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Patient Safety Tip of the Week   

July 23, 2019

Order Sets Can Nudge the Right Way or Wrong Way

Standardized order sets are powerful tools that can improve clinician efficiency and improve patient safety. They can “nudge” you in a good way. For example, they can be used to remind you to consider DVT prophylaxis and provide you with the best options for that prophylaxis. Or they can ensure you use correct drug names and dosages that are appropriate. But they can also nudge you in the wrong direction. When hospitals first began to use order sets (paper- or computer-based) there was a tendency to try to cover all contingencies. For example, order sets might include prn orders for sleep meds, laxatives, antacids, etc. Often, these were included so a clinician did not have to be wakened at night to order such medications. Long ago, we recognized that putting too many options in an order set, particularly those using a “checkbox” format, often resulted in inappropriate orders for many patients. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we noted ISMP’s guideline on order sets cautioned against including blanket-type orders (eg. laxatives, sleep meds, antiemetics, antidiarrheals, antacids, etc).

Remember, any options you include in an order set have a good chance of being selected and ordered. For example, if you include Dilaudid/HYDROmorphone as an option for postop analgesia, there is a good chance someone will order it. In our many columns on the dangers of that drug (see list below), we note that many clinicians fail to recognize the equipotency issues of several opioids and that clinicians often underestimate the relative potency of Dilaudid/HYDROmorphone. Hence, we prefer not to include Dilaudid/HYDROmorphone as an option on a standardized order set but, recognizing that there are a few select circumstances where it may be appropriate, you can create a link in your order set to “other analgesics”.

Keep in mind that “default bias” is a very powerful cognitive bias. In our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts” we noted the importance of considering appropriate default options when designing order sets. One of the cognitive biases we see is the “default bias”, in which it is a natural tendency to select default options when several options are possible. In our April 30, 2019 Patient Safety Tip of the Week “Reducing Unnecessary Urine Cultures” we noted how clinicians and researchers at Barnes-Jewish Hospital implemented a program to reduce unnecessary cultures (Munigala 2019). Their intervention consisted of notifications to providers, changes to order sets, and inclusion of urine culture reflex tests in commonly used order sets. The CPOE intervention they implemented was setting the default option to urine dipstick testing followed by a bacterial culture if positive (i.e. reflex testing), rather than a culture alone, This resulted in a 45% reduction in the urine cultures ordered. That intervention saved approximately $104,000 in laboratory costs alone over the 15-month period plus likely savings from reduced antibiotic use and less contribution to the emergence of resistant organisms.

Another recent study (Strauss 2019) used a multifaceted strategy to reduce unnecessary ordering of certain laboratory tests that add little value to patient management at significant cost. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), were the examples they targeted. They created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback, and removed AST and BUN from institutional order sets. This resulted in ratios of AST/ALT and BUN/Cr decreasing significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), and  a projected annualized cost savings of $221,749.

Li and colleagues (Li 2019) recently evaluated how well standardized order sets were serving their clinicians. Using data from the EHR on all orders of medication, laboratory, imaging and blood product items, they focused on four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.

Ordering rates for individual order set items varied greatly, ranging from 0.001% to 100%, with a median of 4.1%. Laboratory items had higher median ordering rates (11.5%) in general than medications (2.3%,), imaging (4.7%) and blood product items (2.6%).

Regarding medication orders retracted within 30 minutes, 2.2% ordered via order sets were retracted, compared to 3.9% that had been ordered ala carte. But there was considerable variability. 3% of medications ordered from order sets were significantly more likely to be retracted than if the same medication was ordered ala carte. Order set medication items with ordering rates in the lowest quartile were approximately twice as likely to be retracted than those in the other quartiles.

They then looked at items that were additionally ordered ala carte within 10 min. of an order set use more often than the median ordering rate of items in the corresponding order set. 39% of order sets had such an item commonly added ala carte, with a median of 4 distinct additional a la carte items per order set.

Lastly, they looked at items that were ordered ala carte even though they had been in the order set used. 45% contained at least one such ‘a la carte over order set’ item, with a median of 4 distinct items per order set.

Overall, their analysis found that many order sets were seldom used and many order sets

may be “bloated” with low yield items. Rarely used items were also more likely to be rapidly retracted. Furthermore, many order sets may also be missing items that users need.

