Alternatives to opioids for pain management in the emergency department decreases opioid usage and maintains patient satisfaction.

OBJECTIVE: The objective of this study was to assess opioid use in an emergency department following the development and implementation of an alternative to opioids (ALTO)-first approach to pain management. The study also assessed how implementation affected patient satisfaction scores. METHODS: This study compared data collected from October to December of 2015 (prior to implementation) to data collected between October and December of 2016 (after the intervention had been implemented). Emergency department visits during the study timeframe were included. Opioid reduction was measured in morphine equivalents (ME) administered per visit. Secondary outcomes on patient satisfaction were gathered using the Press Ganey survey. RESULTS: Intravenous (IV) opioid administration during the study period decreased by >20%. The predicted mean ME use in 2016 was 0.25 ME less when compared to 2015 (95% CI -0.27 to -0.23). Estimated use for patients in the pre-implementation period was 1.45 ME mgs (SD 0.88), and 1.13 ME mg (SD 0.69) for patients in the post-implementation period. Patient satisfaction scores using the Press Ganey Scale also were assessed. There was no significant difference in the scores between 2015 and 2016 when patients were asked "How well was you pain controlled?" (-0.94, 95% CI -5.29 to 3.4) and "How likely are you to recommend this emergency department?" (-1.55, 95% CI -5.26 to 2.14). CONCLUSION: In conclusion, by using an ALTO-first, multimodal treatment approach to pain management, participating clinicians were able to significantly decrease the use of IV opioids in the emergency department. Patient satisfaction scores remained unchanged following implementation.

The effect of weight-based volume loading on the inferior vena cava in fasting subjects: a prospective randomized double-blinded trial.

OBJECTIVES: Inferior vena cava ultrasound (IVC-US) assessment has been proposed as a noninvasive method of assessing volume status. Current literature is divided on its ability to do so. The primary objective was to compare IVC-US changes in healthy fasting subjects randomized to either 10 or 30 mL/kg of intravenous (IV) fluid administration versus a control group that received only 2 mL/kg. METHODS: This was a prospective randomized double-blinded trial set in emergency department (ED) clinical care rooms. Volunteer subjects with no history of cardiac disease or hypertension fasted for 12 hours. Subjects were randomly assigned to receive IV 0.9% saline bolus of 2 (control group), 10, or 30 mL/kg over 30 minutes. IVC-US was performed before and 15 minutes after each fluid bolus. RESULTS: Forty-two fasting subjects were enrolled. Analysis of variance (ANOVA) comparison showed that IVC-US was unable to detect any significant difference between the control group and those given either 10 or 30 mL/kg fluid, whether using maximum or minimum IVC diameter or caval index (IVC-CI). The groups receiving 10 and 30 mL/kg each had a statistically significant change in IVC-CI; however, the 30 mL/kg group had no significant change in either of the mean IVC diameters. CONCLUSIONS: Overall, there were statistically significant differences in mean IVC-US measurements before and after fluid loading, but not between groups. Fasting asymptomatic subjects had a wide intersubject variation in both baseline IVC-US measurements and fluid-related changes. The degree of IVC-US change in association with graded acute volume loading was not predictably proportional between our subjects.