2014 Top Stories in Primary Care: Pain Management.

The most important development in pain management in 2014 has been greater scrutiny regarding pain medication use and misuse as well as greater attention paid to appropriate alternatives for the management of pain. We have known for some time of escalating issues including a three- to four-times increase in the number of overdose deaths since the 1990s related to pain medications. This rise seems to be the sharpest in groups such as the military and in women, with an overall estimate of 46 deaths per day from prescription painkiller overdoses in the US:

These finding were highlighted in the 2014 White House Summit on the Opioid Epidemic (http://www.whitehouse.gov/blog/2014/06/19/white-house-summit-opioid-epidemic) and have been followed by a shift in medication options to combat the problem. This has included the FDA rescheduling of hydrocodone to Schedule II, the approval of a new hand-held naloxone auto-injector to reverse overdose, as well as the November 2014 approval of an abuse deterrent version of hydrocodone:

The most significant change in policy has probably been the recent revision to the Joint Commission pain management standards (http://www.jointcommission.org/assets/1/18/Clarification_of_the_Pain_Management__Standard.pdf). The previous standards had been in place since 2000 and said very little about nonpharmacological approaches that should be considered. The new policy, which becomes effective January 1, 2015, states that:

“When considering the use of medications to treat pain, organizations should consider both the benefits to the patient, as well as the risks of dependency, addiction, and abuse of opioids.” More specifically, the Commission mentioned specific interventions to consider:

“Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:

  • Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy),
  • Relaxation therapy,
  • Cognitive behavioral therapy, and
  • Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics.”

Of note, these recommendations are intended not only for inpatient settings, but “for the ambulatory care, critical access hospital, home care, hospital, nursing care centers, and office-based surgery programs.”

In addition to policy and regulatory initiatives underway, a number of publications have noted the need for a more comprehensive approach to truly reduce what is one of the leading causes of accidental or preventable deaths in most US states.1

This coming year will likely see more initiatives in this regard. What hopefully will come out of the discussion is a sharp reduction in overdose deaths. During this pendulum swing, which we have seen before in pain management, it is hoped that the care of those persons in pain is not sacrificed. To balance these goals, it is important to systematically improve the care options of those in pain by consideration, incorporation, and coverage of the integrative approaches outlined in the Joint Commissions report. In this way, we will not only have meaningful recommendations but meaningful pain relief.

Top 10 Healthcare Technology Hazards for 2014.

Alarm hazards and infusion pump medication errors are at the top of a list of technology hazards for 2014, according to a report from the ECRI Institute published in the November 2013 issue of Health Devices.

Each year, the ECRI Institute compiles a Top 10 list of technology safety hazards along with risk-mitigation strategies.

“Nothing on this list was a surprise,” Mary K. Logan, JD, CAE, president and CEO of the Association for the Advancement of Medical Instrumentation, told Medscape Medical News. “A lot of the hazards aren’t about the device itself; they’re about the device in use.”

Here are the top 10:

Alarm Hazards

“Alarm hazards is a national patient safety goal for 2014 of the Joint Commission,” Ms. Logan noted. In April 2013, the Joint Commission issued a Sentinel Event Alert after 98 alarm-related events occurred over a three-and-a-half-year period resulting in death for 80 patients and permanent loss of function for 13 others.

“Beyond alarm fatigue, patients could be put at risk if an alarm does not activate when it should, if the alarm signal is not successfully communicated to staff or does not include sufficient information about the alarm condition, or if the caregiver who receives the alarm signal is unable to respond or is unfamiliar with the proper response protocol,” the report finds.

A comprehensive alarm management program should be in place to minimize clinically insignificant or avoidable alarms and optimize alarm notification and response protocols.

Infusion Pump Medication Errors

“Patients can be highly sensitive to the amount of medication or fluid they receive from infusion pumps, and some medications are life-sustaining-or life-threatening if administered incorrectly,” the report states.

Infusion pump integration, where servers for infusion pumps are connected with other information systems, can provide an additional level of safety by helping to verify that the right patient is being given the right drug.

