Partnering for the future clinic: A multidisciplinary perinatal substance use program.

OBJECTIVE: The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes. METHODS: We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed. RESULTS: Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched. CONCLUSIONS: Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.

Previous missed visits and independent risk of loss to follow-up in the high-risk neonatal follow-up clinic.

BACKGROUND: Neonatal intensive care unit (NICU) patients are at high risk for developmental delays. As a result, many are seen in neonatal follow-up (NFU) clinics. Disparities in NFU follow-up rates by social determinants of health exist. AIMS: Determine how the number of missed visits (composed of patient-canceled visits and no-show visits) relates to risk of loss to follow-up in the NFU clinic. STUDY DESIGN: Retrospective cohort study at a regional specialty center in the United States. SUBJECTS: 262 patients born between January 1, 2014, and December 31, 2017, who were referred to the NFU clinic. OUTCOME MEASURES: Logistic binomial regression was used to model risk ratio of loss to follow-up over two years, defined as not attending a recommended follow-up visit and not informing the clinic of a reason for discontinued care. RESULTS: Of 262 infants, 220 patients (84 %) were seen for at least one visit and 143 (65 %) completed follow-up. Younger maternal age, maternal smoking during pregnancy, maternal drug use during pregnancy, and public insurance were all associated with missing more visits. For each additional missed visit, the risk of loss to follow-up was 1.73 times higher unadjusted (95 % CI: 1.33, 2.26) and 1.81 times higher (95 % CI: 1.36, 2.40) after adjusting for confounders. The risk ratio of loss to follow-up for no-show visits was three times higher than that for patient-canceled visits. CONCLUSIONS: Each missed visit was independently associated with higher risk of loss to follow-up from NFU clinic, even after adjusting for other risk factors.

Use of Opioid-Sparing Protocols and Perceived Postpartum Pain in Patients with Opioid Use Disorder and Chronic Prenatal Opioid Exposure.

INTRODUCTION: Opioid-sparing protocols reduce postpartum opioid prescribing in opioid-naïve patients; however, patients with opioid use disorder (OUD) and complex pain needs who may benefit from these protocols are typically excluded from them. We assessed postpartum pain experiences of patients with OUD and chronic prenatal opioid exposure after implementation of an opioid-sparing protocol. METHODS: A phone survey assessed postpartum pain experiences for people with chronic prenatal opioid exposure who delivered between January 2020 and August 2021 at an academic hospital. Analyses included descriptive statistics, qualitative content analysis, and a joint display comparing themes. RESULTS: Of 25 patients, 18 (72%) participated; most were non-Hispanic White (100%, 18/18), publicly insured (78%, 14/18), multiparous (78%, 14/18), with OUD (100%, 18/18). No patients with a vaginal birth received an opioid prescription; half (4/8) with a cesarean birth received one at discharge. Over one-third (7/18, 39%) reported poor pain control (≥ 5/10) in the hospital and one week post-discharge; scores were higher for cesarean versus vaginal birth. Qualitative sub-analyses of open-ended responses revealed patient perceptions of postpartum pain and treatment. The most effective strategies, stratified by birth type and pain level, ranged from non-opioid medications for vaginal births and minor pain to prescription opioids for cesarean births and moderate-to-intense pain. DISCUSSION: Postpartum opioid prescribing for patients with chronic prenatal opioid use was low for vaginal and cesarean birth following implementation of an opioid-sparing protocol. Patients with OUD reported good pain management with opioid-sparing pain regimens; however, many reported poorly controlled pain immediately postpartum. Future work should assess approaches to postpartum pain management that minimize the risks of opioid medication-particularly in at-risk groups.

What is already known on this subject? Opioid-sparing protocols can reduce postpartum opioid prescribing in opioid-naïve patients; however, there are currently no clear guidelines for opioid prescribing for people with opioid use disorder (OUD) in the postpartum period.What this study adds?Postpartum opioid prescribing for patients with chronic prenatal opioid use was less than the national average and one-third of patients reported poor pain control. Opioid-sparing protocols postpartum should be expanded to patients with OUD to improve pain control and minimize risks associated with opioid medication.

Elucidating academic surgical staff perspectives of medical student learning in the operating room: An embedded mixed methods study.