The Li study emphasizes the critical importance that any time you roll out a new order set (or a new alert or other clinical decision support tool, for that matter) you must monitor usage of that order set. You need to review how often it is used and whether the desired goals are achieved, and whether unintended consequences occur. You need to solicit feedback from users. You need to have a formal process by which you assess all the above. Sometimes our most well-intended evidence-based patient safety interventions end up causing unintended consequences that may produce patient harm. And, don’t forget you need to review all your order sets periodically. Clinical evidence and guidelines often change over time and you don’t want to have items in your order sets that are outdated and no longer recommended practices.

Our discussion on order sets should also include some comments on “Do not use” abbreviations. You, of course, should be using ISMP’s List of Error-Prone Abbreviations (ISMP 2017), rather than The Joint Commission’s more succinct list of “Do not use” abbreviations. In our several columns on dangerous abbreviations (see, for example, our December 22, 2015 Patient Safety Tip of the Week “The Alberta Abbreviation Safety Toolkit”), we note that, as you update your “Do not use”, you need to review all your order sets. When we did this at one hospital, we found numerous dangerous abbreviations still sitting in some old order sets, some “customized” order sets used by individual clinicians, and even in some third-party vendor order sets.

See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:

• June 19, 2007 “Unintended Consequences of Technological Solutions”
• May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
• June 17, 2008 “Technology Workarounds Defeat Safety Intent”
• August 26, 2008 “Pattern Recognition and CPOE”
• September 9, 2008 “Less is More….and Do You Really Need that Decimal?”
• December 16, 2008 “Joint Commission Sentinel Event Alert on Hazards of Healthcare IT”
• February 2009 “Healthcare IT The Good and The Bad”
• March 3, 2009 “Overriding Alerts…Like Surfin’ the Web”
• October 2009  “A Cautious View on CPOE”
• November 24, 2009 “Another Rough Month for Healthcare IT
  
• April 20, 2010 “HIT’s Limited Impact on Quality To Date”
• March 22, 2011 “An EMR Feature Detrimental to Teamwork and Patient Safety”
• January 24, 2012 “Patient Safety in Ambulatory Care”
• June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
• June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”
• July 17, 2012 “More on Wrong-Patient CPOE”
• January 2013 “More IT Unintended Consequences”
• April 30, 2013 “Photographic Identification to Prevent Errors”
• October 8, 2013 “EMR Problems in the ED”
• March 11, 2014 “We Miss the Graphic Flowchart!”
• October 2014 “Ebola Exposes Fundamental Flaw”
• January 2015 “Beneficial Effect of EMR on Patient Safety”
• March 2015 “CPOE Fails to Catch Prescribing Errors”
• March 31, 2015 “Clinical Decision Support for Pneumonia”
• August 2015 “Newborn Name Confusion”
• December 2015 “Opioid Alert Fatigue”
• January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
• January 19, 2016 “Patient Identification in the Spotlight”
• February 9, 2016 “It was just a matter of time…”
• April 5, 2016 “Workarounds Overriding Safety”
• May 2016 “Name Confusion in the Pharmacy”
• May 3, 2016 “Clinical Decision Support Malfunction”
• May 24, 2016 “Texting Orders – Is It Really Safe?”
• August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency”
• November 22, 2016 “Leapfrog, Picklists, and Healthcare IT Vulnerabilities”
• January 2017 “Joint Commission Thinks Twice About Texting Orders”
• February 28, 2017 “The Copy and Paste ETTO”
• March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
• April 2017 “How Much Time Do We Actually Spend on the EMR?”
• June 27, 2017 “Texting – We Told You So!”
• August 1, 2017 “Progress on Wrong Patient Orders”
• January 2018 “Can We Improve Barcoding?”
• January 16, 2018 “Just the Fax, Ma’am”
• January 30, 2018 “Texting Errors Revealed”
• June 19, 2018 “More EHR-Related Problems”
• September 2018 “More Clinical Decision Support Successes”
• December 11, 2018 “Another NMBA Accident”
• January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
• February 5, 2019 “Flaws in Our Medication Safety Technologies”
• March 26, 2019 “Patient Misidentification”
• May 2019 “Too Much Time on the EMR”
• May 21, 2019 “Mixed Message on Number of Open EMR Records”

See our series of columns on the dangers of Dilaudid/HYDROmorphone listed below:

