Introduction This study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors associated with opioid and benzodiazepine misuse in the older adult population. Significance This study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription. Results Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription ( P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill ( P = .0002) and younger (65-74) men were more likely to have a past positive toxicology ( P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled. Conclusions Documented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.

Category: Hindfoot; Trauma Introduction/Purpose: The initial management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem. The results of open reduction internal fixation (ORIF) have been disappointing. Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using screws alone through a sinus tarsi approach. Methods: A retrospective study of all patients from 2013-2019 who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was utilized in all cases consisting of only screws, no plates were utilized. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data was collected. Worker's compensation (WC) claims were noted and analyzed separately. Plain radiographs were assessed preoperatively and post-operatively and Sander's classification was used to characterize injuries. Patient reported outcomes (PROs), complications, and need for revision surgeries was also noted and analyzed at final follow-up. Results: In total, forty-eight DIACFs underwent PSTA with a median follow-up of 194 days. Median time to weight-bearing was 60 days post-operatively. Three fractures were documented as Sanders II, 22 as Sanders III, and 23 as Sanders IV. Seventy-five percent of the WC group returned to work compared to just 58.3% in the non-WC group (p=0.0003). Patients in the WC group were more likely to have had an abnormal pre-operative Bohler's angle (p=0.047) but the two groups did not differ significantly in postoperative Gissane or Bohler angles. Nearly 85% (N=41) achieved >=2 zones of fusion on radiographs by final follow up and 95.8% (N=46) had at least one. Four patients had a complication and 3 required a return to the operative room. Conclusion: Utilizing Screws only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach shows promising results with high rates of return to work and fusion, even in the workers' compensation population.

Objective: Opioid-related adverse drug events continue to occur. This study aimed to characterize the patient population receiving naloxone to inform future intervention efforts. Design: We describe a case series of patients who received naloxone in the hospital during a 16-week time frame in 2016. Data were collected on other administered medications, reason for admission to the hospital, pre-existing diagnoses, comorbidities, and demographics. Setting: Twelve hospitals within a large healthcare system. Patients: 46,952 patients were admitted during the study period. 31.01 percent (n = 14,558) of patients received opioids, of which 158 received naloxone. Intervention: Administration of naloxone. Main outcome of interest: Sedation assessment via Pasero Opioid-Induced Sedation Scale (POSS), administration of sedating medications. Results: POSS score was documented prior to opioid administration in 93 (58.9 percent) patients. Less than half of patients had a POSS documented prior to naloxone administration with 36.8 percent documented 4 hours prior. 58.2 percent of patients received multimodal pain therapy with other nonopioid medications. Most patients received more than one sedating medication concurrently (n = 142, 89.9 percent). Conclusions: Our findings highlight areas for intervention to prevent opioid oversedation. Investing in electronic clinical decision support mechanisms, such as sedation assessment, could detect patients at risk for oversedation and ultimately prevent the need for naloxone. Coordinated order sets for pain management can reduce the percentage of patients receiving multiple sedating medications and promote the use of multimodal pain management in efforts to reduce opioid reliance while optimizing pain control.