Objectives/Goals: A clinical decision support tool (CDS) with an individualized prescribing approach was piloted to determine impact on opioid overprescribing rates for surgical patients at discharge. As a follow-up, clinicians were interviewed to determine current challenges to opioid prescribing and required components of an effective CDS for discharge opioids. Methods/Study Population: In the EHR-based randomized control trial, patients admitted to a qualifying surgical service for 24+ hours postoperatively were randomized to the individualized CDS tool with a taper based on inpatient opioid use or the standard discharge order set. Performance of the CDS tool was assessed by rate of opioid mismatch, that is, the difference between median inpatient and daily discharge dose in morphine milligram equivalents (MMEs). Pilot results were further investigated using a sequential explanatory design. Semi-structured interviews were held with discharging clinicians. A purposive sampling strategy with snowball sampling was used to identify providers. Data saturation was used to determine sample sufficiency. Interview transcripts were coded and thematically analyzed, with 40% group coded. Results/Anticipated Results: Among 61 randomized patients, median discharge MME (30 IQR 22.5, 45 remained four times the median inpatient MME (7.5 IQR 0, 30) after the pilot period. Nine nurse practitioners and six general surgery residents were interviewed (n=15). Perceived challenges to opioid prescribing centered on three themes: limited protocolization for standard cases; lack of workflow efficiency; and systemic barriers (patient insurance and pharmacy). Clinicians identified at least one useful component of the tool for their current practice. Crucial CDS tool components identified by prescribing clinicians included seamless integration with the electronic health record, adequate clinician training, effective communication of treatment plan with the patient, and clinician buy-in to overcome current prescribing culture. Discussion/Significance of Impact: Multiple patient- and system-related factors impede standardization of opioid prescribing for postoperative patients. CDS tools in this area are a well-received idea, and the tool is now being redesigned to promote effective integration into clinician workflow with multiple stages of intervention, prior to resuming the randomized control trial.
Pandey et al. (Wed,) studied this question.