• September 21, 2010    “Dilaudid Dangers”
• November 2011          “FDA Changes on Dilaudid/HYDROmorphone”
• July 3, 2012                “Recycling an Old Column: Dilaudid Dangers”
• November 19, 2013    “Can We Improve Dilaudid/HYDROmorphone Safety?”
• June 2, 2015                “Reminders of Dilaudid Dangers”
• October 13, 2015        “Dilaudid Dangers #3”
• June 20, 2017              “Dilaudid Dangers #4”

References:

Munigala S, Rojek R, Wood H, et al. Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control and Hospital Epidemiology 2019; Published online: 21 February 2019: 1-6

https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/effect-of-changing-urine-testing-orderables-and-clinician-order-sets-on-inpatient-urine-culture-testing-analysis-from-a-large-academic-medical-center/F33152242857207A5241E24044028E38

Strauss R, Cressman A, Cheung M, et al. Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative

BMJ Quality & Safety Published Online First: 09 May 2019

https://qualitysafety.bmj.com/content/early/2019/05/08/bmjqs-2018-008991

Li RC, Wang JK, Sharp C, et al. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. BMJ Quality & Safety 2019; Published Online First: 04 June 2019

https://qualitysafety.bmj.com/content/early/2019/06/04/bmjqs-2018-008968

ISMP (Institute for Safe Medication Practices). List of Error-Prone Abbreviations. ISMP 2017; October 2, 2017

https://www.ismp.org/recommendations/error-prone-abbreviations-list

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What's New in the Patient Safety World?

July2019

·Surgical Fire – A New Risk Factor

·HAI’s and Nurse Staffing

·Increasing Mortality After Falls in Elderly

·Dental Prescribing Called Into Question

Surgical Fire – A New Risk Factor

Our numerous columns on surgical fires have focused on the 3 elements of the “fire triad” – an oxidizer, a fuel, and an ignition source. We’ve pointed out that avoiding free flow of oxygen is an extremely important facet of prevention of surgical fires.

We’ve pointed out that many of the surgical fires in recent years have occurred in relatively “minor” operations. One of the reasons is that oxygen is often delivered in such cases by nasal prongs or a loosely fitting mask. That results in the presence of free oxygen in an operative field. Preventing free oxygen by use of a secure airway (laryngeal mask or endotracheal tube) is thought to to be the safest way to ensure free oxygen won’t be available to contribute to a fire.

But, a recent report of a surgical fire (Rettner 2019) highlighted an unusual source of free oxygen. A 60 y.o. man with COPD was undergoing surgery for an aortic dissection. He was intubated and on a ventilator. During the surgery, the surgeons encountered bullae attached to the sternum. Despite efforts to avoid the bullae, one was punctured. Apparently, the supplemental oxygen was increased to prevent hypoxia. But, when an electrocautery device was used during the procedure, a fire was ignited on surgical gauze within the field. The fire was quickly doused with saline and there was apparently no injury to the patient, Despite the fire incident, the rest of the surgery went well, and the aortic tear was successfully repaired.

This case was presented at the Euroanaesthesia Congress, the annual meeting of the European Society of Anaesthesiology in Vienna, Austria. Lead author of the report, Dr. Ruth Shaylor, noted there have been only seven previous cases of chest cavity fires reported in the medical literature. All seven cases involved the presence of dry surgical materials (such as sponges or gauze); electrocautery devices and increased supplemental oxygen concentrations. All of the patients had COPD or preexisting lung disease.

Thus, a key lesson here is that, during our fire risk assessment (done both in the pre-op “huddle” and the surgical timeout) we need to add COPD as a risk factor in cases of thoracic surgery. The other key lesson is that the surgeon and anesthesiologist still need to coordinate to minimize supplemental oxygen when electrocautery (or other heat source) is about to be used. Even if supplemental oxygen were temporarily stopped here, it’s still possible there would have been enough free oxygen from the leak to contribute to the fire risk. Hence, recognition of the risk and having a ready supply of sterile saline to extinguish a fire is also critical.

