Development and implementation of a clinician report to reduce unnecessary urine drug screen testing in the ED: a quality improvement initiative.

BACKGROUND: Unnecessary testing is a problem-facing healthcare systems around the world striving to achieve sustainable care. Despite knowing this problem exists, clinicians continue to order tests that do not contribute to patient care. Using behavioural and implementation science can help address this problem. Locally, audit and feedback are used to provide information to clinicians about their performance on relevant metrics. However, this is often done without evidence-based methods to optimise uptake. Our objective was to improve the appropriate use of laboratory tests in the ED using evidence-based audit and feedback and behaviour change techniques. METHODS: Using the behaviour change wheel, we implemented an audit and feedback tool that provided information to ED physicians about their use of laboratory tests; specifically, we focused on education and review of the appropriate use of urine drug screen tests. The report was designed in collaboration with end users to help maximise engagement. Following development of the report, audit and feedback sessions were delivered over an 18-month period. RESULTS: Data on urine drug screen testing were collected continually throughout the intervention period and showed a sustained decrease among ED physicians. Test use dropped from a monthly departmental average of 26 urine drug screen tests per 1000 patient visits to only eight tests per 1000 patient visits following the initiation of the audit and feedback intervention. CONCLUSION: Audit and feedback reduced unnecessary urine drug screen testing in the ED. Regular feedback sessions continuously engaged physicians in the audit and feedback intervention and allowed the implementation team to react to changing priorities and feedback from the clinical group. It was important to include the end users in the design of audit and feedback tools to maximise physician engagement. Inclusion in this process can help ensure physicians adopt a sense of ownership regarding which metrics to review and provides a key component for the motivation aspect of behaviour change. Departmental leadership is also critical to the process of implementing a successful audit and feedback initiative and achieving sustained behaviour change.

Hydromorphone neuroexcitation.

Continuous parenteral hydromorphone is used to treat pain in palliative care. Case reports have suggested that neuroexcitatory symptoms, such as agitation, myoclonic activity, and even seizures may occur during administration. However, little information exists on the incidence of these side effects or their relationship to the dose or duration of parenteral hydromorphone. A retrospective chart review was performed on 48 terminally ill hospice patients who received continuous parenteral hydromorphone for pain control. Chart reviews were conducted searching for three neuroexcitatory symptoms: agitation, myoclonus, and seizures; the incidence and relationship of these symptoms were statistically compared to the maximal dose and number of days on continuous parenteral hydromorphone. We found that agitation, myoclonus, and seizures were not associated with the patients gender, age, or diagnosis but found that agitation was associated (p < 0.01) in patients with known metastatic disease. Agitation, myoclonus, and seizures were independently associated with the maximal dose (p < 0.05, p < 0.001, and p < 0.05) and with the duration (p < 0.01, p < 0.05, and p < 0.01) of continuous parenteral hydromorphone A possible mechanism for these findings is hydromorphone-3-glucoronide, a metabolic product of hydromorphone, which has been implicated in neuroexcitatory symptoms in laboratory investigations.

Correlation between myoclonus and the 3-glucuronide metabolites in patients treated with morphine or hydromorphone: a pilot study.

BACKGROUND: The 3-glucuronide metabolites of morphine and hydromorphone have been implicated as a causative factor for patients exhibiting myoclonus. OBJECTIVE: The primary goal of this study was to determine plasma levels of morphine-3-glucuronide (M3G) or hydromorphone-3-glucuronide (H3G) in patients demonstrating myoclonus and identify any trends or associations between the two. SETTING: Patients were recruited from San Diego Hospice and the Institute for Palliative Medicine's inpatient unit. DESIGN: A prospective convenience sample comprised of 17 subjects, 12 with myoclonus and 5 without myoclonus. Analysis included demographic, metabolic and clinical variables. Plasma was assayed via high performance liquid chromatography for morphine, M3G, and morphine-6-glucuronide or hydromorphone and hydromorphone-3-glucuronide. RESULTS: No trends or associations were identified between plasma levels of M3G or H3G and myoclonus. Ratio levels of 3-glucuronide metabolite to their corresponding parent opioid were dramatically lower than anticipated. CONCLUSION: In this small pilot study, it appears that the serum levels of metabolites M3G and H3G do not correlate with myoclonus.