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STUDY OBJECTIVE Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation. METHODS We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression. RESULTS Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time. CONCLUSIONS ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.

Objectives The primary objective was to compare the efficacy of ultrasound (US)-guided three-in-one femoral nerve blocks to standard treatment with parenteral opioids for pain control in elderly patients with hip fractures in the emergency department (ED). Methods A randomized controlled trial was conducted at a large urban academic ED over an 18-month period. A convenience sample of older adults (age ≥ 55 years) with confirmed hip fractures and moderate to severe pain (numeric rating score ≥ 5) were randomized to one of two treatment arms: US-guided three-in-one femoral nerve block plus morphine (FNB group) or standard care, consisting of placebo (sham injection) plus morphine (SC group). Intravenous (IV) morphine was prescribed and dosed at the discretion of the treating physician; physicians were advised to target a 50% reduction in pain or per-patient request. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the 11-point numerical rating scale (NRS) and calculated as the summed pain-intensity difference (SPID) over 4 hours. Secondary outcome measures included the amount of rescue analgesia and occurrence of adverse events (respiratory depression, hypotension, nausea, or vomiting). Outcome measures were compared between groups using analysis of variance for continuous variables and Fisher's exact test for categorical data. Results Thirty-six patients (18 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, fracture type, vital signs (baseline and at 4 hours), ED length of stay (LOS), pre-enrollment analgesia, or baseline pain intensity. In comparing pain intensity at the end of the study period, NRS scores at 4 hours were significantly lower in the FNB group (p 55 anos) con fractura de cadera confirmada y dolor de moderado a grave (puntuacion de escala numerica ≥ 5) a uno de los dos grupos de tratamiento: bloqueo del nervio femoral “tres en uno” guiado con ecografia mas morfina (Grupo BNF), o tratamiento estandar y placebo (inyeccion de placebo) mas morfina (Grupo TE). La morfina intravenosa (IV) se prescribio y dosifico a discrecion del medico que atendio al paciente; se aconsejo a los medicos conseguir una reduccion del dolor del 50% o lo requerido por el paciente. El resultado principal fue el alivio del dolor o la reduccion en la intensidad del dolor, que se obtuvo usando la escala numerica de 11 puntos (numerical rating scale, NRS) y se calculo como la suma de la diferencia en la intensidad del dolor (summed pain-intensity difference, SPID) a las 4 horas. Los resultados secundarios incluyeron la cantidad de analgesia de rescate y la aparicion de eventos adversos (depresion respiratoria, hipotension, nauseas o vomitos). Los resultados entre los grupos se compararon utilizando el analisis de la varianza para variables continuas y el test exacto de Fisher para las variables cualitativas. Resultados Treinta y seis pacientes (18 en cada grupo) completaron el estudio. No hubo diferencias entre los grupos de tratamiento respecto a la edad, el sexo, el tipo de fractura, los signos vitales (basal y a las 4 horas), el tiempo de estancia en el SU, la analgesia preinclusion o la intensidad del dolor basal. Al comparar la intensidad del dolor al final del periodo del estudio, las puntuaciones NRS a las cuatro horas fueron significativamente menores en el grupo BNF (p