Our prior columns on surgical fires:

• December 4, 2007       “Surgical Fires”
• April 29, 2008             “ASA Practice Advisory on Operating Room Fires”
• November 2009          “ECRI: Update to Surgical Fire Prevention”
• January 2011               “Surgical Fires Not Just in High-Risk Cases”
• March 2011                 “APSF Fire Safety Video”
• November 2011          “FDA Initiative on Preventing Surgical Fires”
• December 13, 2011     “Surgical Fires Again”
• April 24, 2012             “Fire Hazard of Skin Preps Oxygen”
• April 2013                  “Reminder: Hand Sanitizers Are Flammable”
• June 25, 2013              “Update on Surgical Fires”
• October 1, 2013          “Fuels and Oxygen in OR Fires”
• August 12, 2014         “Surgical Fires Back in the News”
• December 16, 2014     “More on Each Element of the Surgical Fire Triad”
• December 2015           “Unique Ignition Sources in Surgical/OR Fires”
• January 10, 2017         “The 26-ml Applicator Strikes Again!”
• January 9, 2018           “More on Fire Risk from Surgical Preps”
• June 2018                    “ISMP on Fire Risk from Skin Preps”
• July 2018                    “FDA on Surgical Fires”
• September 11, 2018    “Lessons from a Surgical Fire”

• May 7, 2019                “Simulation Training for OR Fires”

References:

Rettner R. Rare 'Flash Fire' Ignites in Man's Chest Cavity During Surgery. Live Science 2019; June 3, 2019

https://www.livescience.com/65615-chest-cavity-fire-surgery.html

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HAI’s and Nurse Staffing

Do nurse staffing levels impact rates of healthcare-associated infections (HAI’s)? Last year a systematic review of the literature (Mitchell 2018) identified 54 articles dealing with the issue. The majority of the studies found nurse staffing variables to be associated with an increase in HAI rates. But the authors noted studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAI’s. Also, only 5 studies addressed non-nurse staffing, and those had mixed results. The authors concluded that more rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area.

So a new study (Shang 2019) has addressed some of the methodological weaknesses of previous studies. Shang and colleagues analyzed data from a large urban hospital system. HAI’s were diagnosed using the Centers for Disease Control and Prevention's National Healthcare Safety Network definitions and Cox proportional-hazards regression model was used to examine the association of nurse staffing (2 days before HAI onset) with HAI’s after adjusting for individual risks. Fifteen percent of patient-days had 1 shift understaffed, defined as staffing below 80% of the unit median for a shift, and 6.2% had both day and night shifts understaffed. They found that patients on units with both shifts understaffed with RN’s were 15 percent more likely to develop HAI’s on or after the third day of exposure to periods of understaffing compared to patients in units with both day and night shifts adequately staffed. In addition, units understaffed with nursing supporting staff (LPN’s and nurse assistants) had increased patients’ risk of HAI’s.

This is one more study that adds to the evidence base on the importance of adequate nurse:patient staffing ratios. Nursing staffing levels have also been shown to correlate with patient mortality rates. But, as we’ve discussed in so many columns, the issue is more complex than simple nurse:patient ratios. Those ratios do not take into account actual nurse workload nor do they take into account the fatigue factor that may accompany long work shifts or forced overtime. One factor that comes into play in those conditions is the concept of “missed nursing care” or “care left undone” (see our Patient Safety Tips of the Week for November 26, 2013 “Missed Care: New Opportunities?” and May 9, 2017 “Missed Nursing Care and Mortality Risk”).

We discussed the issue of nursing workload in detail in our Patient Safety Tips of the Week for March 6, 2018 “Nurse Workload and Mortality” and May 29, 2018 “More on Nursing Workload and Patient Safety” and our February 2019 What's New in the Patient Safety World column “Nurse Staffing, Workload, Missed Care, Mortality”. In those columns we discussed the issue of how to best measure workload.

Some of our other columns on nursing workload and missed nursing care/care left undone:

November 26, 2013    “Missed Care: New Opportunities?”

May 9, 2017                “Missed Nursing Care and Mortality Risk”

March 6, 2018             “Nurse Workload and Mortality”

May 29, 2018              “More on Nursing Workload and Patient Safety”

October 2018               “Nurse Staffing Legislative Efforts”

February 2019             “Nurse Staffing, Workload, Missed Care, Mortality”

References:

Mitchell BG, Gardner A, Stone PW, at al. Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature. Joint Commission Journal on Quality and Patient Safety 2018; 44(10): 613-622

https://www.jointcommissionjournal.com/article/S1553-7250(17)30538-X/fulltext

Shang J, Needleman J, Liu J, et al. Nurse Staffing and Healthcare-Associated Infection, Unit-Level Analysis. JONA: The Journal of Nursing Administration 2019; 49(5): 260-265

https://journals.lww.com/jonajournal/Abstract/2019/05000/Nurse_Staffing_and_Healthcare_Associated.7.aspx

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Increasing Mortality After Falls in Elderly

Recent publications have revealed a couple disturbing trends about falls in the elderly. Hartholt et al. (Hartholt 2019) found an increasing age-adjusted trend in mortality from falls was observed among older US adults from 2000 to 2016. Mortality rates increased with age and throughout the study period, with the worst trends in the oldest age groups. Crude mortality rate increased from 51.6 per 100,000 persons in 2000 to 122.2 per 100,000 persons in 2016. Age-adjusted mortality rates among adults aged 75 years or older increased from 60.7 per 100,000 men in 2000 to 116.4 per 100,000 men in 2016 and from 46.3 per 100,000 women in 2000 to 105.9 per 100,000 women in 2016.

