Effect of a Multimodal Analgesic Protocol on Short-Term and Long-Term Opioid Use After Orthopaedic Trauma.

OBJECTIVE: To determine whether the use of a multimodal analgesic protocol reduced short-term and long-term opioid use in patients hospitalized after orthopaedic trauma. DESIGN: Retrospective pre-post intervention study. SETTING: Regional, academic, Level 1 trauma center in Central Kentucky. PATIENTS/PARTICIPANTS: Patients were hospitalized after orthopaedic injury before (n = 393) and after (n = 378) the implementation of a multimodal analgesic protocol. INTERVENTION: The intervention involved a multimodal analgesic protocol consisting of acetaminophen, ibuprofen/ketorolac, gabapentinoids, skeletal muscle relaxants, and standardized doses of opioids plus standardized pain management education before hospital discharge. MAIN OUTCOME MEASUREMENTS: End points included discharge opioid prescription, days' supply and daily morphine milligram equivalent (MME), and long-term opioid use after hospitalization. Opioid use in the 90 days before and after hospitalization was assessed using state prescription drug monitoring program data. RESULTS: Discharge opioid prescription rates were similar in the intervention and control cohorts [79.9% vs. 78.4%, odds ratio (OR) 1.30 (0.83-2.03), P = 0.256]. Patients in the intervention cohort received a shorter days' supply [5.7 ± 4.1 days vs. 8.1 ± 6.2 days, rate ratio 0.70 (0.65-0.76), P < 0.001] and lower average daily MME [34.8 ± 24.9 MME vs. 51.5 ± 44.0 MME, rate ratio 0.68 (0.62-0.75), P < 0.001]. The incidence of long-term opioid use was also significantly lower in the intervention cohort [7.7% vs. 12.0%, OR 0.53 (0.28-0.98), P = 0.044]. CONCLUSIONS: Implementation of a multimodal analgesic protocol was associated with reductions in both short-term and long-term opioid use, including long-term opioid therapy, after orthopaedic trauma. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Suspected Malignant Hyperthermia and the Application of a Multidisciplinary Response.

PURPOSE: Malignant hyperthermia (MH) is a critical and potentially life-threatening emergency associated with inhaled anesthetic and depolarizing neuromuscular blocker administration. This is a single center's response to MH. SUMMARY: When signs of MH are observed, a page for "anesthesia STAT-MH crisis" is called, triggering a multidisciplinary response, including the deployment of a Malignant Hyperthermia Cart. The MH cart and the delegation of duties allows nurses, physicians and pharmacists to quickly understand their role in the stabilization, transition and recovery of a suspected MH patient. CONCLUSION: This case highlights the importance of multi-disciplinary involvement in these rare, but potentially fatal, cases.

Prevalence and predictors of HIV testing among a probability sample of homeless women in Los Angeles County.

OBJECTIVES: To describe the prevalence and predictors of HIV testing in a probability cluster sample of urban homeless women. METHODS: Analysis of data from the University of California Los Angeles-RAND Access to Health Care for Homeless Women of Reproductive Age Study, a survey conducted in six waves from January 1997 through November 1997 at shelters and soup kitchens in Los Angeles (LA) County, California. The sampling unit consists of homeless woman-visits, and data were collected using structured face-to-face interviews for which respondents were paid US dollars 10. Each sampling unit was weighted to take into account the frequency with which the respondent used shelters or meal programs. The main outcome measure was receipt of HIV test in the past year. RESULTS: The response rate was 83%, and the final sample size was N=970. Sixty-eight percent of our sample reported receiving an HIV test in the past year, and 1.6% reported ever being diagnosed with HIV. HIV testing in the past year was most strongly associated with pregnancy in the past year (OR 2.99; p<.001) and having a regular source of care (OR 2.13; p<.001). Approximately 25% of homeless women with indications for HIV testing had not been tested in the past year. CONCLUSIONS: The reported HIV seroprevalence of greater than 1% suggests that providers should offer and encourage HIV testing for all homeless women in LA County. Our data, which show a high rate of testing and few statistically significant independent predictors, indicate that this may be what is happening in practice.

Psychiatric symptoms, health services, and HIV risk factors among homeless women.

The authors determined whether psychiatric symptoms and lack of health and/or social services contacts were associated with HIV risk behaviors among a probability sample of homeless women. Women were interviewed regarding socioeconomic indicators, psychiatric symptoms, health and/or social services contacts, and past-year HIV risk behaviors. Overall, 8 percent of the women injected drugs, 64 percent engaged in unprotected sex, and 22 percent traded sex. Multiple logistic regression results revealed that substance abuse was positively associated with injection drug use and trading sex. Homeless women with case managers were less likely to inject drugs. Although barriers to obtaining drug treatment were associated with trading sex, women attending self-help meetings for substance abuse were also more likely to trade sex. Homeless women who are substance abusers are vulnerable to HIV risk behaviors. Risk reduction interventions for homeless women should be implemented through substance abuse and intensive case management programs.