Clinical perspectives on hospitals' role in the opioid epidemic.

BACKGROUND: Policymakers, legislators, and clinicians have raised concerns that hospital-based clinicians may be incentivized to inappropriately prescribe and administer opioids when addressing pain care needs of their patients, thus potentially contributing to the ongoing opioid epidemic in the United States. Given the need to involve all healthcare settings, including hospitals, in joint efforts to curb the opioid epidemic, it is essential to understand if clinicians perceive hospitals as contributors to the problem. Therefore, we examined clinical perspectives on the role of hospitals in the opioid epidemic. METHODS: We conducted individual semi-structured interviews with 23 clinicians from 6 different acute care hospitals that are part of a single healthcare system in the Midwestern United States. Our participants were hospitalists (N = 12), inpatient registered nurses (N = 9), and inpatient adult nurse practitioners (N = 2). In the interviews, we asked clinicians whether hospitals play a role in the opioid epidemic, and if so, how hospitals may contribute to the epidemic. We used a qualitative thematic analysis approach to analyze coded text for patterns and themes and examined potential differences in themes by respondent type using Dedoose software. RESULTS: The majority of clinicians believed hospitals contribute to the opioid epidemic. Multiple clinicians cited Center for Medicare and Medicaid Services' (CMS) reimbursement policy and the Joint Commission's report as drivers of inappropriate opioid prescribing in hospitals. Furthermore, numerous clinicians stated that opioids are inappropriately administered in the emergency department (ED), potentially as a mechanism to facilitate discharge and prevent re-admission. Many clinicians also described how overreliance on pre-populated pain care orders for surgical (orthopedic) patients, may be contributing to inappropriate opioid use in the hospital. Finally, clinicians suggested the following initiatives for hospitals to help address the crisis: 1) educating patients about negative consequences of using opioids long-term and setting realistic pain expectations; 2) educating medical staff about appropriate opioid prescribing practices, particularly for patients with complex chronic conditions (chronic pain; opioid use disorder (OUD)); and 3) strengthening the hospital leadership efforts to decrease inappropriate opioid use. CONCLUSIONS: Our findings can inform efforts at decreasing inappropriate opioid use in hospitals.

Texting is caring: a content analysis of clinical text messages by hospitalists.

BACKGROUND: Clinical texting systems (CTS) are widely used in hospitals for team communication about patients. With more institutions adopting such systems, there is a need to understand how texting is being used in clinical practice. METHODS: We conducted content analysis of 809 randomly selected message threads sent to and from hospitalists in a 9-month window. The process, purpose and content of messages were analysed. We also examined messages for personal content (to identify whether CTS was being used for professional matters) and discussion of near miss errors. The risk levels of these near misses were also assessed. RESULTS: Most messages focused on clinical management of patient needs (62%; n=498) and functioned to provide a notification or update regarding clinical care (64%; n=518) or make a request of the recipient (63%; n=510). Personal content was infrequent in message threads (10%; n=80). Five per cent (n=38) of message threads included discussion of a near miss, and most near misses posed low clinical risk overall (66%; n=25). CONCLUSION: Most CTS communication centred around direct clinical management. Fewer messages were focused on non-clinical areas such as administrative tasks or personal communication. Further examination of care delivery, error communication and the consequences of the care discussed in messages would help clinical leaders understand the impact of clinical texting on teamwork and quality of care.

Receipt of opioids and patient care experiences among nonsurgical hospitalized adults.

OBJECTIVE: To examine the association between receipt of opioids and patient care experiences among nonsurgical hospitalized adults. DATA SOURCES: A total of 17 691 patient-level responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient care experience survey linked to medical records from nonsurgical hospitalizations in an 11-hospital health care system in a Midwestern state, years 2011-2016. STUDY DESIGN: We conducted a pooled cross-sectional study that used propensity score matching analyses and logistic regression to estimate the relationship between patients' care experience measures (overall and pain-specific) and their receipt of opioids while hospitalized. In supplementary analyses, we used the same propensity score matching methods to estimate the relationship between patient care experience measures and receipt of opioids in four patient subgroups based on average patient-reported pain during hospitalization (no pain; mild pain; moderate pain; and severe pain). PRINCIPAL FINDINGS: Receipt of opioids was not associated with patient care experience measures in our main analysis. In our supplementary analysis, we found lower ratings for pain control among hospitalizations for patients who reported moderate pain (Marginal Effects = -4.5 percent; P value = .015). CONCLUSIONS: Counter to some previous studies, we observed that receipt of opioids was not associated with patient care experience measures for nonsurgical hospitalized adults. These findings may be due to different pain experiences of adults hospitalized for nonsurgical versus surgical reasons.

Balancing Patient-Centered and Safe Pain Care for Nonsurgical Inpatients: Clinical and Managerial Perspectives.

BACKGROUND: Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are ensuring that care is patient centered, meaning that it is respectful of patients' values, preferences, and experiences. However, little is known about delivering care in cases in which these goals may not align. For example, hospitals and clinicians are facing the daunting challenge of balancing safe and patient-centered pain care for nonsurgical patients, due to lack of comprehensive care guidelines and complexity of this patient population. METHODS: To gather clinical and managerial perspectives on the importance, feasibility, and strategies used to balance patient-centered care (PCC) and safe pain care for nonsurgical inpatients, the research team conducted in-depth, semistructured interviews with hospitalists, registered nurses, and health care managers from one health care system in the Midwestern United States. We systematically examined transcribed interviews and identified major themes using a thematic analysis approach. RESULTS: Participants acknowledged the importance of balancing PCC and safe pain care. They envisioned this balance as a continuum, with certain patients for whom it is easier (for example, an opioid-naive patient with a fracture), vs. more difficult (for example, a patient with opioid use disorder). Participants reported several strategies they use to balance PCC and safe pain care, including offering alternatives to opioids, setting realistic pain goals and expectations, and using a team approach. CONCLUSION: Clinicians and health care managers use various strategies to balance PCC and safe pain care for nonsurgical patients. Future studies should examine the effectiveness of these strategies on patient outcomes.