Another study (Hoffman 2019) found that posthospital fall-related injuries were a leading readmission diagnosis, particularly for patients originally admitted with a fall-related injury or cognitive impairment. Overall, among Medicare beneficiaries aged 65 years and older, 14.4% of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, fall-related injuries ranked as the third-leading readmission diagnosis, accounting for 5.1% of all readmission diagnoses. For those with a fall-related injury at index admission and discharged home or to home health care, fall-related injuries were the leading readmission diagnosis.

And yet another study (Piau 2019) found that some falls classified in the literature as non-injurious may nevertheless increase the risk of loss of autonomy and undesired outcomes. They found that, among falls that did not give rise to any formal healthcare intervention, 8% resulted in a modification of walking ability. Their study was a retrospective analysis of falls prospectively self-reported by older adults via an online weekly health form over four years. 62% of the falls occurred indoors and, somewhat surprisingly, 81% occurred in well-lit areas. Bedrooms were the most common places for in-home falls. Commonly observed precipitating factors included loss of balance or a slip/trip. Almost one-third of falls were defined as injurious and 22% resulted in a change in walking ability, often leading to the use of a cane or walker.

Fortunately, there is evidence that we can do something to prevent such falls in the elderly. Liu-Ambrose and colleagues (Liu-Ambrose 2019) evaluated a home-based exercise program as a fall prevention strategy in adults aged at least 70 years who were referred to a fall prevention clinic after an index fall. Participants were randomized to receive usual care plus a home-based strength and balance retraining exercise program delivered by a physical therapist or usual care, consisting of fall prevention care provided by a geriatrician. A total of 236 falls occurred among 172 participants in the exercise group vs 366 falls among 172 participants in the usual care group (estimated incidence rates of falls per person-year were 1.4 vs 2.1, respectively). The absolute difference in fall incidence was 0.74 falls per person-year and the incident rate ratio was 0.64. No adverse events related to the intervention were reported. The authors emphasize that these results apply to secondary prevention and that studies in other clinical settings would be needed to see if such an intervention works in primary fall prevention.

In the accompanying editorial (Pahor 2019) Pahor points out that the home-based exercise program reduced the number of falls without improving physical performance measures, including the Short Physical Performance Battery and the Timed Up and Go Test, suggesting that the reduction in fall risk was mediated by mechanisms other than detectable improvements in muscle strength or physical function. He suggests that other factors, such as improvements in self-efficacy and self-controlled coping awareness, may have played a role.

Some of our prior columns related to falls:

• April 16, 2007             “Falls With Injury”
• July 17, 2007              “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
• January 1, 2008           “Fall Prevention”
• October 7, 2008          “Lessons from Falls....from Rehab Medicine”
• November 18, 2008    “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
• August 4, 2009           “Faulty Fall Risk Assessments?”
• September 22, 2009    “Psychotropic Drugs and Falls in the SNF”
• December 22, 2009     “Falls on Toileting Activities”
• January 2010               “Falls in the Radiology Suite”
• June 2010                     “Seeing Clearly a Common Sense Intervention”
• May 29, 2012              “Falls, Fractures, and Fatalities”
• June 5, 2012                “Minor Head Trauma in the Anticoagulated Patient”.
• January 15, 2013         “Falls on Inpatient Psychiatry”
• March 2013                 “Sedative/Hypnotics and Falls”
• December 3, 2013       “Reducing Harm from Falls on Inpatient Psychiatry”
• June 2014                     “New Glasses and Fall Risk”
• July 8, 2014               “Update: Minor Head Trauma in the Anticoagulated Patient”
• August 2014                “Cataract Surgery and Falls”
• November 4, 2014      “Progress on Fall Prevention”
• March 2015                 “Another Paradox: Falls Due to Walking Aids”
• June 9, 2015                “Add This to Your Fall Risk Assessment”
• July 28, 2015              “Not All Falls Are the Same”
• October 2015              “Patient Perception of Fall Risk”
• October 27, 2015        “Sentinel Event Alert on Falls and View from Across the Pond”
• February 16, 2016       “Fall Prevention Failing?”
• March 14, 2017           “More on Falls on Inpatient Psychiatry”
• July 2017                    “Mobility vs. Falls”
• February 2018             “Global Sensory Impairment and Patient Safety”
• February 20, 2018       “Delirium and Falls”

