Using m-health tools to reduce the misuse of opioid pain relievers.

BACKGROUND: Emergency department (ED) patients are among the many groups at risk for prescription drug overdose. There is limited research on how best to communicate with ED patients about options for pain management and the risks of opioids. The aim of this study is to pilot test a web-based, patient-centred educational programme that encourages the patient to have an informed discussion about pain medication options with their ED provider. METHODS: This multisite, randomised trial will evaluate an m-health programme designed to aid the patient in making an informed decision about their pain treatment. Patients reporting to the ED with an injury-related or pain- related chief complaint who agree to participate are randomised to receive the intervention programme, My Healthy Choices, or an attention-matched control. My Healthy Choices pairs tailored education with a patient decision aid to describe what opioid and non-opioid pain medications are, assess the patient's risk factors for opioid-related adverse effects, and produce a tailored report that patients are encouraged to share with their doctor. Data are collected through surveys at three time points during the ED encounter (baseline, immediately after the intervention and just before discharge), and at a 6-week follow-up survey. The primary outcomes are whether the patient prefers an opioid pain reliever (OPR) and whether the patient takes an OPR. DISCUSSION: We hope this programme will facilitate patient-provider communication, as well as reduce the number of prescriptions written for OPRs and thus the number of patients exposed to prescription opioids and the associated risks of addiction and overdose. TRIAL REGISTRATION NUMBER: NCT03012087; Pre-results.

Development and implementation of procedures for outpatient naloxone prescribing at a large academic medical center.

PURPOSE: An interprofessional initiative to operationalize outpatient naloxone prescribing at a large academic medical center is described. SUMMARY: The initiative was carried out by a work group of clinical pharmacists and pharmacy administrators in collaboration with physicians and nursing staff leaders from multiple practice settings. An opioid overdose risk-assessment guide was developed on the basis of literature review and expert opinion. An institutional policy to guide identification of high-risk patient populations and facilitate naloxone prescribing and dispensing was developed and vetted by multiple expert committees. Patient education materials were created, and patients at high risk for opioid overdose were educated about overdose risk factors and naloxone use by a pharmacist and/or nurse before discharge or, in some cases, by outpatient pharmacists; when feasible, patients' friends, family members, and/or caregivers were included in education sessions. Interventions included distribution of a pamphlet emphasizing the importance of contacting emergency medical services personnel immediately in the event of an overdose, depicting the process for administration of injectable and nasal spray formulations of naloxone, and providing information on other first-response steps. Collaboration with outpatient pharmacies allowed for successful dispensing of naloxone prescriptions. CONCLUSION: The implementation of an outpatient naloxone prescribing policy at a large academic medical center created a streamlined approach for the interprofessional healthcare team to use in providing naloxone education and improved naloxone access to patients at high risk for opioid overdose.

No decrease in clindamycin susceptibility despite increased use of clindamycin for pediatric community-associated methicillin-resistant Staphylococcus aureus skin infections.

A previous study at our institution revealed 98% of methicillin-resistant Staphylococcus aureus (MRSA) isolates were susceptible to clindamycin; however, beta-lactams were then the predominant empiric treatment. This follow-up chart review study examined subsequent staphylococcal skin and soft tissue infection treatment and susceptibility patterns over a 2-year period. Of 296 S. aureus skin and soft tissue infections, 73% were MRSA, of which 87% were community-associated-MRSA; MRSA infections peaked in warm summer months. Despite a significant increase in empiric clindamycin use, 97% of community-associated-MRSA isolates retained susceptibility to clindamycin.

Implementation of an emergency department-based clinical pharmacist transitions-of-care program.

PURPOSE: The implementation of an emergency department (ED)-based clinical pharmacist transitions-of-care (TOC) program is described. SUMMARY: The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits. CONCLUSION: A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.

Management of first-trimester complications in the emergency department.

PURPOSE: The pharmacologic management and the nonpharmacologic management of first-trimester complications in the emergency department are reviewed. SUMMARY: The obstetric complications most commonly seen in early pregnancy (less than 20 weeks' gestation) include ectopic pregnancy, threatened and inevitable abortions, and incomplete, complete, and missed abortions. The treatment options for ectopic pregnancy include expectant management, medical management with methotrexate, and surgery. If patients have signs and symptoms of tubal rupture, surgery must be performed immediately. In other cases, the choice of management technique is based on the patient's clinical condition, factors related to the ectopic pregnancy, and the patient's preferences. Pharmacologic therapies for women with confirmed threatened abortion include human chorionic gonadotropin, progesterone, uterine muscle relaxants, and Rh immune globulin prophylaxis. Treatment goals for women whose condition has advanced to inevitable abortion include evacuating any retained products of conception, either with expectant (conservative) management or pharmacologic or surgical intervention. The best treatment option is often determined by the mother's clinical status at the time of presentation and her preference of management strategy. Management of complete abortion may not require any further intervention; however, it is often difficult to identify a complete versus incomplete abortion. Treatment options for complete, incomplete, and missed abortions include expectant, surgical, and medical management. CONCLUSION: Ectopic pregnancy, threatened and inevitable abortions, and incomplete, complete, and missed abortions are common complications during early pregnancy. Various medical and surgical treatment options are available for managing these complications, including expectant management, medical management, and surgery.

Strategies for implementing emergency department pharmacy services: results from the 2007 ASHP Patient Care Impact Program.

PURPOSE: Strategies proposed during a patient care impact program for implementing emergency department (ED) pharmacy services are described. SUMMARY: In June 2007, the American Society of Health-System Pharmacists developed a patient care impact program entitled "Introducing an Emergency Department Pharmacist into Your Institution" to provide experiential training to practicing pharmacists seeking to establish ED services in their institutions. Under the guidance of four mentors, 19 pharmacists from a variety of practice settings, including community-based hospitals and academic and tertiary-care-based institutions, were selected for participation the six-month program. Participants were divided into two groups, and each group was assigned two mentors. During their initial meeting, participants identified anticipated challenges to implementation of pharmacy services in the ED and began to define strategies with their mentors for effectively managing the anticipated challenges. Each group participated in one-hour monthly teleconferences with their mentors. In addition to monthly teleconferences, participants regularly contacted their mentors for additional assistance and several visited their mentors' institutions. Participants developed job descriptions for an ED pharmacist, developed a rationale and justification for implementing pharmacy services in the ED, obtained approval and support from appropriate parties for the ED pharmacist's role, developed plans for introducing a pharmacist to the ED, and developed quality-assurance methods to monitor the effectiveness of the pharmacist's role. CONCLUSION: Despite the diversity in practice settings, participants of the program faced similar challenges in implementing ED pharmacy services at their institutions. Various strategies toward solutions to these challenges were shared among participants and mentors.