In-Hospital Methadone Enrollment: a Novel Program to Facilitate Linkage from the Hospital to the Opioid Treatment Program for Vulnerable Patients with Opioid Use Disorder.

INTRODUCTION: Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP. AIM: Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage. SETTING: Seven hundred-bed university hospital in Aurora, CO. PROGRAM DESCRIPTION: A physician dually affiliated with a hospital's addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins. PROGRAM EVALUATION METRICS: IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments. RESULTS: Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%). CONCLUSION: IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.

Promoting appropriate midline catheter and PICC placement through implementation of an EHR-based clinical decision support tool: An interrupted time-series analysis.

BACKGROUND: Inappropriate use of peripherally inserted central catheters (PICCs), including multilumen PICCs, may increase the risk of patient complications. OBJECTIVE: Implement computerized decision support to: (a) increase the use of midline catheters over PICCs when appropriate and (b) decrease PICC lumens when a PICC is necessary. DESIGNS: Quasi-experimental, interrupted time series. SETTING: Single tertiary academic medical center. PATIENTS: Hospitalized adults who received a midline or PICC during clinical care. INTERVENTION: Decision support on appropriate vascular access device choice via a set of electronic orders embedded within the electronic health record. MEASUREMENTS: Proportion of midline catheter and single-lumen PICCs placed between January 2, 2017 and November 19, 2017 (preintervention) versus November 20, 2017 to December 1, 2019 (postintervention). RESULTS: A total of 8758 midline and PICCs were inserted during the study period. A statistically significant increase in the insertion of midline catheters was observed during the intervention (p = .006). In parallel, single-lumen PICC insertion as a proportion of all PICCs also increased after the intervention (p = .035). Results were consistent across multiple disciplines, including internal medicine, surgery, and intensive care. After considering the hospital census, total PICC and midline utilization rates and rates of complications did not change over time. However, an increase in catheter exchanges from less to more invasive devices occurred. CONCLUSIONS: In this single-center study, the implementation of electronic decision support to inform appropriate catheter use led to a more appropriate midline catheter and single-lumen PICC insertion. Dissemination of this single, effective intervention to examine efficacy in other hospital settings would be welcomed.

External validation of a model to predict future chronic opioid use among hospitalized patients.

BACKGROUND: Previous research demonstrates an association between opioid prescribing at hospital discharge and future chronic opioid use. Various opioid guidelines and policies contributed to changes in opioid prescribing practices. How this affected hospitalized patients remains unknown. OBJECTIVE: Externally validate a prediction model to identify hospitalized patients at the highest risk for future chronic opioid therapy (COT). DESIGNS: Retrospective analysis of health record data from 2011 to 2022 using logistic regression. PARTICIPANTS: Hospitalized adults with limited to no opioid use 1-year prior to hospitalization. SETTINGS: A statewide healthcare system. MAIN MEASUREMENTS: Used variables associated with progression to COT in a derivation cohort from a different healthcare system to predict expected outcomes in the validation cohort. KEY RESULTS: The derivation cohort included 17,060 patients, of whom 9653 (56.6%) progressed to COT 1 year after discharge. Compared to the derivation cohort, in the validation cohort, patients who received indigent care (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.27-0.59, p < .001) were least likely to progress to COT. Among variables assessed, opioid receipt at discharge was most strongly associated with progression to COT (OR = 3.74, 95% CI = 3.06-4.61, p < .001). The receiver operating characteristic curve for the validation set using coefficients from the derivation cohort performed slightly better than chance (AUC = 0.55). CONCLUSIONS: Our results highlight the importance of externally validating a prediction model prior to use outside of the derivation population. Periodic updates to models are necessary as policy changes and clinical practice recommendations may affect model performance.

Using Iterative RE-AIM to enhance hospitalist adoption of lung ultrasound in the management of patients with COVID-19: an implementation pilot study.

BACKGROUND: Lung ultrasound (LUS) is a clinician-performed evidence-based imaging modality that has multiple advantages in the evaluation of dyspnea caused by multiple disease processes, including COVID-19. Despite these advantages, few hospitalists have been trained to perform LUS. The aim of this study was to increase adoption and implementation of LUS during the 2020 COVID-19 pandemic by using recurrent assessments of RE-AIM outcomes to iteratively revise our implementation strategies. METHODS: In an academic hospital, we implemented guidelines for the use of LUS in patients with COVID-19 in July 2020. Using a novel "RE-AIM dashboard," we used an iterative process of evaluating the high-priority outcomes of Reach, Adoption, and Implementation at twice monthly intervals to inform revisions of our implementation strategies for LUS delivery (i.e., Iterative RE-AIM process). Using a convergent mixed methods design, we integrated quantitative RE-AIM outcomes with qualitative hospitalist interview data to understand the dynamic determinants of LUS Reach, Adoption, and Implementation. RESULTS: Over the 1-year study period, 453 LUSs were performed in 298 of 12,567 eligible inpatients with COVID-19 (Reach = 2%). These 453 LUS were ordered by 43 out of 86 eligible hospitalists (LUS order adoption = 50%). However, the LUSs were performed/supervised by only 8 of these 86 hospitalists, 4 of whom were required to complete LUS credentialing as members of the hospitalist procedure service (proceduralist adoption 75% vs 1.2% non-procedural hospitalists adoption). Qualitative and quantitative data obtained to evaluate this Iterative RE-AIM process led to the deployment of six sequential implementation strategies and 3 key findings including (1) there were COVID-19-specific barriers to LUS adoption, (2) hospitalists were more willing to learn to make clinical decisions using LUS images than obtain the images themselves, and (3) mandating the credentialing of a strategically selected sub-group may be a successful strategy for improving Reach. CONCLUSIONS: Mandating use of a strategically selected subset of clinicians may be an effective strategy for improving Reach of LUS. Additionally, use of Iterative RE-AIM allowed for timely adjustments to implementation strategies, facilitating higher levels of LUS Adoption and Reach. Future studies should explore the replicability of these preliminary findings.