• March 2019                 “Newborn Falls”

References:

Hartholt KA, Lee R, Burns ER, van Beeck EF. Mortality From Falls Among US Adults Aged 75 Years or Older, 2000-2016. JAMA 2019; 321(21): 2131-2133

https://jamanetwork.com/journals/jama/fullarticle/2735063

Hoffman GJ, Liu H, Alexander NB, et al. Posthospital Fall Injuries and 30-Day Readmissions in Adults 65 Years and Older. JAMA Netw Open 2019; 2(5): e194276

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734065

Piau A, Mattek N, Duncan C, et al. The five W’s of falls - weekly online health survey of community-dwelling older adults: analysis of four years prospective follow-up. The Journals of Gerontology: Series A 2019; Published: 04 May 2019

https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/glz114/5485710?redirectedFrom=fulltext

Liu-Ambrose T, Davis JC, Best JR, et al. Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a Fall. A Randomized Clinical Trial. JAMA 2019; 321(21):2 092-2100 June 4, 2019

https://jamanetwork.com/journals/jama/article-abstract/2735075

Pahor M. Falls in Older Adults. Prevention, Mortality, and Costs. JAMA 2019; 321(21): 2080-2081 June 4, 2019

https://jamanetwork.com/journals/jama/article-abstract/2735053

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Dental Prescribing Called Into Question

We’ve done a few columns on dental patient safety. While most have focused on the risks associated with sedation in dental settings, our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” covered what we thought was the gamut of patient safety issues in dental patients. But one issue has flown under the radar: prescribing patterns.

Some new studies have pointed out overprescribing of opioids and prophylactic antibiotics by dentists.

Hudgins et al. (Hudgins  2019) analyzed visits to ED’s and outpatient clinics for adolescents (13–17 years old) and young adults (18–22 years old). Rates of opioid prescribing were calculated. The authors noted that teens and young adults are at particular high risk for opioid misuse, and opioid prescription in this age group has been linked to future long-term opioid use. Among ED visits, opioid-prescribing rates were highest among adolescents and young adults with dental disorders (59.7% and 57.9%, respectively), followed by adolescents with clavicle (47.0%) and ankle fractures (38.1%).

But who is prescribing these opioids for the dental conditions? It’s quite likely that the emergency physicians are evaluating the patients for the dental problem, prescribing the analgesics, and referring the patients to a dentist or dental clinic.

However, a second study (Suda 2019a) compared opioid prescribing by dentists in the United States and England. The researchers note that dentists are one of the most frequent US prescribers of opioids despite data suggesting that nonopioid analgesics are similarly effective for oral pain. They found that, in 2016, the proportion of prescriptions written by US dentists that were for opioids was 37 times greater than the proportion written by English dentists. In all, 22.3% of US dental prescriptions were opioids compared with 0.6% of English dental prescriptions.

The rate of opioid prescriptions per 1000 population was 35.4 per 1000 for the US population vs 0.5 per 1000 in the England population (a rate 70 times higher in the US) and the number of opioid prescriptions per dentist in the US was 58.2 prescriptions per dentist vs 1.2 prescriptions per dentist in England.

Moreover, opioids with a high potential for abuse, such as oxycodone, were frequently prescribed by US dentists but not prescribed in England.

The same group also looked at dental prescribing of antibiotics (Suda 2019b). They found that 81% of antibiotics prescribed by dentists to prevent infections prior to dental visits are probably unnecessary. Factors associated with unnecessary antibiotic prophylaxis included prosthetic joint devices, tooth implant procedures), female sex, and visits occurring in the western United States. The authors point out something we were unaware of: dentists prescribe about 10% of all antibiotics in the US and, in fact, are the top specialty other than primary care for prescribing antibiotics (Hicks 2015).

