Study Objective-To evaluate blood pressure (BP) control following discontinuation of a physician\pharmacist collaborative intervention.Design-BP was previously measured at baseline and at the end of a 9-month clusterrandomized intervention trial. This study abstracted medical record data for mean BP and BP control at 18 months (9 months after the discontinuation of the intervention) and at 27 months (18 months after discontinuation of the intervention).Setting-Five primary care medical offices operated by a university health system.Patients-Subjects with hypertension who were enrolled in a previous controlled trial and who consented to have data abstracted for an additional 18 months following the end of that study.Intervention-A physician\pharmacist collaborative intervention to improve BP control was withdrawn after 9 months and BP and the change in BPs following withdrawal of the intervention were evaluated.Measurements-A research nurse measured BP during the 9-month interventional study. BP values were then abstracted from the medical record for the 18 month period after the end of that study.Main Results-104 patients had BP values at all 4 time periods. At baseline, systolic BP (SBP) was 152.5 ± 9.5 and 150.1 ± 9.6 mm Hg in the intervention and control groups, respectively Conclusions-This study found a sustained effect on BP control up to 18 months following discontinuation of a pharmacist intervention. However, BP control deteriorated at a similar rate in both the intervention and control group but remained significantly higher in the intervention group. This study suggests that continued interventions by pharmacists may be necessary to maintain high rates of BP control, especially in those patients who lose BP control.

The acute care of burn patients is critical and can be a daunting experience for emergency personnel because of the scarcity of burn injuries. Telemedicine that incorporates a visual component can provide immediate expertise in the treatment and management of these injuries. The authors sought to evaluate the addition of video telemedicine to our current telephone burn transfer program. During a 2-year period, 282 patients, 59.4% of all burn patients transferred from outside hospitals, were enrolled in the study. In addition to the scripted call with the charge nurse (ChargeRN) and the accepting physician, nine hospitals also transmitted video images of the wounds before transfer as part of a store and forward telemedicine transfer program (77, 27.6%). The accuracy of burn size estimations (BSA burned) and management changes (fluid requirements, transfer mode, and final disposition) were analyzed between the telephones-only sites (T only) and the video-enhanced sites. Referringstaff participating in video-enhanced telemedicine were sent a Google survey assessing their experience the following day. The referring staff (Referringstaff) was correct in their burn assessment 20% of the time. Video assessment improved the ChargeRN BSA burned and resulted in more accurate fluid resuscitation (P = .030), changes in both transportation mode (P = .042), and disposition decisions (P = .20). The majority of the Referringstaff found that video-enhanced telemedicine helped them communicate with the burn staff more effectively (3.4 ± 0.37, scale 1-4). This study reports the successful implementation of video-enhanced telemedicine pilot project in a rural state. Video-enhanced telemedicine using a store and forward process improved burn size estimation and facilitated management changes. Although not quantitatively assessed, the low cost of the system coupled with the changes in transportation and disposition strongly suggests a decrease in healthcare costs associated with the addition of video to a telephone-only transfer program.

Satisfactory treatment of burn pain continues to be elusive. The perioperative period is particularly challenging. The contributions of acute tolerance and opioid-induced hyperalgesia have not been previously explored in burn patients. As these phenomena have been identified perioperatively in other patient populations, we sought to characterize the burn perioperative period and to determine variables associated with poor postoperative (post-OR) pain control. A retrospective review of 130 adult burn patients who underwent surgical treatment for their burn injuries was performed. Variables collected included: demographics, burn injury data, perioperative self-reported pain scores, and perioperative opioid amounts. Correlations and multiple logistic regressions were used to assess the relationship between these variables and post-OR pain control. Pain increased throughout the perioperative period from 2.64 24 hours prior to the operation (pre-OR) to 3.81 24 hours following the OR (post-OR, P < .0001). Post-OR pain was correlated with pre-OR pain, pre-OR opioid amounts, OR opioid amounts, and post-OR opioid amounts. When the subgroup of patients with controlled pre-OR pain (<3 pain rating) was analyzed, only pre-OR opioids and post-OR opioids remained correlated with worse post-OR pain. While this study is retrospective, there is a suggestion that opioid amounts given pre-OR and intraoperatively are correlated with worse post-OR pain. While an increase in pain ratings postoperatively are anticipated, the additional contributions of acute tolerance and opioid-induced hyperalgesia need to be determined. Pharmacologic intervention directed at these mechanisms can then be administered to achieve better postoperative pain control.

Opioids are the cornerstone of pain treatment in burn patients. Undertreatment of pain has been associated with psychological sequela. However, prescription opioids have been increasingly associated with adverse drug effects. Safe opioid prescribing practices have been established in other populations. The purpose of this study was to explore postdischarge prescribing practices in a regional burn center. A retrospective review of hospital and discharge records of patients ≥18 years admitted to the burn center from December 2009 to June 2012 was performed. Charts were reviewed for demographic, burn, hospital treatment, and follow-up data. Pain scores and opioid needs were assessed 24 and 48 hours before discharge. Discharge opioid prescriptions and opioid refills were recorded. Pearson correlation and multiple linear regression was used to assess variables related to discharge opioid amounts. Jonckheere-Terpstra nonparametric test was used to identify the variables associated with the number of refills of opioid analgesia. Of the 140 patients, 120 (85.7%) were discharged on opioids. The median daily prescribed amount was 114 (interquartile range, 90-180) mg morphine equivalents (ME) for a median total duration of 6 (interquartile range: 4-10) days. Age (P < .0001), male sex (P = .024), and total mg ME before discharge (P < .0001) were independently associated with the amount of opioids prescribed at discharge. The number of refills was significantly associated with the average pain within 48 hours before discharge (P = .005) and with 24 hour predischarge mg ME (P = .006). By 14 days, 114 (84.3%) patients were still being seen in clinic and 127 (90.0%) were no longer taking opioids. The treatment of burn pain requires large amounts of opioids. Continued opioid therapy is necessary as the patients transition to the out-patient setting. This study identified several areas that could be modified to align with safer opioid prescribing practices, including lowering daily amount of prescribed opioids, prescribing only short-acting opioids, and providing patient opioid education. Future studies should focus on the adverse effects of opioid use in burn patients.

Considerable risk of burn injury exists for those patients on home oxygen therapy (HOT) who continue to smoke. In this study, the authors sought to establish the national incidence of burns incurred while smoking on HOT and to determine the resource utilization and sequelae of these injuries. A retrospective review of the American Burn Association's National Burn Repository was conducted to identify patients burned while on HOT during the years 2002 to 2011. Duplicate entries, as well as records of follow-up visits and readmissions, were removed. Univariate analysis was used to compare the differences between patients sustaining burn injuries related to HOT and patients with other mechanisms of injury. Multivariate analysis provided odds ratios for mortality controlling for all significant variables. The frequency of burns sustained on HOT significantly increased during the 10-year period reviewed and were associated with increased comorbidities and certain complications. Compared with non-HOT injuries, HOT injuries had higher incidence of inhalation injury and mortality. Inhalation injury was the strongest predictor of mortality in HOT burn injuries. The likelihood of poor prognosis was even more pronounced in patients who required intubation. Smoking was responsible for 83% of the HOT burn injuries described here. Therefore, smoking cessation counseling and treatment should be mandatory in all patients prescribed HOT.