CT Radiation Exposures in Pediatric Patients

Computed tomography is a valuable diagnostic tool, but pediatric patients are particularly sensitive to ionizing radiation, which is delivered in comparatively high amounts. The risk can be lessened by using safer diagnostic tests such as traditional X-rays, magnetic resonance imaging, and ultrasound. Repeat testing should be avoided whenever possible, and the lowest possible amount of radiation should be used.

Data Integrity Failures in EHRs and Other Health IT Systems

“When designed and implemented well, an EHR [electronic health record] or other IT [information technology]-based system will provide complete, current, and accurate information about the patient and the patient’s care so that the clinician can make appropriate treatment decisions,” the report states. The presence of incorrect data can result in patient harm. System testing, adequate staff training, and a system for reporting errors are important steps in reducing risk associated with EHRs.

Occupational Radiation Hazards in Hybrid Operating Rooms

Hybrid operating rooms with advanced imaging capabilities are increasingly common, and may expose operating room staff to excessive radiation, particularly because staff may not be as alert to the hazards as staff in a dedicated radiology department. All hybrid operating rooms should have a radiation protection program in place.

Inadequate Reprocessing of Endoscopes and Surgical Instruments

“When reprocessing is not performed properly…patient cross-contamination is possible, potentially leading to the transmission of infectious agents and the spread of diseases such as hepatitis C, HIV, and tuberculosis,” the report notes.

Appropriate reprocessing protocols need to be in place, and staff must be trained in them and have sufficient time to perform reprocessing correctly.

Neglecting Change Management for Networked Devices and Systems

“[O]ne underappreciated consequence of system interoperability is that updates, upgrades, or modifications made to one device or system can have unintended effects on other connected devices or systems,” the report states. IT, clinical engineering, and nursing/medical personnel need to work together to prevent IT-related changes from having an adverse effect on networked medical devices and systems.

Risks to Pediatric Patients from “Adult” Technologies

“[D]ue to their smaller size and ongoing physiologic changes, children may suffer adverse effects when subjected to adult-oriented healthcare techniques,” the report finds. Pediatric-specific technologies should be used whenever possible.

Robotic Surgery Complications Due to Insufficient Training

The use of robotic surgery has increased dramatically in recent years. Training provided by the device supplier can familiarize users with the equipment, but hospitals need to verify that surgical staff develop procedure-specific skills, the report states.

Retained Devices and Unretrieved Fragments

“In October 2013, the Joint Commission issued a Sentinel Event Alert on the unintended retention of foreign objects, noting that 772 such incidents were reported to its Sentinel Event Database from 2005 to 2012, including 16 that resulted in death,” the report notes. Key preventive measures include visually inspecting devices before and after use, and following accepted surgical count procedures.

“Clinicians really need to realize that these hazards are really important for them to pay attention to because they are the only ones who can do something about reducing these hazards,” Ms. Logan explained. “Technology is a tool, but it’s not just a tool to take out of the box and start using it.”

Physician Groups Recommend Steps to Limit Overuse of Five Treatments.

A physician consortium convened by the American Medical Association and the Joint Commission has released recommendations aimed at reducing the unnecessary use of five interventions. Here’s a quick look at the targeted interventions, including steps to limit their use:

  • Antibiotic therapy for viral upper respiratory infections: Develop clinical definitions for viral versus bacterial URIs.
  • Over-transfusion of red blood cells: Create a toolkit of educational materials for clinicians, broaden education on transfusion alternatives.
  • Tympanostomy tubes for short-duration middle ear effusion: Develop performance measures to assess appropriate use.
  • Early-term, nonmedically indicated elective delivery: Educate patients about the risks, standardize how gestational age is determined.
  • Elective percutaneous coronary intervention: Encourage patient understanding of both the benefits and risks.

“The recommendations … will raise awareness that will help both doctors and patients make better decisions going forward, and ultimately improve quality and patient safety,” the president of the Joint Commission said in a news release.

Source: Joint Commission news