In our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” one of the items we noted in the literature was failure to prescribe prophylactic antibiotics before dental procedures in “at risk” patients. But we pointed out that guidelines and recommendations for prophylactic antibiotics had changed considerably and that the evidence was not strong for their use in patients with conditions like total joint prosthetics.

Failure to use antibiotic prophylaxis in patients with artificial heart valves or other foreign bodies that might become infected has been listed as a safety concern. However, most recent guidelines have actually done away with prophylaxis in many cases. Compared with previous recommendations, there are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures (ADA 2016). For example, for those with hip arthroplasties the current guidelines do not recommend antibiotic prophylaxis prior to dental surgery unless there have been complications related to the hip surgery.

But, before you go blaming dentists, keep in mind that the above studies utilized administrative data and those do not tell us who really recommended the antibiotic prophylaxis. Our own dentist tells us that local orthopedic surgeons from one group always recommend their total joint arthroplasty patients get prophylactic antibiotics before dental work, whereas the other group does not recommend them. And even the orthopedic specialty societies add to the confusion.

The Suda study looked at dental procedures performed between 2011 and 2015, a time period in which recommendations and guidelines for use of prophylactic antibiotics in patients with joint replacements were in a state of flux. In 2012, a joint effort by the American Academy of Orthopedic Surgeons and the American Dental Association did a thorough review of the issue of antibiotic prophylaxis in patients with joint implants in 2012 (AAOS/ADA 2012) and came up with the following recommendation: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.” The word “might” sounds pretty squishy to us, and obviously was not strong enough to dissuade some orthopedic surgeons from recommending antibiotic prophylaxis for their total joint replacement patients undergoing dental procedures.

The most recent ADA recommendation for patients with prosthetic joint implants (ADA 2019) cites the January 2015 ADA clinical practice guideline (Sollecito 2015), based on a 2014 systematic review and states, “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” It does note that for patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and orthopedic surgeon.

The Suda article (Suda 2019b) points out that, while the rate of antibiotic prescriptions overall has decreased nationally in the past several years, antibiotic prescriptions by dentists have remained steady.

Recommendations now for antibiotic prophylaxis during dental procedures involve primarily patients at highest risk for infective endocarditis (eg. those with prosthetic valves, previous endocarditis, congenital heart disease, transplant patients with valvulopathy). Bottom line: always check to ensure the most up-to-date guidelines for prophylaxis are followed.

Good antibiotic stewardship prevents unnecessary administration of antibiotics that may lead to emergence of microbial resistance to the antibiotics or promote C. difficile infections or other antibiotic-associated adverse events. These risks outweigh the relatively small risk of seeding a prosthetic joint.

Some of our previous columns on dental patient safety issues:

March 15, 2016 “Dental Patient Safety”

August 2016 “Guideline Update for Pediatric Sedation”

March 28, 2017 “More Issues with Dental Sedation/Anesthesia”

August 8, 2017 “Sedation for Pediatric MRI Rising”

November 28, 2017 “More on Dental Sedation/Anesthesia Safety”

References:

Hudgins JD, Porter JJ, Monuteaux MC, Bourgeois FT. Trends in Opioid Prescribing for Adolescents and Young Adults in Ambulatory Care Settings. Pediatrics 2019; 143(6): e20181578

https://pediatrics.aappublications.org/content/143/6/e20181578?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

Suda KJ, Durkin MJ, Calip GS, et al. Comparison of Opioid Prescribing by Dentists in the United States and England. JAMA Netw Open 2019; 2(5): e194303 May 24, 2019

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734067

(Suda 2019a)

Suda KJ, Calip GS, Zhou J, et al. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open 2019; 2(5): e193909 May 31, 2019

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734798

(Suda 2019b)

Hicks LA, Bartoces MG, Roberts RM,  et al.  US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015; 60(9): 1308-1316

https://academic.oup.com/cid/article/60/9/1308/405905

ADA (American Dental Association). Antibiotic Prophylaxis Prior to Dental Procedures. February 18, 2016

http://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis

AAOS (American Academy of Orthopedic Surgeons) and ADA (American Dental Association). Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. Evidence-Based Guideline and Evidence Report. December 7, 2012

http://www.aaos.org/Research/guidelines/PUDP/PUDP_guideline.pdf

ADA (American Dental Association). Antibiotic Prophylaxis Prior to Dental Procedures.

Last updated March 19, 2019

https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis

Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. The Journal of the American Dental Association 2015; 146(1): 11-16.e8

https://jada.ada.org/article/S0002-8177(14)00019-1/fulltext

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