determine amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. Multivariable linear regression was used to examine predictors of opioid prescribing, consumption, and doses remaining. RESULTS Median number of opioid doses dispensed was 43 (interquartile range, 30-85 doses), and median duration of therapy was 4 days (interquartile range, 1-8 days). Children who underwent orthopedic or Nuss surgery consumed 25.42 (95% confidence interval, 19.16-31.68) more doses than those who underwent other types of surgery (P < .001), and number of doses consumed was positively associated with higher discharge pain scores (P = .032). Overall, 58% (95% confidence interval, 54%-63%) of doses dispensed were not consumed, and the strongest predictor of number of doses remaining was doses dispensed (P < .001). Nineteen percent of families were informed how to dispose of leftover opioid, but only 4% (8 of 211) did so. CONCLUSIONS Pediatric providers frequently prescribed more opioid than needed to treat pain. This unconsumed opioid may contribute to the epidemic of nonmedical use of prescription opioids. Our findings underscore the need for further research to develop evidence-based opioid prescribing guidelines for physicians treating acute pain in children.
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31
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Myers MF, Zhang X, McLaughlin B, Kissell D, Perry CL, Veerkamp M, Zhang K, Holm IA, Prows CA. Prior opioid exposure influences parents' sharing of their children's CYP2D6 research results. Pharmacogenomics 2017; 18:1199-1213. [PMID: 28745549 DOI: 10.2217/pgs-2017-0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
AIM To determine parents' use of their children's CYP2D6 research result. We hypothesized that perceived utility, likelihood of sharing and actual sharing of results would differ between parents with children previously exposed (cases) or unexposed (controls) to opioids. METHODS We returned results by phone (baseline). We surveyed parents about perceived utility and likelihood of sharing their child's research result at baseline, and actual sharing at 3 and 12 months. RESULTS Cases were more likely than controls to agree that they (p = 0.022) and the doctors (p = 0.041) could use the results to care for their child, to report higher likelihood of sharing (p = 0.042) and to actually share results with the child's doctor (p = 0.026). CONCLUSION Prior opioid exposure influenced perceived clinical utility and sharing behaviors.
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Affiliation(s)
- Melanie F Myers
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Xue Zhang
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Brooke McLaughlin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Diane Kissell
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Cassandra L Perry
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA
| | - Matthew Veerkamp
- Center for Autoimmune Genomics & Etiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kejian Zhang
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Ingrid A Holm
- Division of Genetics & Genomics & The Manton Center for Orphan Disease Research, Department of Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Cynthia A Prows
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Patient Services, Department of Clinical Shared Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Chiao FB, Wang A. An Examination of Disparities in Pediatric Pain Management Centered on Socioeconomic Factors and Hospital Characteristics. J Racial Ethn Health Disparities 2017; 5:73-77. [PMID: 28181199 DOI: 10.1007/s40615-017-0343-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 01/14/2017] [Accepted: 01/15/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Very little is known about pediatric pain management resource differences. In contrast, disparities in pain management within the adult population are known to exist. This research examined whether significant differences exist between hospitals in the state of New York and what factors impact these pain resources. METHODS The study was approved by the institutional review board. A questionnaire was sent to the anesthesia/pediatric/pain directors of every hospital in the state of New York via SurveyMonkey. Poverty-enriched areas were identified based on the Census Bureau definition of poverty-enriched areas. The Chi-square test or Fisher exact test was used. Analyses were conducted to compare hospitals with and without a pediatric pain service (PPS) on several hospital characteristics. All analyses were in SAS-V9.4. RESULTS Of 160 physicians contacted, 40 completed the survey. Twenty-five percent reported that their hospital had a PPS. In these hospitals, 60% were separate from the adult pain service and 90% performed neuraxial but 30% did not offer more specialized nerve blocks. Socioeconomic status in which the hospital is situated did not impact the likelihood of having a PPS. PPSs were significantly more likely to be present in academic centers (p = 0.05) and children's hospitals (p = 0.01). Rural hospitals were least likely to have a PPS (0%). CONCLUSION A minority of hospitals have a PPS and disparity exists. The results indicate to us that targeting rural areas and community hospitals for enhancement of PPS would be valuable. Additional teaching of peripheral nerve blocks would also be valuable.
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Affiliation(s)
- Franklin B Chiao
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medical College, New York 525 East 68th St, New York, NY, 10065, USA.
| | - Alan Wang
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medical College, New York 525 East 68th St, New York, NY, 10065, USA
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