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2nd October 2023
Tailoring opioid prescriptions for patients discharged from an emergency department (ED) with acute pain can support recovery and help to avoid the risk of drug misuse, according to a study presented at the European Society of Emergency Medicine (EUSEM)‘s recent congress.
The study found half of patients discharged from an ED with acute pain required five tablets or fewer of morphine 5 mg or an equivalent opioid painkiller to help manage their pain and recover from their injury or condition at home.
By tailoring the number of opioid painkillers prescribed for each patient, ED clinicians can ensure the right balance between sufficient pain relief and avoiding the over-prescribing of these drugs, which can lead to dependence and abuse in some cases.
Professor Raoul Daoust, from the University of Montreal, Canada, who presented the research, said: ‘Opioids such as morphine can be very beneficial for patients suffering acute pain, for example when they have injured their neck or broken a bone. However, patients are often prescribed too many opioid tablets and that means unused tablets are available for misuse. On the other hand, since the opioid crisis, the tendency in the USA is to not prescribe opioids at all, leaving some patient in agonising pain.
‘With this research I wanted to provide a tailored approach to prescribing opioids so that patients have enough to manage their pain but almost no unused tablets available for misuse.‘
Some 2,240 adult patients were recruited for the study, all of whom were treated at one of six hospital EDs in Canada for a condition that causes acute pain. They were each discharged with an opioid prescription and were asked to complete a pain medication diary for the following two weeks.
While half of patients took five 5 mg morphine tablets or fewer, the researchers noted that the number of tablets each patient required during the two-week period varied greatly according to the patient’s painful condition. For example, patients suffering from renal colic or abdominal pain needed only eight tablets and patient with broken bones needed 24 tablets.
Professor Daoust added: ‘Our findings make it possible to adapt the quantity of opioids we prescribe according to patient need. We could ask the pharmacist to also provide opioids in small portions, such as five tablets initially, because for half of patients that would be enough to last them for two weeks.’
Also commenting on the results, Professor Youri Yordanov from the St Antoine Hospital emergency department in Paris, France, who is chair of the EUSEM 2023 abstract committee but was not involved in the research, added: ‘It’s estimated that millions of people around the world are struggling with opioid addiction and more than 100,000 people die of opioid overdose every year. These drugs play an important role in emergency medicine, but we need to ensure they are prescribed wisely.
‘This study shows how opioid prescriptions could be adapted to specific acute pain conditions, and how they could be dispensed in relatively small numbers at the pharmacy to lower the chance of misuse. This research could provide a safer way to prescribe opioids that could be applied in emergency departments anywhere in the world.‘
Although widely prescribed in an emergency setting, a recent study has found that using opioids for patients with acute low back or neck pain offers no significant pain relief advantage compared to placebo.
25th September 2023
NHS England has confirmed it is developing a ‘national standard for rapid discharge’ from hospitals in its new guidance for ICBs on ‘intermediate care’.
Concerns have been raised that it does not sufficiently take into account the impact on general practice, with GPs inevitably picking up a larger share of the workload if patients are discharged sooner.
The framework recommends a number of actions for system commissioners to consider to improve short-term health and social care to adults who need support after discharge from acute settings.
Earlier this year, in its urgent and emergency care recovery plan, NHSE committed to developing a new planning framework and national standard for rapid discharge ‘by autumn 2023’.
The new guidance confirmed that this national standard is in development, however it emphasised that ‘improved data’ is needed to ‘inform the approach’.
It said data on discharge ‘are not standardised, consistent and are often collected at a local level in multiple formats’.
‘This limits the understanding of the timescales and processes that support optimum discharge into intermediate care,’ it added.
The framework therefore sets out actions for ICBs to improve ‘data quality, coverage and completeness at system, regional and national-level’.
NHS England’s guidance also aims to improve workforce mapping, increase therapist input by releasing their capacity and implementing ‘care transfer hubs’.
The hubs are intended to be a ‘focal point for coordinating discharge’, particularly complex discharges, and are made up of a multidisciplinary team of health, social care, housing and voluntary sector partners.
Walsall Healthcare NHS Trust, one of the so-called frontrunner sites that has been trialling new approaches to step-down care, has a care transfer hub which currently includes only social care, mental health, acute and community health, but is working towards primary care inclusion.
