Publications

INTRODUCTION: Simulation-based learning (SBL) is a recognised teaching and learning tool within higher education (HE) and one capable of facilitating skill retention and knowledge retrieval. Successfully achieving these outcomes relies on effective design, delivery and debriefing; yet a limited range of publications draw together these fundamental components. High-fidelity simulation (HFS) describes a sub-division of SBL that, in recent years, has generated traction within healthcare education.

AIMS: To support educators in orchestrating HFS with greater impact and influence, the author set out to compose an article outlining five constructs that collectively possess scope to optimise HE teaching and learning outcomes. These five constructs consist of: (1) creating a believable scenario; (2) integrating the five principles of 'fidelity harmony'; (3) selecting an appropriate modality; (4) adopting a clear pedagogical stance; and (5) amalgamating concepts of experiential learning theory into the briefing and debriefing. When dynamically incorporated, important gaps between theory and practice can be bridged and learner experience will be significantly enhanced.

CONCLUSION: This article offers HE educators a series of recommendations for creating deeply immersive learning experiences for augmenting learner performance, and provides a new definition for HFS, which challenges the erroneous notion that 'high fidelity' represents 'high technology'.

Pain and addiction are persistent public health issues that can lead to serious and fatal consequences on individuals, families, and communities. With the continued development of the opioid epidemic and the subsequent rise in opioid use and misuse, it is important to recognize the need for intervention at a public health level. Opioid stewardship programs (OSPs) are promising public health interventions that aim to coordinate safe and effective pain management through evidence-based intervention strategies. This narrative literature review examined the current evidence for implementation of OSPs in emergency departments and acute care hospitals to identify best practices and gaps in evidence. We reviewed publications found through PubMed and Embase, and articles were selected for inclusion after being evaluated through the inclusion criteria. One hundred and ninety-six articles were first found via the database search, and a final 24 articles were included in the sample for full review. The results indicated that all but two studies were published within the last 4 years, and one study mentioned a rural location. Most of the studies were pre- and post-OSP implementation studies. On average, the studies implemented four of the 11 total OSP strategies of interest. Twenty-two studies included information on care coordination, with the most prevalent effect being a decrease in total morphine milligram equivalents being prescribed at discharge. Nine studies included data on patient safety measures, including adverse events such as return emergency room visits, need for naloxone administration, and increase in post-operative clinic visits. This narrative review provides us with a preliminary understanding of OSP implementation in hospital settings and provides evidence that they are feasible and accepted with a wide variety of implementation interventions and strategies. It also demonstrates a gap in the literature regarding implementation in rural settings and with some specific implementation strategies.

Despite efforts to reduce abuse, opioids remain a societal concern. Coronavirus disease 2019 (COVID-19) brought new challenges, and research is needed to understand its impact on opioid abuse in the population. Three data sources were used to investigate trends in misuse and abuse of XTAMPZA® ER compared to extended-release (ER) and single-entity immediate-release (SE-IR) oxycodone from 2019Q3 through 2022. Changes in trends over 6-month intervals were investigated using linear spline models with a breakpoint at 2020Q3 to measure the impact of COVID-19. Poison center call rates for misuse or abuse of ER and SE-IR oxycodone showed significant changes during COVID-19 (both p < 0.001), reversing trends and significantly decreasing (201327.56 percent change and -12.91 percent change, respectively). In contrast, XTAMPZA ER trend rates showed no change during COVID-19, remaining fairly stable. The odds of abuse of ER oxycodone among those entering opioid use disorder treatment significantly changed during COVID-19 (p = 0.025), resulting in a stabilization of the trend. For SE-IR oxycodone, no change was observed in the decreasing trend (-12.88 percent change during COVID-19). XTAMPZA ER had no significant change during COVID-19 (p = 0.200) and appeared stable. Since 2021Q3, among the general adult population, the prevalence of past-year nonmedical use of XTAMPZA ER was rare (0.04 percent), as was the case for other oxycodone products (<1 percent). Overall, there is no evidence that oxycodone misuse and abuse worsened during COVID-19 in these populations, and XTAMPZA ER was consistently lower than other oxycodone products. Low rates and improving trends in oxycodone misuse and abuse may signify an ongoing reduction in prescription opioid contributions to the opioid crisis.

OBJECTIVES: To investigate post-operative opioid use, functionality, and overall survival following internal fixation for pathologic or impending fractures at 3 and 6 months.

BACKGROUND: Pathologic and impending fractures commonly occur in the proximal femur, and patients may be prescribed opioids prior to surgery and often require opioids for post-operative pain relief. This study compared post-operative opiate usage and ambulatory functional status in patients with impending versus pathologic fractures in the proximal femur.

DESIGN: This was a retrospective case-control study of patients using opioids post-operatively who underwent internal fixation for a pathologic or impending fracture between 2016 and 2022. Preoperative and post-operative opioid usage as well as ambulation status and risk factors at 3 and 6 months associated with post-operative opioid use were recorded.

RESULTS: Twenty-four pathologic fractures and 23 impending fractures were included. Preoperative opioid daily morphine milligram equivalent was significantly higher in the pathologic fracture group, but there were no significant differences at 3 or 6 months. There was statistically significant post-operative improvement in ambulation status in the combined cohort and impending fracture cohort at 3 months and 6 months.

