Integrating Adjuvant Analgesics into Perioperative Pain Practice: Results from an Academic Medical Center

Abstract Background Opioid-sparing postoperative pain management therapies are important considering the opioid epidemic. Total knee arthroplasty (TKA) is a common and painful procedure accounting for a large number of opioid prescriptions. Adjuvant analgesics, nonopioid drugs with primary indications other than pain, have shown beneficial pain management and opioid-sparing effects following TKA in clinical trials. We evaluated the adjuvant analgesic gabapentin for its usage patterns and its effects on opioid use, pain, and readmissions. Methods This retrospective, observational study included 4,046 patients who received primary TKA between 2009 and 2017 using electronic health records from an academic tertiary care medical institute. Descriptive statistics and multivariate modeling were used to estimate associations between inpatient gabapentin use and adverse pain outcomes as well as inpatient oral morphine equivalents per day (OME). Results Overall, there was an 8.72% annual increase in gabapentin use (P < 0.001). Modeled estimates suggest that gabapentin is associated with a significant decrease in opioid consumption (estimate = 0.63, 95% confidence interval = 0.49–0.82, P < 0.001) when controlling for patient characteristics. Patients receiving gabapentin had similar discharge pain scores, follow-up pain scores, and 30-day unplanned readmission rates compared with patients receiving no adjuvant analgesics (P > 0.05). Conclusions When assessed in a real-world setting over a large cohort of TKA patients, gabapentin is an effective pain management therapy that is associated with reduced opioid consumption—a national priority in this time of opioid crisis—while maintaining the same quality of pain management.

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Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial

Pain Medicine ◽

10.1093/pm/pny253 ◽

2018 ◽

Vol 20 (8) ◽

pp. 1584-1591 ◽

Cited By ~ 7

Author(s):

Sylvia H Wilson ◽

Bethany J Wolf ◽

Stefanie M Robinson ◽

Cecil Nelson ◽

Latha Hebbar

Keyword(s):

Cesarean Delivery ◽

Medical Center ◽

Academic Medical Center ◽

Opioid Consumption ◽

Pain Scores ◽

Academic Medical ◽

Intravenous Acetaminophen ◽

Intravenous Morphine ◽

Elective Cesarean ◽

Secondary Outcomes

Abstract Objective Examination of postoperative analgesia with intravenous and oral acetaminophen. Design Prospective, three-arm, nonblinded, randomized clinical trial. Setting A single academic medical center. Subjects Parturients scheduled for elective cesarean delivery. Methods This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects. Results Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group. Conclusions Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.

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Trends in Acute Pain Management for Renal Colic in the Emergency Department at a Tertiary Care Academic Medical Center

Journal of Endourology ◽

10.1089/end.2020.0402 ◽

2020 ◽

Vol 34 (11) ◽

pp. 1195-1202

Author(s):

Hal D. Kominsky ◽

Justin Rose ◽

Amy Lehman ◽

Marilly Palettas ◽

Tasha Posid ◽

...

Keyword(s):

Emergency Department ◽

Pain Management ◽

Acute Pain ◽

Renal Colic ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Acute Pain Management ◽

Academic Medical

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Clinical Team Distribution and Antibiotic Use Patterns at a Tertiary-Care Academic Medical Center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.695 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s168-s169

Author(s):