Aside from this case study, there is no direct reference to general practice or primary care involvement in the action plan.
Professor Azeem Majeed, professor of primary care and public health at Imperial College London, said the guidance aims to ‘improve patient outcomes and reduce hospital readmissions’ which will ultimately result in a better use of resources and improved patient experience.
‘But successful implementation will require support from general practices and this is not discussed in any detail in the plans (e.g. in sharing of patient data),’ he said.
The guidance said: ‘Implementation of step-down intermediate care as outlined here is expected to result in improved outcomes, experiences and independence of people discharged, reduced avoidable hospital readmissions, and reduced avoidable/premature long-term care provision.
‘Further expected benefits include improved flow and discharge from acute and community hospitals, freeing-up NHS hospital capacity for those who need it most.’
A recent study showed that medication errors when people go into or are discharged from hospital in England could be reduced by nearly 40% with the introduction of this standard which makes it easier to share information across hospital and GP systems.
Over the summer, NHS England announced plans to speed up patients’ discharge this winter, including additional ambulance hours, extra beds, and new ‘care traffic control centres’ to act as ‘one stop’ for staff to coordinate discharges.
This article was originally published by our sister publication Pulse.
28th July 2023
Medication errors when people go into or are discharged from hospital in England could be reduced by nearly 40% with the introduction of new digital information standards being rolled out this year, say researchers.
Analysis by a team at the University of Manchester found that medication errors would be cut from 1.8 million to 1.1 million (39%) by the easier sharing of information across hospital and GP systems.
They also calculated that there could be around 12,000 fewer people experiencing harm from their medicines, with 14,000 fewer days spent in hospital at a saving to the NHS of £6.6m.
But they stressed, there still needs to be a healthcare professional, usually a pharmacist, doing medicines reconciliation.
The standards, which first came into effect in October 2021 with NHS organisations having to show compliance by this year, should make that work easier and quicker so more patients can have their medicines checked properly, they added.
A report commissioned by NHS England looked at published research on medication errors in the UK as well as evidence from other countries where similar changes to digital information standards have been made.
Overall, they estimated that around 31,000 people experience harm from a transition medication error, with over half of these happening to mistakes made at hospital admission.
They also estimated that such errors lead to 45 deaths a year, 20 of which could be prevented when the standards are introduced.
This is not just a UK issue, the researchers said. Errors relating to medicines missed off the list, extra ones added, or wrong doses written down are common worldwide, and the World Health Organization has made it a priority for health services to find ways to reduce them, they added.
Speaking to Hospital Pharmacy Europe‘s sister publication Pulse, study lead Professor Rachel Elliott, professor of health economics, said the standards were being rolled out this year but it was a very complex process with lots of different stakeholders.
She added: ‘Medicines reconciliation done at admission and discharge has been shown to reduce medication errors. This is not about replacing that process but it is about making it easier to access the information which at the moment is all over the place and all the different systems can’t talk to each other. It is enabling the human element to be done more quickly.’
This article was originally published by our sister publication Pulse.
NHS England has announced plans to help speed up patients’ discharge this winter, including additional ambulance hours, extra beds and new ‘care traffic control centres’, to ‘boost capacity and resilience’ across the NHS.
A nationwide rollout of ‘care traffic control centres’ will provide ‘one stop’ for staff to locate and co-ordinate the best and quickest discharge options for patients, according to NHS England.
The centres are expected to bring together teams from across NHS, social care, housing and voluntary services in one place to help ‘make live decisions and offer patients everything they need in one place’.
Around a quarter of local areas currently offer this service 12 hours a day, seven days a week, and this is set to expand to every area of the country by winter, NHS England said.
The commissioner expects a third of patients to be discharged using this model by December, drawing information from electronic patient records to track patients and link up with housing services.
Chelsea and Westminster Hospital NHS Foundation Trust has been able to speed up and improve staff rounds and discharge patients more easily using the Timely Care Hub, where staff can track tasks and patient statuses live, and check information like anticipated discharge date and pathways. In future, the Trust will also be able to use the Timely Care Hub to check outstanding risk assessments for things like falls, infection control and pain assessment.
North Tees and Hartlepool NHS Foundation Trust also has a new system which operates in a dedicated control room and tracks patients from admission through their hospital journey, highlighting in real-time any issues that could delay their discharge once they are medically ready to leave. Following a successful pilot, this system is now being rolled out around the country by NHS England.
