Improving Intranasal Naloxone Prescribing Through EMR Modification and Automation.

BACKGROUND: In 2017, approximately 11.4 million Americans used opioids inappropriately. Nearly 47,600 deaths in 2017 were attributable to overdose on opioids. Intranasal naloxone was approved by the Food and Drug Administration in 2015 as a rescue medication for opioid overdose. New York State launched a prescription drug monitoring program in 2012, the Internet System for Tracking Over-Prescribing (I-STOP), that required completion before dispensing any controlled substance. Currently, prescribing naloxone at our institution requires 10 clicks and 2 free text boxes. The goal of this project was to increase the prescribing of intranasal naloxone by utilizing EMR automation and visualization tools. METHODS: Our intervention embedded a section within the required I-STOP note, displaying the last date naloxone was prescribed and an option to "prescribe intranasal naloxone." If checked, a prepopulated order dialog box was generated. RESULTS: Intranasal naloxone orders for the institution totaled 65 for 2 months before the intervention and 203 for 2 months after the intervention, with 112 (55%) coming directly from the I-STOP note modification. Ease of prescribing improved as total clicks were reduced from 10 to 2, and free text boxes from 2 to 0. CONCLUSIONS: Our findings suggest that a clinical decision support system can be an effective way to increase hospital-wide naloxone prescribing rates. We were able to increase prescribing rates by more than three-fold, significantly increasing the availability of a rescue medication to individuals at high-risk for overdose. Intranasal naloxone prescribing increased with the implementation of a visual reminder and a more intuitive ordering experience while preserving provider autonomy.

Improving smoking cessation referrals among elective surgery clinics through electronic clinical decision support.

INTRODUCTION: Preoperative visits are an exceptional opportunity to encourage smoking cessation, as studies demonstrate the experience of scheduling elective surgery produces an actionable incentive to quit. However, studies suggest surgeons do not regularly assess smoking behavior or offer cessation therapies. Clinical decision support (CDS) is a system in which providers are presented with clinically integrated tools to enhance decision-making. METHODS: A CDS tool was designed to facilitate treatment referrals for smoking cessation services among patients seeking elective surgery. Two clinics were selected: the plastic and vascular surgeries. The study objectives were to assess the utilization rate and effectiveness of this system. RESULTS: No smoking cessation referrals had been submitted by the plastic surgery or vascular surgery clinics in the year before CDS tool implementation. Providers at the plastic surgery clinic utilized the CDS tool in 95.0% (191 of 201) eligible patient encounters. Of these patients, 16.3% were identified as active smokers, and 16.1% of these smokers accepted treatment referrals. Providers at the vascular surgery clinic utilized the CDS tool in 50.3% (98 of 195) eligible patient encounters. Of these patients, 10.2% were identified as active smokers, and 30.0% of these smokers accepted treatment referrals. CONCLUSIONS: The CDS tool improved the incidence of smoking cessation referrals in two surgical clinics from pretest baselines and achieved satisfactory utilization rates. This report demonstrates the feasibility of CDS tools to actualize the preoperative visit as an opportunity to promote smoking cessation.

Comparing the da Vinci si single console and dual console in teaching novice surgeons suturing techniques.

BACKGROUND AND OBJECTIVES: Robot-assisted laparoscopic surgery is often taught with the surgical mentor at the surgeon console and the trainee at the patient's bedside. The da Vinci dual console (Intuitive Surgical, Sunnyvale, California) allows a surgical mentor to teach with both the mentor and the trainee working at a surgeon console simultaneously. The purpose of this study is to evaluate the effectiveness of the dual console versus the single console for teaching medical students robotic tasks. METHODS: Forty novice medical students were randomized to either the da Vinci single-console or dual-console group and were taught 4 knot-tying techniques by a surgical mentor. The students were timed while performing the tasks. RESULTS: No statistically significant differences in mean task times were observed between the single- and dual-console groups: interrupted stitch with a 2-handed knot (300 seconds for single vs 294 seconds for dual, P=.59), interrupted stitch with a 1-handed knot (198 seconds for single vs 212 seconds for dual, P=.88), figure-of-8 stitch with a 2-handed knot (261 seconds for single vs 219 seconds for dual, P=.20), and figure-of-8 stitch with a 1-handed knot (200 seconds for single vs 199 seconds for dual, P=.53). CONCLUSION: No significant difference was observed in performance time when teaching knot-tying techniques to medical students using the da Vinci dual console compared with the single console. More research needs to be performed on the utility of the da Vinci dual console in surgical training.