Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study.

BACKGROUND: AIM: This pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care. DESIGN: This was a prospective feasibility single group pilot study at a level 1 trauma center. METHOD: The LCS is a paraprofessional behavior-based "pain coach" and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time. RESULTS: Twenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%). CONCLUSIONS: The findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.

Impact of pharmacist intervention on anticoagulation management and risk for potential COVID-19 exposure during the COVID-19 pandemic.

INTRODUCTION: Patients taking warfarin require frequent international normalized ratio (INR) monitoring in healthcare settings, putting them at increased risk of Coronavirus disease 2019 (COVID-19) exposure during the pandemic. Thus, strategies to limit in-person visits to healthcare facilities were recommended by the Anticoagulation Forum. The objective of this study was to describe the number and types of changes made to anticoagulation therapy as a result of pharmacist intervention during the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective chart review of patients included in a primary care COVID-19 anticoagulation intervention was conducted. During this intervention, pharmacists provided individualized recommendations for anticoagulation changes in patients taking warfarin to limit their healthcare facility exposure while also maintaining safe anticoagulation management practices. RESULTS: As a result of pharmacist intervention, 83 (55.7 %) of the 149 patients included in the intervention had changes in anticoagulation including: switching to a direct oral anticoagulant (n = 12), extending the INR monitoring interval (n = 48), switching to home INR monitoring (n = 21), or stopping anticoagulation (n = 2). For those patients who were taking warfarin for the entire 6 months pre- and post-intervention, the total number of healthcare facility and laboratory visits with an INR completed decreased from 8.8 to 6.4 (p < 0.001) per patient without a statistically significant decrease in time in therapeutic range (p = 0.76). CONCLUSIONS: This study depicts rapid implementation of a population health-based approach to assess all patients taking warfarin for options to minimize healthcare visits and decrease risk for COVID-19 exposure. Methods to reduce healthcare visit burden while maintaining patient safety should be considered as a regular component of anticoagulation management post-pandemic.

Readmission Outcomes of Sliding Scale Insulin Compared to Basal-Bolus Insulin Prescribed at Discharge in an Insulin-Naive Patient Population.

BACKGROUND: Limited data are available that examine hospital readmission outcomes of sliding scale compared to basal-bolus insulin in indigent and insulin-naive patients. OBJECTIVE: To evaluate hospital readmission outcomes in patients who are insulin naive with type 2 diabetes mellitus who are initiated on either sliding scale or basal-bolus insulin upon hospital discharge. METHODS: A retrospective chart review was conducted of adult patients with a history of type 2 diabetes mellitus, who were insulin naive, had a hemoglobin A1c (HbA1c) 10% or greater, and were discharged with a prescription for sliding scale or basal-bolus insulin from January 2015 to July 2018. The primary objective measured all-cause 30-day hospital readmissions. The secondary objectives measured diabetes-related 30-day hospital readmissions and HbA1c change after 3 months of initial hospital admission. Data were analyzed using descriptive statistics, χ2 test, paired sample t test, and logistic regression. RESULTS: Forty-one patients were prescribed sliding scale insulin and 105 patients were prescribed basal-bolus insulin. The majority were male (60%), spoke English (84%), were self-pay (39%), and had a mean age of 51 ± 10.2 years, initial HbA1c of 13% ± 1.9%, and LACE+ score of 51 ± 15.6 upon discharge. All-cause 30-day hospital readmissions occurred in 14.6% of sliding scale and 6.7% of basal-bolus insulin groups (odds ratio [OR]: 2.40, 95% confidence interval [CI]: 0.75-7.63). Hyperglycemia occurred in 7.3% of sliding scale and 0.9% of basal-bolus insulin groups. Mean HbA1c difference for basal-bolus and sliding scale insulin was 3.3 ± 3.1 and 2.9 ± 2.7, respectively (P = 0.459). CONCLUSION: There was no significant difference in all-cause 30-day hospital readmissions comparing sliding scale to basal-bolus insulin.

The effect of a Life Care Specialist on pain management and opioid-related outcomes among patients with orthopedic trauma: study protocol for a randomized controlled trial.

BACKGROUND: Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma. METHODS: In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education. DISCUSSION: There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04154384 . Registered on 11/6/2019 (last updated on 6/10/2021).