The NHS will also be announcing a new scheme to encourage local teams to ‘overachieve’ on performance measures with financial incentives provided for these areas.
Winter preparations have been well underway since the publication of the NHS Urgent and Emergency Care Recovery Plan, NHS England said.
The NHS has also outlined how it is bracing for another winter facing the possibility of higher than usual levels of respiratory illness including Covid, flu and respiratory syncytial virus.
The use of Acute Respiratory Hubs, for urgent, same-day face-to-face assessment for conditions like Covid, flu and RSV, will also be expanded to be available in every part of the country.
Australia, whose activity often predicts what the NHS in England is likely to see in winter, is experiencing one of the biggest flu seasons on record with children particularly affected, making up four in five of flu-related hospital admissions, NHS England said.
Hospitals are putting more beds in place for patients and are on track to hit 5,000 additional ‘core’ permanent general and acute beds.
Plans will also be put in place to ‘strengthen ambulance response to mental health calls, to raise the profile of all-age 24/7 urgent mental health helplines’ and to avoid long lengths of stay in mental health inpatient settings.
Sarah-Jane Marsh, NHS national director of urgent and emergency care, said: ‘Ahead of winter we will not only have more ambulances and beds in place, but we will also be continuing to work more closely as an entire NHS and social care system, increasing the capacity of community services that help keep patients safe at home.
‘We will continue to build on this progress and do everything we can to put the NHS on the front foot ahead of what has the potential to be another challenging winter with covid and flu.’
Dr Vin Diwakar, NHS medical director for transformation, said: ‘The rapid expansion of ‘care traffic control centres‘, means patients can be more easily discharged with the right support when medically fit to leave hospital with the latest information available to staff in one spot – this is both better for patients and for the NHS.’
A version of this article was originally published by our sister publication Pulse.
8th February 2023
A randomised trial of a patient-centred deprescribing intervention in older adults led to a significant reduction in medicine use compared to a control group who did not receive the intervention according to a study by US researchers based in Tennessee.
Polypharmacy is defined by the use of five or more medicines and one US study found that in 2010, among elderly patients (65 years and older), polypharmacy was present in 39% of cases. Polypharmacy increases the risk of adverse drug reactions and somewhat alarmingly in one analysis of 2,105 older adults discharged from hospital, 74% were prescribed a polypharmacy regimen.
Consequently, deprescribing interventions to reduce medication burden are likely to decrease the risk subsequent adverse events associated with the use of multiple treatments. In the current study, the US team examined the effectiveness of a deprescribing framework at reducing medication burden. The intervention had been previously piloted in one centre and was found to be effective, leading to US to undertake randomised, controlled trial of the intervention.
The intervention itself involved nurses or pharmacists reviewing the medicines of older adults prior to hospital discharge to a post-acute care (PAC) facility and the outcomes compared with the usual hospital discharge care.
The primary outcome was the total medication count at hospital and PAC discharge and participants were followed-up for assessment, 90 days after being discharged from the PAC facility. Secondary outcomes included the total number of potentially inappropriate medications (PIMs) as well as the drug burden index (DBI) which measured sedative and anticholinergic burden.
Deprescribing intervention and total medication burden
A total of 284 participants (142 per group) with a mean age of 76.2 years (62% female) were included in the final analysis and the median length of PAC facility stay was 22 days. Overall, the median number of prehospital medications per patient was 16.
As a result of the intervention, participants were taking a mean of 14% fewer medications upon discharge from the PAC facility (mean ratio, MR = 0.86, 95% CI 0.80 – 0.93, p < 0.001). In addition, at the 90-day assessment, those previously assigned to the intervention were taking 15% fewer medicines (MR = 0.85, 95% CI 0.78 – 0.92, p < 0.001) compared to the control group.
The intervention group were also prescribed fewer PIMs and had a lower DBI after 90 days yet the incidence of adverse drug events was similar between the intervention and control groups (hazard ratio, HR = 0.83, 95% CI 0.52 – 1.30).
The authors concluded that their deprescribing intervention was both safe and effective at reducing overall medication burden and called for future studies to examine the impact of the intervention on both patient-reported and long-term clinical outcomes.
Citation
Vasilevskis EE et al. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute CareA Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023.
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