At our community teaching hospital, orders for end of life often lacked instructions to titrate opioids based on evidence-based principles and failed to address nonpain symptoms. An order set and a nursing-driven opioid titration protocol were implemented in August 2016 after extensive education. The purpose of this retrospective preintervention and postintervention study was to evaluate the impact of this intervention on the quality of end-of-life orders. We evaluated 69 patients with terminal illness receiving morphine infusions. After implementation, more morphine infusion orders included an as-needed bolus dose with an objective indication and appropriate instructions on when and how to titrate the infusion compared with before the intervention (94.6% vs 18.8%, P < .0001). Morphine infusion orders were also significantly more likely to include a maximum dose (P = .041) and an initial bolus dose (P < .0001). In addition, prescribers were more likely to order additional medications to manage nausea/vomiting, constipation, anxiety, or pain using a nonopioid (P < .05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the quality of morphine infusion orders for pain management at the end of life and increased the use of medications to manage nonpain symptoms in dying patients.

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Introduction Cryoprecipitate (CRYO), a blood product prepared from FFP, is rich in fibrinogen, von Willebrand’s factor, and factors VIII and XIII. ​The major indication for CRYO transfusion is fibrinogen deficiency with increased risk of bleeding when fibrinogen is <100 mg/dL, a transfusion trigger rarely followed by the house staff or other clinicians. To limit wastage, Transfusion Services issue them as pools of five individual CRYO units. The use of CRYO at Robert Wood Johnson University Hospital (RWJUH) has significantly risen since 2010, so we conducted a study to identify the factors leading to increased CRYO transfusions. Methods Data on CRYO transfusions from 2010 to 2017 were obtained and analyzed for trends in overall usage and by nursing unit/departments. Cost-analysis was performed to determine the cost of CRYO usage. Conclusion Overall, CRYO usage has risen since 2010, with a sharp increase between 2015 and 2017 attributed to increased transfusions in the operating room (OR), surgical intensive care unit, and hematology-oncology units. There was a sixfold rise in transfusions in the hematology-oncology units. During this time, the lower limit of the fibrinogen reference range decreased from 234 to 190 mg/dL along with a drop in the number of trauma alerts. Values less than the lower reference range were used as the transfusion trigger by some overzealous hematology fellows. Cost-analysis showed that RWJUH lost 75% revenue per patient based on Medicare reimbursement despite efforts to limit wastage and lowering purchasing cost per unit by changing to a new blood supplier. The major determinants of intensified CRYO transfusions at RWJUH are (1) changes in the fibrinogen reference range concomitant with enhanced awareness, monitoring, and early treatment of hypofibrinogenemia, particularly in hematology-oncology units and (2) the complexity of surgical procedures (ie, VAD procedures) requiring more CRYO transfusions rather than the number of trauma alerts.