BACKGROUND: The operating room (OR) is a complex environment for medical students. Little is known about the OR staff's perception of medical students. METHODS: We utilized an embedded mixed methods design to characterize surgical staff perceptions of students at an academic institution. We surveyed 408 OR nursing/technician staff with 16 follow-up interviews. RESULTS: 139 respondents. 91.3% reported having daily-to-weekly interactions with medical students. Yet, only 37.9% agreed that "patient care is better when medical students are part of the team." 25.2% felt confident that they knew what a student's education entails outside the OR. 93.5% agreed that interprofessional training between physicians and OR staff should be included in educational programs. 54% agreed that their responsibilities include medical student training in the OR setting. CONCLUSIONS: Despite an overall desire for teamwork, this study highlights a lack of knowledge of each others' roles. To improve OR culture and team dynamics, concerted efforts need to be made around interprofessional training.

Risk factors for obstructive sleep apnea in cystic fibrosis.

INTRODUCTION: Despite emerging data that suggest a high frequency and severity of obstructive sleep apnea (OSA) among patients with cystic fibrosis (CF), few of them are referred for polysomnography. Little is known about which patients with CF are at increased risk for OSA and which sleep symptoms merit investigation. METHODS: A single-center retrospective analysis of clinical and polysomnographic data from 2009, January 1 to October 31, 2020 in referred children and adults with CF. RESULTS: Among 74 patients (42 children, 32 adults) with CF, 39 (53%) had OSA. No age or sex differences emerged in OSA frequency. Mean apnea-hypopnea index (AHI) was higher among overweight/obese adults (n = 16) as compared with adults of normal weight or underweight (11.4 vs. 6.2; p = 0.005). Adults with (n = 10) versus without a crowded oropharynx had 13.0 times greater odds of OSA (95% confidence interval (CI): 1.4, 121.4; p = 0.02). Children with (n = 24) versus without tonsillar hypertrophy had a higher risk for OSA (OR = 5.2; 95% CI: 1.4, 19.8; p = 0.02), as did children with (n = 10) versus without symptomatic chronic sinusitis (OR = 5.8; 95% CI: 1.1, 32.1; p = 0.04). Neither snoring, excessive daytime sleepiness, nor lung disease severity were associated with OSA. CONCLUSION: Key risk factors for OSA may differ between children and adults with CF: upper airway pathology appears important in children and overweight/obesity or a crowded oropharynx in adults. Given the lack of sensitivity of snoring, daytime sleepiness, and lung disease severity, detection of OSA may require a low threshold for polysomnographic assessment in this vulnerable population.

Sleep-disordered breathing in cystic fibrosis.

INTRODUCTION: Cystic fibrosis (CF) is a life-shortening, genetic disease that affects approximately 30,000 Americans. Although patients frequently report snoring, mouth breathing, and insomnia, the extent to which sleep-disordered breathing (SDB) may underlie these complaints remains unknown. METHODS: Single-center retrospective review of polysomnography results from referred patients with and without CF individually-matched (1:2) for age, gender, race, and body mass index (BMI). RESULTS: Mean ages were 8.0 ± 5.2 (sd) and 35.9 ± 12.9 years, among 29 children and 23 adults with CF respectively. The CF and non-CF groups were well-matched in age and BMI. Subjects with vs. without CF had three times greater odds of moderate-severe SDB (apnea-hypopnea index (AHI) ≥ 5 in children, ≥ 15 in adults) (p = 0.01). Nocturnal oxygen saturation nadir (Minimum SpO2) was lower among CF vs. non-CF groups (p = 0.002). For every 1-unit increase in AHI, the decline in Minimum SpO2 was larger for subjects with vs. without CF (p = 0.05). In subjects with CF, forced expiratory volume in 1 s percent predicted (FEV1 PPD) was associated with Minimum SpO2 (Pearson r = 0.68, p < 0.0001) but not AHI (r = -0.19, p = 0.27). For every 1-unit increase in AHI, magnitude of decline in Minimum SpO2 was larger for those with low vs. normal FEV1 PPD (p = 0.01). CONCLUSION: Severity of SDB may be worse among referred patients with vs. without CF. The SDB may modify the relationship between CF lung disease and nocturnal hypoxemia. Markers of lung disease severity including lung function do not predict SDB severity, suggesting the need for routine polysomnography to screen for this sleep disorder.