Aim: This study aimed to examine the prevalence of any opioid use before elective orthopaedic surgery with a focus on regional and rural hospitals in New South Wales, Australia. Methods: This was a cross-sectional, observational study of patients undergoing orthopaedic surgery conducted between April 2017 and November 2019 across five hospitals that included a mix of capital city, regional, rural, private and public settings. Preoperative patient demographics, pain scores and analgesic use were collected during pre-admission clinic visits, held on average two to six weeks before surgery. Results: Of the 430 patients included (53.3% (229/430) women; mean age, 67.5 [standard deviation [SD] 10.1] years), the overall prevalence of any preoperative opioid use was 37.7% (162/430). Rates of preoperative opioid use ranged from 20.6% (13/63) at a capital city metropolitan hospital to 48.8% (21/43) at a regional metropolitan hospital. Multivariable logistic regression showed that the regional metropolitan setting was a significant predictor of opioid use before orthopaedic surgery (adjusted odds ratio [aOR], 2.6; 95% confidence interval [CI], 1.0 – 6.7) after adjusting for covariates. Conclusion: Opioid use prior to orthopaedic surgery is common and appears to vary by geographic location. Given its use is associated with worse postoperative outcomes, rigorous efficacy studies involving different geographic locations are required to determine whether opioid tapering prior to surgery can reduce harm.

Aim: To examine and understand the work processes of AMS teams across two hospitals that use the same digital intervention, and to identify the challenges and enablers to effective AMS in each setting. Methods: Employing a contextual inquiry approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model, observations and semi-structured interviews were conducted with AMS team members (n=15) in two Australian hospitals. Qualitative data analysis was conducted, mapping themes to the SEIPS framework. Results: Both hospitals utilised similar systems, however, they displayed variations in AMS processes, particularly in post-prescription review, interdepartmental AMS meetings, and the utilisation of digital tools. An antimicrobial dashboard was available at both hospitals but was utilised more at the hospital where the AMS team members were involved in the dashboard’s development, and there were user champions. At the hospital where the dashboard was utilised less, participants were unaware of key features, and interoperability issues were observed. Establishing strong relationships between the AMS team and prescribers emerged as key to effective AMS at both hospitals. However, organisational and cultural differences were found, with one hospital reporting insufficient support from executive leadership, increased prescriber autonomy, and resource constraints. Conclusion: Organisational and cultural elements, such as executive support, resource allocation, and interdepartmental relationships, played a crucial role in achieving AMS goals. System interoperability and user champions further promoted the adoption of digital tools, potentially improving AMS outcomes through increased user engagement and acceptance.

Aim: To summarise the effectiveness of organisational interventions on appropriate opioid use for non-cancer pain upon hospital discharge. Methods: A systematic search was conducted on six electronic databases by two independent reviewers. We included original research articles reporting on quantitative outcomes of organisational interventions targeting appropriate opioid use on hospital discharge. Quality assessment was performed by two independent reviewers. The protocol for this review was prospectively registered on PROSPERO (ID: CRD42020156104). Results: Out of 173 full texts assessed for eligibility, 43 were included in this review. The majority of studies had a moderate to serious risk of bias (33 out of 43). Most of the studies implemented a multifaceted organisational intervention (16 studies). Other interventions included guideline implementation, prescriber education and default opioid prescribing quantity changes in electronic medical records. Multiple studies found that the dissemination of patient-specific and procedure-specific guidelines reduced the quantity of opioids prescribed by 44-57%. Prescriber education provided with feedback was implemented in four studies and resulted in a 33-44% decrease in prescribing rates. Lowering the default quantities in the electronic medical records produced a 40% decrease in opioids prescribed in one study. Conclusion: Guideline implementation, prescriber education and default opioid prescribing quantity changes all appear effective in improving the appropriate use of opioids on hospital discharge. However, the extent of reduction of opioid prescribing upon hospital discharge after the implementation of multifaceted intervention strategies appears similar to that of simpler interventions which require fewer resources.