Background: Pain is common among hospitalized patients. Inpatient opioid prescribing is not without risk. Acute pain management guidelines could inform safe opioid prescribing in the hospital and limit associated unintended consequences. Purpose: To evaluate the quality and content of existing guidelines for acute, non-cancer pain management. Data Sources: The National Guideline Clearinghouse, MEDLINE via PubMed, websites of relevant specialty societies and other organizations, and selected international search engines. Study Selection: Guidelines published between January 2010 to August 2017 addressing acute, non-cancer pain management among adults were considered. Guidelines focused on chronic pain, specific diseases, and non-hospital setting were excluded. Data Extraction: Quality assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Data Synthesis: Four guidelines met selection criteria. Most recommendations were based on expert consensus. Guidelines recommended restricting opioids to severe pain or pain that has not responded to non-opioid therapy, using the lowest effective dose of short-acting opioids for the shortest duration possible, and co-prescribing opioids with non-opioid analgesics. Guidelines generally recommended checking the prescription drug monitoring program when prescribing opioids, developing goals for patient recovery, and educating patients regarding risks and side effects of opioid therapy. Additional recommendations included using an opioid dose conversion guide, avoidance of co-administration of parenteral and oral opioids, and using caution when co-prescribing opioids with other central nervous system depressants. Conclusions: Guidelines, based largely on expert opinion, recommend judicious opioid prescribing for severe, acute pain. Future work should assess the implications of these recommendations on hospital-based pain management.

Objective: Our objective was to determine the percentage of opioid overdose events among medical and surgical inpatient admissions, and to identify risk factors associated with these events. Methods: We searched PubMed and CINAHL databases from inception through July 30, 2017 and identified additional studies from reference lists and other reviews. Articles were included if they reported original research on the rate of opioid overdoses or opioid-related adverse events, and the adverse events occurred in a general medical hospital during an inpatient stay. We extracted information on study population, design, results, and risk for bias using the Newcastle-Ottawa Quality Assessment Scale. We performed this review in accordance with recently suggested standards and report our findings as per the Meta-Analyses and Systematic Reviews of Observational Studies guidelines. Results: Thirteen studies met our eligibility criteria. The percentage of opioid overdoses ranged from 0.06% to 2.50% of hospitalizations. The majority of studies used only 1 method of event detection. Risk factors for overdose included older age, infancy, medical comorbidity, substance use disorder diagnosis, combining opioids with other sedatives, and admission to hospitals with higher opioid-prescribing rates. Conclusions: Opioid overdose in the inpatient setting is a serious preventable harm and is likely underestimated in much of the current literature. Improved detection methods are needed to more accurately measure the rate of inpatient opioid overdose. Refined estimates of opioid overdose should be used to drive safety and quality improvement initiatives in hospitals.

Electronic order volume is significantly associated with patient complexity and may provide valuable additional information in measuring resident physician workload.

Background: Approximately 10% of patients report allergies to penicillin, yet >90% of these allergies are not clinically significant. Patients reporting penicillin allergies are often treated with second-line, non–β-lactam antibiotics that are typically broader spectrum and more toxic. Orders for β-lactam antibiotics for these patients trigger interruptive alerts, even when there is electronic health record (EHR) data indicating prior β-lactam exposure. Objective: To describe the rate that interruptive penicillin allergy alerts display for patients who have previously had a β-lactam exposure. Design: Retrospective EHR review from January 2013 through June 2018. Setting: A nonprofit health system including 1 large tertiary-care medical center, a smaller associated hospital, 2 emergency departments, and ˜250 outpatient clinics. Participants: All patients with EHR-documented of penicillin allergies. Methods: We examined interruptive penicillin allergy alerts and identified the number and percentage of alerts that display for patients with a prior administration of a penicillin class or other β-lactam antibiotic. Results: Of 115,081 allergy alerts that displayed during the study period, 8% were displayed for patients who had an inpatient administration of a penicillin antibiotic after the allergy was noted, and 49% were displayed for patients with a prior inpatient administration of any β-lactam. Conclusions: Many interruptive penicillin allergy alerts display for patients who would likely tolerate a penicillin, and half of all alerts display for patients who would likely tolerate another β-lactam.

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