Most opioid stewardship initiatives are multicomponent interventions, involving clinical interventions or care processes and often implementation strategies as well. The implementation strategies included education, policies, dashboards, audit and feedback, monitoring and metrics, health information exchange, and EHR tools. The EHR tools included an embedded PDMP, registry, alerts, autopopulation features, and templates. Weiner et al. (2019) found that it is critical to determine metrics and gain access to data at the beginning in order to guide the opioid stewardship effort. 112 They also experienced a mismatch when primary care providers referred patients to pain specialists with the expectation that the pain physicians would prescribe opioids, whereas the specialists would only recommend opioid regimens and provide injections. Additionally, while their health system had increased access to substance use disorder treatment, their outpatient practices perceived there was inadequate access. Finally, they learned that many of these implementation challenges could be addressed by convening the various stakeholders to resolve the issues. Buy-in and administrative support were identified as key for two opioid stewardship initiatives, also. It should be noted that while most opioid stewardship efforts are aimed at preventing or reducing harms due to opioids with appropriate prescribing, the stewardship efforts could also result in unintended negative consequences, such as patients having poorly controlled pain, experiencing the negative consequences of forced MAT is a proven method to treat OUDs. Effective MAT includes a combination of behavioral therapy and medications approved by the Food and Drug Administration (methadone, buprenorphine, and naltrexone). Individuals with OUD can safely take medications used in MAT as part of a long- term recovery plan. This section focuses on initiation of MAT, as MAT’s effectiveness in reducing illicit opioid use and overdose deaths has already been demonstrated in multiple randomized clinical trials. 113 Initiation of MAT can occur in primary care offices, EDs, hospitals, and community-based centers and clinics. The setting of MAT initiation might impact process and clinical outcomes, including engagement in and adherence to the patient’s treatment and recovery plan. Initiation usually refers to the first prescription of a medication, as the psychosocial aspects of the treatment are not available in every setting (e.g., hospital) in which the prescriptions can be given. The maintenance phase of treatment occurs when a patient is doing well on a stable dose of MAT medication, without side effects, cravings, or problematic use. Patients achieve the maintenance phase at different lengths of time following medication initiation. A patient may remain in the maintenance phase on the same dose ofmedication indefinitely or may choose to taper off of the medication. tapers, or turning to illicit opioids. Medication-Assisted Treatment
Evidence suggests advantages to maintenance therapy as opposed to tapering MAT medications. Specifically, maintenance treatment was associated with less use of illicit opioids, as measured by urine drug tests (UDTs), as opposed to tapering off the medication after stabilization was achieved. For example, Liebschutz et al. (2014) conducted an RCT of 139 hospitalized opioid- dependent patients in the general medical units of one urban safety-net hospital between 2009 and 2012. 114 Patients were randomized to receive either transition to hospital-based outpatient buprenorphine treatment upon discharge or to receive a 5-day buprenorphine taper, which was continued at home if discharge occurred before finishing the taper. At 6-month follow-up, participants who received linkage to outpatient treatment were more likely to enter outpatient buprenorphine treatment (72.2% vs. 11.9%; p<0.001); were more likely to remain in treatment (16.7% vs. 3%]; p=0.007); and were less likely to report illicit opioid use in the past month. Results have generally been mixed regarding the benefit to clinical outcomes of adding psychosocial interventions to MAT, which generally involved some form of individual or group psychotherapy using a modality such as cognitive behavioral therapy (CBT), Acceptance and Commitment Therapy (ACT), or motivational interviewing. Key findings about MAT • MAT can be initiated and provided safely in a variety of healthcare settings • It has been most studied in primary care settings, hospitals, EDs, and community-based centers and clinics— for example, HIV/AIDS clinics • Initiation of MAT in the ED, primary care setting or outpatient clinics may result in faster access to care and longer retention in or adherence to treatment • The majority of the studies found through the searches of the literature had sample sizes too small to detect differences between treatment groups—for example, RCTs with limited power to detect differences. Additionally, many of the studies’ follow-up periods were relatively short—for example, less than 6 months. Delirium Patient safety research and quality improvement efforts have been underway in the delirium harm area for many years, but clear and consistent recommendations regarding best practices have proven elusive. Studies have been conducted, including rigorously designed systematic reviews, but they have reached conclusions that have been contradictory and difficult to apply across settings. A 2019 systematic review that focused on the effectiveness of nonpharmacological interventions in reducing the incidence and duration of delirium in critically ill patients concluded that “current evidence does not support the use of non-pharmacological interventions in reducing incidence and duration of delirium in critically ill patients” and recommended further research with clearly defined outcomes. 115
A 2019 Cochrane systematic review that targeted older adults in institutional long-term care (LTC) found only limited evidence on interventions for preventing delirium in the LTC setting. 116 In recent systematic reviews examining antipsychotics for treating and preventing delirium in hospitalized adults, researchers found that current evidence does not support routine use of haloperidol or second-generation antipsychotics for prevention or treatment of delirium. 117 There is limited evidence that second- generation antipsychotics may lower the incidence of delirium in postoperative patients, but more research is needed. This section discusses three patient safety practices focused on delirium: use of screening and assessment tools for recognition of patients with delirium; training and education of staff to recognize signs and symptoms of delirium; and nonpharmacological interventions aimed at prevention or reduction of delirium among critically ill patients in intensive care. Background Delirium is the term used to refer to an acute decline in attention and cognition that constitutes a serious problem for older hospitalized patients and many residents in LTC facilities. Precipitating risk factors for delirium include acute illness, surgery, pain, dehydration, sepsis, electrolyte disturbance, urinary retention, fecal impaction, and exposure to high-risk medications. It is the most common complication among hospitalized individuals 65 years and over. Delirium in older hospitalized patients ranges from 14 to 56%, with hospital mortality rates ranging from 25 to 33 percent. Adults over 65 years of age account for 48 percent of all delirium-associated hospital days. 118 Delirium is associated with increased mortality, postoperative complications, longer lengths of stay, functional decline, and significant financial costs. One study estimated that delirium is unrecognized in about 60 percent of all cases. 119 This statistic is particularly troubling, as early detection of delirium has been demonstrated to improve health outcomes. However, to recognize delirium, it is necessary to know the older adult’s baseline health status so that any changes—which can occur within hours—can be quickly identified. Therefore, older adults should be assessed frequently using standardized tools so that up- to-date baseline information is readily available. Further, appropriate training and education for staff in recognizing and treating delirium should be provided. With a longstanding and still-growing body of evidence pointing to significant health and financial impacts of delirium on hospitalization and other healthcare costs, it is clear that individuals at risk for delirium should be identified as quickly as possible and preventive strategies should be implemented early in an encounter with the healthcare system.
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