CONCLUSIONS: Although patients did not experience a significant post-operative change in opioid use, patients with pathologic fractures notably required higher opioid dosages preoperatively, and there was overall improvement in function following fixation. Future studies should examine post-operative opioid use with careful consideration of concurrent pain management pain therapies and tumor characteristics.

OBJECTIVE: To examine associations between race, comorbidity, opioid and nonopioid treatment burden, and socioeconomic status (SES) in patients with chronic low back pain (CLBP).

DESIGN: A case-control study.

SETTING: Tertiary academic system.

PARTICIPANTS: A total of 4,193 subjects with CLBP and 4,193 age-, sex-, race-, and region-matched subjects with nonchronic low back pain participated in this study.

MAIN OUTCOME MEASURE(S): The primary outcome measures were prescription frequencies of opioid and nonopioid medications as well as nonpharmaceutical interventions. Secondary measures pertained to the prevalence of comorbidities, race, and SES traits.

RESULTS: The median age of the subjects was 55.50 years, with 61.75 percent female distribution, 48.84 percent Black or African American, 30.65 percent White non-Hispanic, and 15.93 percent non-White Hispanic or Latino among the subjects. Black or African American and non-White Hispanic or Latino identity was associated with higher hardship compared to patients identifying as White non-Hispanic (Tukey-Kramer adjusted p-value < 0.0001). Opioid use was significantly higher in the CLBP group (Cochran-Armitage trend test p-value < 0.0001), and there was a significant positive trend between the number of comorbidities and opioids used. As hardship index group (HIG) increased by 1, the expected number of comorbidities increased by a factor of 1.09 (95 percent confidence interval [CI]: 1.06-1.11), and the expected number of treatments increased by a factor of 1.07 (95 percent CI: 1.04-1.09). Physical therapy and spine procedures had a significant negative relationship with hardship.

CONCLUSIONS: Higher opioid prescribing behavior, particularly for morphine, hydrocodone, and tramadol, exists in patients with CLBP, especially in patients facing hardship and identifying as Black or African American and non-White Hispanic or Latino. Further prospective studies are needed to strengthen causality.

AIM: This study aims to assess the application of opioids for pain control in patients following a cesarean section (CS) at a tertiary referral obstetric hospital.

METHODS: A retrospective cohort audit of CSs in September 2022 was conducted. Medical records were reviewed to capture patient demographics, opioid used, and discharge medications.

RESULTS: Medical records of 46 patients were reviewed. Of those, 46 percent (n = 21) had a non-elective lower uterine CS (NELUSCS), 43 percent (n = 20) had an elective lower uterine CS (ELUSCS), and the remainder had a nonelective classical CS (NEClassicalCS). NEClassicalCS had higher total morphine equivalent opioid use with an average of 245.7 mg, compared with 92.4 mg and 60.1 mg for NELUSCS and ELUSCS, respectively. Tramadol was the most common opioid supplied on discharge (85 percent), followed by buprenorphine (17 percent) and oxycodone/naloxone (15 percent). An average discharge medication supply of 3 days was provided.

CONCLUSIONS: NEClassicalCS procedures had higher use of opioid pain medications. All patients were initiated on opioids post-CS, with 93 percent (n = 43) discharged with at least one opioid.

INTRODUCTION: Previous investigations reveal that protracted resuscitative efforts are associated with poorer long-term patient outcomes. Aside from certain patient characteristics and interventions, such as shockable rhythms, bystander CPR and early defibrillation, little is known about factors influencing resuscitation duration and time to return of spontaneous circulation (ROSC). We hypothesised that early public safety answering point (PSAP) call-receipt-to-pressor (PSAP-to-pressor) administration would decrease the pressor-to-ROSC interval and shorten low-flow duration. Our objective was to quantify the relationship between the PSAP-to-pressor and pressor-to-ROSC intervals.

METHODS: We conducted a retrospective analysis using the 2020 ESO dataset containing calls from January to December 2020. Adults with non-traumatic, bystander-witnessed arrests were included. A Cox proportional hazard model was used to determine the association between PSAP-to-pressor interval and pressor-to-ROSC interval while controlling for potential confounders. The end of the event was defined as ROSC, field termination of resuscitation or hospital arrival without ROSC. Patients without ROSC upon hospital arrival were right censored.

RESULTS: Overall, 10,093 patients had data sufficient for analysis. The mean age of the participants was 65.3 (±15.5) years and 64.5% were male. Presumed cardiac aetiology was present in 83.7% of arrests, 29.4% presented with a shockable rhythm and 35.9% attained ROSC. The mean PSAP-to-pressor and pressor-to-ROSC intervals were 16.2 (±5.0) and 14.6 (±11.1) minutes, respectively. The mean time from the first adrenaline administration to the end of the event was 32.7 (±1.0), 41.5 (±1.2) and 51.6 (±3.8) minutes for the 0-10-, 11-20- and 21-30-minute PSAP-to-pressor intervals, respectively (p <0.001). After controlling for confounders, the PSAP-to-pressor time interval was associated with decreased likelihood of ROSC (HR = 0.97 per minute, p <0.001). When stratified by 10-minute increments with 0-10 minutes as reference, PSAP-to-pressor was negatively associated with ROSC for the 11-20- (HR = 0.86, p = 0.002) and 21-30- (HR = 0.66, p <0.001) minute categories.

CONCLUSION: This retrospective analysis from a national database revealed that increasing delays to first adrenaline administration were associated with prolonged resuscitation duration after drug administration and decreasing likelihood of ROSC.