IntroductionOpioid prescribing patterns have come under increasing scrutiny with the recent rise in opioid prescriptions, opioid misuse and abuse, and opioid-related adverse events. To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry.MethodsWe performed a retrospective observational study at a single academic, urban ED with 58,000 annual visits. We identified all adult patients (18 years or older) seen in the ED and discharged home with prescriptions for tablet forms of hydrocodone and oxycodone (including mixed formulations with acetaminophen). We compared the quantity of tablets prescribed per opioid prescription 12 months before and 10 months after the electronic order-entry prescription default quantity of 20 tablets was removed and replaced with no default quantity. No specific messaging was given to providers, to avoid influencing prescribing patterns. We used two-sample Wilcoxon rank-sum test, two-sample test of proportions, and Pearson’s chi-squared tests where appropriate for statistical analysis.ResultsA total of 4,104 adult patients received discharge prescriptions for opioids in the pre-intervention period (151.6 prescriptions per 1,000 discharged adult patients), and 2,464 post-intervention (106.69 prescriptions per 1,000 discharged adult patients). The median quantity of opioid tablets prescribed decreased from 20 (interquartile ration [IQR] 10–20) to 15 (IQR 10–20) (p<0.0001) after removal of the default quantity. While the most frequent quantity of tablets received in both groups was 20 tablets, the proportion of patients who received prescriptions on discharge that contained 20 tablets decreased from 0.5 (95% confidence interval [CI] [0.48–0.52]) to 0.23 (95% CI [0.21–0.24]) (p<0.001) after default quantity removal.ConclusionAlthough the median number of tablets differed significantly before and after the intervention, the clinical significance of this is unclear. An observed wider distribution of the quantity of tablets prescribed after removal of the default quantity of 20 may reflect more appropriate prescribing patterns (i.e., less severe indications receiving fewer tabs and more severe indications receiving more). A default value of 20 tablets for opioid prescriptions may be an example of the electronic medical record’s ability to reduce practice variability in medication orders actually counteracting optimal patient care.
Skin and soft tissue infections (SSTIs) are frequently treated in the emergency department (ED) setting. Recent studies provide critical new information that can guide new approaches to the diagnosis and treatment of SSTIs in the ED. Rapid polymerase chain reaction assays capable of detecting MRSA in approximately 1 h hold significant potential to improving antibiotic stewardship in SSTI care. Emergency ultrasound continues to demonstrate value in guiding appropriate management of SSTIs, including the early diagnosis of necrotizing infections. Since emerging in the 1990s, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) continues to increase in prevalence, and it represents a significant challenge to optimizing ED antibiotic use for SSTI management. Growing literature reinforces the current recommendation of incision and drainage without antibiotics for uncomplicated abscesses. Selecting antibiotics with CA-MRSA coverage is recommended when treating purulent SSTIs; however, it is generally not necessary in cases of nonpurulent cellulitis. Future advances in ED SSTI care may involve expansion of outpatient parenteral antimicrobial therapy protocols and the recent development of a novel, once weekly antibiotic with activity against MRSA.
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