Rebecca Choudhury ◽

Ronald Beaulieu ◽

Thomas Talbot ◽

George Nelson

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Antibiotic Use ◽

Care Hospital ◽

Hospital Units ◽

Antibiotic Utilization ◽

Academic Medical ◽

Level Data ◽

Utilization Data

Background: As more US hospitals report antibiotic utilization to the CDC, standardized antimicrobial administration ratios (SAARs) derived from patient care unit-based antibiotic utilization data will increasingly be used to guide local antibiotic stewardship interventions. Location-based antibiotic utilization surveillance data are often utilized given the relative ease of ascertainment. However, aggregating antibiotic use data on a unit basis may have variable effects depending on the number of clinical teams providing care. In this study, we examined antibiotic utilization from units at a tertiary-care hospital to illustrate the potential challenges of using unit-based antibiotic utilization to change individual prescribing. Methods: We used inpatient pharmacy antibiotic use administration records at an adult tertiary-care academic medical center over a 6-month period from January 2019 through June 2019 to describe the geographic footprints and AU of medical, surgical, and critical care teams. All teams accounting for at least 1 patient day present on each unit during the study period were included in the analysis, as were all teams prescribing at least 1 antibiotic day of therapy (DOT). Results: The study population consisted of 24 units: 6 ICUs (25%) and 18 non-ICUs (75%). Over the study period, the average numbers of teams caring for patients in ICU and non-ICU wards were 10.2 (range, 3.2–16.9) and 13.7 (range, 10.4–18.9), respectively. Units were divided into 3 categories by the number of teams, accounting for ≥70% of total patient days present (Fig. 1): “homogenous” (≤3), “pauciteam” (4–7 teams), and “heterogeneous” (>7 teams). In total, 12 (50%) units were “pauciteam”; 7 (29%) were “homogeneous”; and 5 (21%) were “heterogeneous.” Units could also be classified as “homogenous,” “pauciteam,” or “heterogeneous” based on team-level antibiotic utilization or DOT for specific antibiotics. Different patterns emerged based on antibiotic restriction status. Classifying units based on vancomycin DOT (unrestricted) exhibited fewer “heterogeneous” units, whereas using meropenem DOT (restricted) revealed no “heterogeneous” units. Furthermore, the average number of units where individual clinical teams prescribed an antibiotic varied widely (range, 1.4–12.3 units per team). Conclusions: Unit-based antibiotic utilization data may encounter limitations in affecting prescriber behavior, particularly on units where a large number of clinical teams contribute to antibiotic utilization. Additionally, some services prescribing antibiotics across many hospital units may be minimally influenced by unit-level data. Team-based antibiotic utilization may allow for a more targeted metric to drive individual team prescribing.Funding: NoneDisclosures: None

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Implementation of a Leeches + Antimicrobial Prophylaxis Order Panel to Optimize Medicinal Leech Use at a Tertiary Care Academic Medical Center

Journal of Pharmacy Practice ◽

10.1177/0897190021993683 ◽

2021 ◽

pp. 089719002199368

Author(s):

Nicole M. Palm ◽

Jill C. Wesolowski ◽

Janet Y. Wu ◽

Pavithra Srinivas

Keyword(s):

Antimicrobial Prophylaxis ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Medicinal Leech ◽

Aeromonas Species ◽

Leech Therapy ◽

Before And After ◽

Timing Of Initiation ◽

Medicinal Leeches

Medicinal leech therapy promotes vascular flow and can be used to salvage grafts. Medicinal leeches have a symbiotic relationship with Aeromonas species and can therefore present a risk of bacterial transmission to patients. Antimicrobial prophylaxis is warranted for the duration of leech therapy, however, an institutional evaluation of 40 patients receiving medicinal leech therapy demonstrated poor adherence with recommendations. An electronic medical record order panel for antimicrobial prophylaxis with medicinal leech therapy was implemented, leading to a subsequent improvement in adherence to prophylaxis use, including significant increases in the ordering of antibiotics and the appropriate timing of initiation in the subsequent 10 patients receiving medicinal leech therapy after panel implementation. Aeromonas infections were rare before and after panel implementation, and developed only in the patient subset with non-optimized prophylaxis.

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Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.578 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s84-s84

Author(s):

Lorinda Sheeler ◽

Mary Kukla ◽

Oluchi Abosi ◽

Holly Meacham ◽

Stephanie Holley ◽

...

Keyword(s):

Screening Tool ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The United States ◽

World Health ◽

Communication Campaign ◽

Electronic Screening ◽

Novel Coronavirus ◽

The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

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Evaluation of Patient Experience from Telemedicine Use for an Anesthesiology Pain Division: Time, Cost, and Patient Satisfaction Analysis (Preprint)

10.2196/preprints.33926 ◽

2021 ◽

Author(s):

Laleh Jalilian ◽

Irene Wu ◽

Jakun Ing ◽

Xuezhi Dong ◽

George Pan ◽

...

Keyword(s):

Patient Satisfaction ◽

Pain Management ◽

Travel Time ◽

Medical Center ◽

Academic Medical Center ◽

Cost Savings ◽

Travel Distance ◽

Patient Cost ◽

Academic Medical ◽

Pain Patients

BACKGROUND An increasing number of patients require outpatient and interventional pain management. To help meet the rising demand for anesthesia pain subspecialty care in rural and metropolitan areas, healthcare providers have utilized telemedicine for pain management of both interventional and chronic pain patients. OBJECTIVE This study describes telemedicine implementation for pain management at an academic pain division in a large metropolitan area. The study estimates patient cost savings from telemedicine, before and after the California COVID-19 "Safer at Home" directive, and patient satisfaction with telemedicine for pain management care. METHODS This was a retrospective, observational case series study of telemedicine use in a pain division at an urban academic medical center. From August 2019 to June 2020, we evaluated 1,398 patients and conducted 2,948 video visits for remote pain management care. We utilize publicly available IRS Statistics of Income data to estimate hourly earnings by zip code in order to estimate patient cost savings. We estimate median travel time, travel distance, direct cost of travel, and time-based opportunity savings and report patient satisfaction scores. RESULTS Telemedicine patients avoided an estimated median roundtrip driving distance of 26 miles and a median travel time of 69 minutes during afternoon traffic conditions. Within sample, the median hourly earnings was $28/hr. Patients saved a median of $22 on gas and parking and a total of $52 per telemedicine visit based on estimated hourly earnings and travel time. Patients evaluated serially with telemedicine for medication management saved a median of $156 over three visits. 91% of patients surveyed (n = 313) were satisfied with their telemedicine experience. CONCLUSIONS Telemedicine use for pain management reduced travel distance, travel time, and travel and time-based opportunity costs for pain patients. We achieved the successful implementation of telemedicine across a pain division in an urban academic medical center with high patient satisfaction and patient cost savings.

