Williams Kimberly D, Wilson Beverly L, Jurkovitz Claudine T, Melson Jo A, Reitz Jeffrey A, Pal Carmen K, Hausman Sherry P, Booker Erin, Lang Linda J, Horton Terry L
Institute for Research on Equity and Community Health, ChristianaCare, Wilmington, DE, USA.
Behavioral Health, ChristianaCare, Wilmington, DE, USA.
Implement Res Pract. 2022 Jan-Dec;3. doi: 10.1177/26334895221096290. Epub 2022 Apr 27.
Opioid-related inpatient hospital stays are increasing at alarming rates. Unidentified and poorly treated opioid withdrawal may be associated with inpatients leaving against medical advice and increased health care utilization. To address these concerns, we developed and implemented a clinical pathway to screen and treat medical service inpatients for opioid withdrawal.
The pathway process included a two-item universal screening instrument to identify opioid withdrawal risk (Opioid Withdrawal Risk Assessment [OWRA]), use of the validated Clinical Opiate Withdrawal Scale (COWS) to monitor opioid withdrawal symptoms and severity, and a 72-h buprenorphine/naloxone-based treatment protocol. Implementation outcomes including adoption, fidelity, and sustainability of this new pathway model were measured. To assess if there were changes in nursing staff acceptability, appropriateness, and adoption of the new pathway process, a cross-sectional survey was administered to pilot four hospital medical units before and after pathway implementation.
Between 2016 and 2018, 72.4% (77,483/107,071) of admitted patients received the OWRA screening tool. Of those, 3.0% (2,347/77,483) were identified at risk for opioid withdrawal. Of those 2,347 patients, 2,178 (92.8%) were assessed with the COWS and 29.6% (645/2,178) were found to be in active withdrawal. A total of 49.5% (319/645) patients were treated with buprenorphine/naloxone. Fifty-seven percent (83/145) of nurses completed both the pre- and post-pathway implementation surveys. Analysis of the pre/post survey data revealed that nurse respondents were more confident in their ability to determine which patients were at risk for withdrawal ( = .01) and identify patients currently experiencing withdrawal ( < .01). However, they cited difficulty working with the patient population and coordinating care with physicians.
Our study demonstrates a process for successfully implementing and sustaining a clinical pathway to screen and treat medical service inpatients for opioid withdrawal. Standardizing care delivery for patients in opioid withdrawal can also improve nursing confidence when working with this complex population.
与阿片类药物相关的住院时间正以惊人的速度增长。未被识别和治疗不佳的阿片类药物戒断可能与患者擅自离院以及医疗保健利用率增加有关。为解决这些问题，我们制定并实施了一条临床路径，用于筛查和治疗医疗服务住院患者的阿片类药物戒断情况。
该路径流程包括一种两项通用筛查工具，用于识别阿片类药物戒断风险（阿片类药物戒断风险评估[OWRA]），使用经过验证的临床阿片类药物戒断量表（COWS）来监测阿片类药物戒断症状及严重程度，以及一个基于丁丙诺啡/纳洛酮的72小时治疗方案。对这一新路径模型的实施结果，包括采用情况、依从性和可持续性进行了评估。为评估护士对新路径流程的可接受性、适宜性和采用情况是否有变化，在路径实施前后对四个医院医疗科室进行了横断面调查。
2016年至2018年期间，72.4%（77,483/107,071）的入院患者接受了OWRA筛查工具。其中，3.0%（2,347/77,483）被确定有阿片类药物戒断风险。在这2,347名患者中，2,178名（92.8%）接受了COWS评估，其中29.6%（645/2,178）被发现处于急性戒断状态。共有49.5%（319/645）的患者接受了丁丙诺啡/纳洛酮治疗。57%（83/145）的护士完成了路径实施前后的调查。对调查前后数据的分析显示，护士受访者在确定哪些患者有戒断风险（P = 0.01）和识别当前正在经历戒断的患者方面（P < 0.01）更有信心。然而，他们提到与这类患者群体合作以及与医生协调护理存在困难。
我们的研究展示了一个成功实施和维持用于筛查和治疗医疗服务住院患者阿片类药物戒断的临床路径的过程。规范阿片类药物戒断患者的护理服务，也可以提高护士在处理这类复杂患者群体时的信心。
