From the Department of Surgery (K.J.K., A.W., J.W.G., R.Y., N.B., J.M., M.R.K., M.K.K., M.L.R., B.L.D., A.P.), University of Arkansas for Medical Sciences; Department of Pharmacology and Toxicology (B.J.B., A.K.J., R.R.S.), University of Arkansas for Medical Sciences; Center for Implementation Research, Department of Pharmacy Practice, and Department of Psychiatry (G.M.C.), University of Arkansas for Medical Sciences.
J Trauma Acute Care Surg. 2024 Nov 1;97(5):716-723. doi: 10.1097/TA.0000000000004365. Epub 2024 Apr 30.
High doses and prolonged duration of opioids are associated with tolerance, dependence, and increased mortality. Unfortunately, despite recent efforts to curb outpatient opioid prescribing because of the ongoing epidemic, utilization remains high in the intensive care setting, with intubated patients commonly receiving infusions with a potency much higher than doses required to achieve pain control. We attempted to use implementation science techniques to monitor and reduce excessive opioid prescribing in ventilated patients in our surgical intensive care unit (SICU).
We conducted a prospective study investigating opioid administration in a closed SICU at an academic medical center over 18 months. Commonly accepted conversions were used to aggregate daily patient opioid use. Patients with a history of chronic opioid use and those being treated with an intracranial pressure monitor/drain, neuromuscular blocker, or extracorporeal membrane oxygenation were excluded. If the patient spent a portion of a day on a ventilator, that day's total was included in the "vent group." morphine milligram equivalents per patient were collected for each patient and assigned to the on-call intensivist. Intensivists were blinded to the data for the first 7 months. They were then provided with academic detailing followed by audit and feedback over the subsequent 11 months, demonstrating how opioid utilization during their time in the SICU compared with the unit average and a blinded list of the other attendings. Student's t tests were performed to compare opioid utilization before and after initiation of academic detailing and audit and feedback.
Opioid utilization in patients on a ventilator decreased by 20.1% during the feedback period, including less variation among all intensivists and a 30.9% reduction by the highest prescribers.
Implementation science approaches can effectively reduce variation in opioid prescribing, especially for high outliers in a SICU. These interventions may reduce the risks associated with prolonged use of high-dose opioids.
Therapeutic/Care Management; Level II.
高剂量和长时间使用阿片类药物会导致耐受、依赖和死亡率增加。不幸的是，尽管最近努力遏制因持续流行而导致的门诊阿片类药物处方，但在重症监护环境中，其使用率仍然很高，接受插管的患者通常接受的输注剂量远远高于实现疼痛控制所需的剂量。我们试图使用实施科学技术来监测和减少我们外科重症监护病房（SICU）中接受通气治疗的患者过度使用阿片类药物。
我们进行了一项前瞻性研究，调查了在学术医疗中心的封闭 SICU 中使用阿片类药物的情况，为期 18 个月。使用常用的转换方法来汇总患者每天的阿片类药物使用量。排除有慢性阿片类药物使用史和接受颅内压监测/引流、神经肌肉阻滞剂或体外膜氧合治疗的患者。如果患者在某一天的一部分时间接受通气治疗，则该天的总剂量将包括在“通气组”中。收集每位患者的每患者吗啡毫克当量，并分配给值班的重症监护医生。在最初的 7 个月里，重症监护医生对数据不知情。然后，在接下来的 11 个月里，他们接受了学术细节说明，随后进行了审核和反馈，展示了他们在 SICU 期间的阿片类药物使用情况与单位平均值和其他主治医生的盲名单相比的情况。使用学生 t 检验比较学术细节说明和审核反馈前后的阿片类药物使用情况。
在反馈期间，接受通气治疗的患者的阿片类药物用量减少了 20.1%，包括所有重症监护医生之间的差异减少，以及最高剂量的处方者减少了 30.9%。
实施科学方法可以有效地减少阿片类药物处方的差异，特别是对于 SICU 中的高剂量使用情况。这些干预措施可能会降低长期使用高剂量阿片类药物相关的风险。
治疗/护理管理；等级 II。
