Impact of Universal Screening and Automated Clinical Decision Support for the Treatment of Opioid Use Disorder in Emergency Departments: A Difference-in-Differences Analysis.

STUDY OBJECTIVE: Emergency department (ED)-initiated buprenorphine improves outcomes in patients with opioid use disorder; however, adoption varies widely. To reduce variability, we implemented a nurse-driven triage screening question in the electronic health record to identify patients with opioid use disorder, followed by targeted electronic health record prompts to measure withdrawal and guide next steps in management, including initiation of treatment. Our objective was to assess the impact of screening implementation in 3 urban, academic EDs. METHODS: We conducted a quasiexperimental study of opioid use disorder-related ED visits using electronic health record data from January 2020 to June 2022. The triage protocol was implemented in 3 EDs between March and July 2021, and 2 other EDs in the health system served as controls. We evaluated changes in treatment measures over time and used a difference-in-differences analysis to compare outcomes in the 3 intervention EDs with those in the 2 controls. RESULTS: There were 2,462 visits in the intervention hospitals (1,258 in the preperiod and 1,204 in the postperiod) and 731 in the control hospitals (459 in the preperiod and 272 in the postperiod). Patient characteristics within the intervention and control EDs were similar across the time periods. Compared with the control hospitals, the triage protocol was associated with a 17% greater increase in withdrawal assessment, using the Clinical Opioid Withdrawal Scale (COWS) (95% CI 7 to 27). Buprenorphine prescriptions at discharge also increased by 5% (95% CI 0% to 10%), and naloxone prescriptions increased by 12% points (95% CI 1% to 22%) in the intervention EDs relative to controls. CONCLUSION: An ED triage screening and treatment protocol led to increased assessment and treatment of opioid use disorder. Protocols designed to make screening and treatment the default practice have promise in increasing the implementation of evidence-based treatment ED opioid use disorder care.

Accuracy of Consumer-marketed smartphone-paired alcohol breath testing devices: A laboratory validation study.

BACKGROUND: Although alcohol breath testing devices that pair with smartphones are promoted for the prevention of alcohol-impaired driving, their accuracy has not been established. METHODS: In a within-subjects laboratory study, we administered weight-based doses of ethanol to two groups of 10 healthy, moderate drinkers aiming to achieve a target peak blood alcohol concentration (BAC) of 0.10%. We obtained a peak phlebotomy BAC and measured breath alcohol concentration (BrAC) with a police-grade device (Intoxilyzer 240) and two randomly ordered series of 3 consumer smartphone-paired devices (6 total devices) with measurements every 20 min until the BrAC reached <0.02% on the police device. Ten participants tested the first 3 devices, and the other 10 participants tested the other 3 devices. We measured mean paired differences in BrAC with 95% confidence intervals between the police-grade device and consumer devices. RESULTS: The enrolled sample (N = 20) included 11 females; 15 white, 3 Asian, and 2 Black participants; with a mean age of 27 and mean BMI of 24.6. Peak BACs ranged from 0.06-0.14%. All 7 devices underestimated BAC by >0.01%, though the BACtrack Mobile Pro and police-grade device were consistently more accurate than the Drinkmate and Evoc. Compared with the police-grade device measurements, the BACtrack Mobile Pro readings were consistently higher, the BACtrack Vio and Alcohoot measurements similar, and the Floome, Drinkmake, and Evoc consistently lower. The BACtrack Mobile Pro and Alcohoot were most sensitive in detecting BAC driving limit thresholds, while the Drinkmate and Evoc devices failed to detect BAC limit thresholds more than 50% of the time relative to the police-grade device. CONCLUSIONS: The accuracy of smartphone-paired devices varied widely in this laboratory study of healthy participants. Although some devices are suitable for clinical and research purposes, others underestimated BAC, creating the potential to mislead intoxicated users into thinking that they are fit to drive.

Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients.

PURPOSE: Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors. DESIGN: Semi-structured interviews of patients prescribed naloxone at ED discharge. SETTINGS: Three urban academic EDs in Philadelphia, PA. PARTICIPANTS: 25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose. METHODS: Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes. RESULTS: We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone. CONCLUSIONS: Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. OUTCOMES AND ANALYSIS: We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. RESULTS: We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. CONCLUSIONS: Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Development and Validation of the Agency for Healthcare Research and Quality Measures of Potentially Preventable Emergency Department (ED) Visits: The ED Prevention Quality Indicators for General Health Conditions.

OBJECTIVE: To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health. DATA SOURCES: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008-2010 State Inpatient Databases and State Emergency Department Databases. STUDY DESIGN: Empirical analyses and structured panel reviews. METHODS: Panels of 14-17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county-level poverty, uninsurance, and density of primary care physicians (PCPs). PRINCIPAL FINDINGS: ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end-user panel separately rated the indicators as having strong face validity for most uses evaluated. CONCLUSIONS: The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research.