Global acceleration in rates of vegetation change over the past 18,000 years.

Global vegetation over the past 18,000 years has been transformed first by the climate changes that accompanied the last deglaciation and again by increasing human pressures; however, the magnitude and patterns of rates of vegetation change are poorly understood globally. Using a compilation of 1181 fossil pollen sequences and newly developed statistical methods, we detect a worldwide acceleration in the rates of vegetation compositional change beginning between 4.6 and 2.9 thousand years ago that is globally unprecedented over the past 18,000 years in both magnitude and extent. Late Holocene rates of change equal or exceed the deglacial rates for all continents, which suggests that the scale of human effects on terrestrial ecosystems exceeds even the climate-driven transformations of the last deglaciation. The acceleration of biodiversity change demonstrated in ecological datasets from the past century began millennia ago.

Accumulation of metals and polycyclic aromatic hydrocarbons in agricultural soil after additions of street sediment in southern Ontario.

Prior to 2012 street sediment from the Greater Toronto Area was being managed by a local authority and provided to rural landowners under the assumption it was clean fill. The aim of this study was to characterise the chemical and physical composition of that street sediment applied to an agricultural field in southwestern Ontario, Canada and determine if contaminants had migrated to native soil. Soil was sampled from an impact and a background location during the fall of 2016 at four soil depths (0-10, 10-20, 20-30 and 30-40 cm below the surface) to characterise texture, pH, organic content, recoverable metals and total polycyclic aromatic hydrocarbons (PAHs). Textural analysis revealed street sediment was dominated by very coarse and coarse sand which differed from the native silty clay loam and extended to 30 cm below the surface. Some PAHs, including benzo(a)pyrene (1.29 µg g-1) exceeded the typical regional background concentrations. A distinct pattern of high molecular mass PAHs in the native soil below street sediments suggests that PAHs have migrated to native soil. To our knowledge this is the first study to report PAH concentrations in street sediment in Ontario and to show their potential movement and introduction to native soil. Future studies should focus on transport mechanisms and understanding movement of PAHs in native coarse textured soil.

Model systems for a no-analog future: species associations and climates during the last deglaciation.

As the earth system moves to a novel state, model systems (experimental, observational, paleoecological) are needed to assess and improve the predictive accuracy of ecological models under environments with no contemporary analog. In recent years, we have intensively studied the no-analog plant associations and climates in eastern North America during the last deglaciation to better constrain their spatiotemporal distribution, test hypotheses about climatic and megaherbivory controls, and assess the accuracy of species- and community-level models. The formation of no-analog plant associations was asynchronous, beginning first in the south-central United States; at sites in the north-central United States, it is linked to declining megafaunal abundances. Insolation and temperature were more seasonal than present, creating climates currently nonexistent in North America, and shifting species-climate relationships for some taxa. These shifts pose a common challenge to empirical paleoclimatic reconstructions, species distribution models (SDMs), and conservation-optimization models based on SDMs. Steps forward include combining recent and paleoecological data to more fully describe species' fundamental niches, employing community-level models to model shifts in species interactions under no-analog climates, and assimilating paleoecological data with mechanistic ecosystem models. Accurately modeling species interactions under novel environments remains a fundamental challenge for all forms of ecological models.

The influence of aridity and fire on holocene prairie communities in the eastern Prairie Peninsula.

The role of climate and fire in the development, maintenance, and species composition of prairie in the eastern axis of the tallgrass Prairie Peninsula intrigued early North American ecologists. However, evaluation of the long-standing hypotheses about the region's environmental history has been hampered by the scarcity of paleorecords. We conducted multiproxy analyses on early and middle Holocene sediments from two Illinois, USA, lakes to assess long-term climatic, vegetational, and fire variability in the region. Sediment mineral composition, carbonate delta18O, ostracode assemblages, and diatom assemblages were integrated to infer fluctuations in moisture availability. Pollen and charcoal delta13C were used to reconstruct vegetation composition, and charcoal influx was used to reconstruct fire. Results indicate that fire-sensitive trees (e.g., Ulmus, Ostrya, Fraxinus, and Acer saccharum) declined and prairie taxa expanded with increased aridity from 10,000 yr BP to 8500 yr BP. Between approximately 8500 yr BP and approximately 6200 yr BP, aridity declined, and prairie coexisted with fire-sensitive and fire-tolerant (e.g., Quercus and Carya) trees. After approximately 6200 yr BP, prairie taxa became dominant, although aridity was not more severe than it was around 8500 yr BP. Along with aridity, fire appears to have played an important role in the establishment and maintenance of prairie communities in the eastern Prairie Peninsula, consistent with the speculations of the early ecologists. Comparison of our data with results from elsewhere in the North American midcontinent indicates that spatial heterogeneity is a characteristic feature of climatic and vegetational variations on millennial time scales.