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Financial Impact of Tertiary Care in an Academic Medical Center

Annals of Surgery ◽

10.1097/00000658-200006000-00010 ◽

2000 ◽

Vol 231 (6) ◽

pp. 860-868 ◽

Cited By ~ 16

Author(s):

Thomas S. Huber ◽

Lori M. Carlton ◽

Donna G. O’Hern ◽

Nancy S. Hardt ◽

C. Keith Ozaki ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Financial Impact ◽

Academic Medical

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421. Effect of SARs-Cov-2 mRNA Vaccination in Healthcare Workers with Household COVID Exposure

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.621 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S311-S311

Author(s):

Laura Selby ◽

Richard Starlin

Keyword(s):

Healthcare Workers ◽

Screening Program ◽

Medical Center ◽

Severe Disease ◽

Academic Medical Center ◽

Tertiary Care ◽

Limited Data ◽

Viral Shedding ◽

Academic Medical ◽

Significant Burden

Abstract Background Healthcare workers have experienced a significant burden of COVID-19 disease. COVID mRNA vaccines have shown great efficacy in prevention of severe disease and hospitalization due to COVID infection, but limited data is available about acquisition of infection and asymptomatic viral shedding. Methods Fully vaccinated healthcare workers at a tertiary-care academic medical center in Omaha Nebraska who reported a household exposure to COVID-19 infection are eligible for a screening program in which they are serially screened with PCR but allowed to work if negative on initial test and asymptomatic. Serial screening by NP swab was completed every 5-7 days, and workers became excluded from work if testing was positive or became symptomatic. Results Of the 94 employees who were fully vaccinated at the time of the household exposure to COVID-19 infection, 78 completed serial testing and were negative. Sixteen were positive on initial or subsequent screening. Vaccine failure rate of 17.0% (16/94). Healthcare workers exposed to household COVID positive contact Conclusion High risk household exposures to COVID-19 infection remains a significant potential source of infections in healthcare workers even after workers are fully vaccinated with COVID mRNA vaccines especially those with contact to positive domestic partners. Disclosures All Authors: No reported disclosures

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An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States

Journal of Educational Evaluation for Health Professions ◽

10.3352/jeehp.2018.15.31 ◽

2018 ◽

Vol 15 ◽

pp. 31

Author(s):

Nila S. Radhakrishnan ◽

Margaret C. Lo ◽

Rohit Bishnoi ◽

Subhankar Samal ◽

Robert Leverence ◽

...

Keyword(s):

Quality Improvement ◽

Systems Of Care ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

The United States ◽

Case Review ◽

Failure To Rescue ◽

Internal Medicine Residents ◽

Mortality Case

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

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Evaluation of opioid sparing effect of dexmedetomidine and pregabalin using acute pain model in male wistar rats

International Journal of Basic & Clinical Pharmacology ◽

10.18203/2319-2003.ijbcp20193201 ◽

2019 ◽

Vol 8 (8) ◽

pp. 1911

Author(s):

Sudar Codi R. ◽

Sumina . ◽

Uma N. ◽

Manimekalai K.

Keyword(s):

Reaction Time ◽

Pain Management ◽

Heated Surface ◽

Opioid Consumption ◽

Tail Flick ◽

Hot Plate ◽

Plate Method ◽

Opioid Sparing ◽

Male Wistar Rats ◽

Sparing Effect

Background: Adjuvant analgesics are added to pain management regimen to reduce opioid consumption and minimise their side effect. Newer ones like dexmedetomidine and pregabalin have not been thoroughly researched. Objectives of the study to study the opioid sparing effect of dexmedetomidine and pregabalin using tail flick and hot plate method in male wistar rats.Methods: Forty two rats were grouped into seven groups with six in each group. Analgesic activity was tested using tail flick, where in the reaction time to flick its tail on a heated surface was noted. In the hot plate method, the reaction time to withdraw or lick the paws when placed on heated surface was noted.Results: The reaction time to flick its tail was prolonged with dexmedetomidine and pregabalin when combined with opioids even in sub therapeutic doses.Conclusion: Adjuncts like dexmedetomidine and pregabalin can be very useful in mutimodal pain management and also to reduce the opioid consumption.

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