CHSP, CPSO RN, BSN, JD,

Transcription

1 Presented by: Ann Lambrecht, RN, JD, FASHRM and John Lee, CHSP, CPSO Opioid Prescribing and the Substance Abuse Epidemic: Statistics and One Hospital s Success Story Coverys Risk Management Disclaimers/Disclosures This presentation is a work product of the Coverys Education Department. This information is intended to provide general guidelines for risk management. It is not intended and should not be construed as legal or medical advice. Laws are constantly changing, and each federal law, state law, and regulations should be checked by legal counsel for the most current version. We make no claims, promises, or guarantees about the accuracy, completeness, or adequacy of the information contained in this presentation. Do not act upon this information without seeking the advice of an attorney. Neither your attendance nor the presenters answering a specific audience member question creates an attorney-client relationship. Ann Lambrecht and John Lee have no relevant financial relationships to disclose COPYRIGHTED Today s Presenters Ann Lambrecht, RN, BSN, JD, FASHRM Senior Clinical Risk Consultant, Coverys John Lee CHSP, CPSO Director of Safety and Risk Management Carteret General Hospital 1

2 Objectives After participating in this program, the attendee will be able to: - State the statistics of opioid overdoses - Define some untoward impacts of the opioid prescribing problem - Describe methods one hospital employed to reduce inappropriate opioid prescribing within its facility and solutions to better serve patients National Opioid Statistics Between million people abuse opioids worldwide US comprises 5% of world population and 80% of opioid consumption In 2014 more than 47,000people died from a drug overdose in the US - Of these 61% of drug overdose deaths involved an opioid In 2015 more than 52,000 people died from a drug overdose in US - Of these, 63.1% involved a prescription or illicit opioid CDC Morbidity and Mortality Weekly Report, December 2016 National Opioid Statistics, Continued Two distinct but related trends: - A 15-year increase in prescription opioid-related overdose deaths - A more recent increase in illicit overdose deaths largely due to heroin and illicitly produced fentanyl (synthetic opioid) Past misuse of prescription opioids is strongest risk factor for starting heroin Since 2000, more than 500,000 Americans have lost their lives to an opioid overdose CDC Mortality and Morbidity Weekly Report, January

3 State Opioid Statistics GA = Number of painkiller prescriptions/100 people 1 GA Deaths from opiate overdoses , , 1, , 1098 SC = Number of painkiller prescriptions/100 people 1 SC Deaths from opioid overdoses , , , 620 One of greatest increases in the heroin death rate was in South Carolina (57.1 percent) 1 1 CDC Vital Signs, July CDC Mortality and Morbidity Weekly Report, January 2016 Scope of the Opioid Problem 1 death 9 admissions 32 ED visits 734 Non-medical opioid users Examining the Federal Government s Response to the Prescription Drug Abuse Crisis, June 2013 Prescription Opioid Abuse The Perfect Storm Physicians initially reluctant to prescribe opioids 1990s - Significant shift in pain management 2000 The Joint Commission implemented pain management standards Aggressive pharmaceutical marketing campaign 3

4 Other Opioid Related Impacts 75% injured workers receive opioid prescriptions 1 A 2012 study reported 16% teens misused a prescription painkiller 2 Hospitalization for opioid overdoses among Medicare recipients quintupled from 1993 through Every 25 minutes an infant is born with NAS total pharmacy robberies in 2014, a 16% increase from the 713 total pharmacy robberies in OxyContin & Hydrocodone main targets 70% of employers feeling the impact of prescription drug misuse in their workplace 6 1 Worker s Comp Research Institute, Oct School Nurses Stock Drug to Reverse Opioid Overdoses, Sept / reports/stat briefs/sb177 4 CDC Mortality and Morbidity Weekly Report, March Pharmacy Times, May 2015, 6 National Safety Council, March 2017 Healthcare Employees David Kwiatkowski, traveling medical technician, who was charged with causing an outbreak of Hepatitis C in New Hampshire. Exeter Hospital Hepatitis C Outbreak David Kwiatkowski was infected with Hepatitis C He injected himself with patient s Fentanyl and refilled syringes with saline Several unexplained cases of Hepatitis C discovered at Exeter Hospital, NH 32 total patients infected and sued hospital for negligent hiring and managing perpetrator 1 Only 57% hospitals drug testing all employees and 41% of those who are testing are not testing for opioids 2 1 Federal Bureau of Investigation, U.S. Attorney s office, December 6, National Safety Council, March

5 Our Solutions to Reduce ED Drug Seeking Behaviors and Improve the Quality of Care CALL TO ACTION Carteret County - Highest rate of Controlled Substance Prescribing (26,697/10,000 population) among the NC Eastern Seaboard Counties 3 rd Highest per capita Death Rate secondary to Narcotic overdose Youth report higher usage of prescribed painkillers (for non-medical purposes) than their peers throughout NC ( 16.3% in Carteret County compared with 7.2% for NC) Unintentional Poisoning Death Rates by County in NC Source: NC Injury & Violence Prevention Branch Report, January

6 Fatal Unintentional Overdose Mortality Rates: NC (Grey) and US (Green), Source: Mortality data - NC and US WISQARS, obtained 9/1/08. NC rates, NC State Center for Health Statistics, , reviewed October 2016 Illicit Opioid Deaths vs. Prescription Deaths Source: NC Injury & Violence Prevention Branch Report, September 2016 CHC Pain Medication Doses Administered Per 100 Visits Total Pain Med Dosages 83 = Non-Narcotic Pain Oral Narcotic Injected Narcotic Medicines 6

7 Process Description Controlled Substance Review Panel Intention to Select Patients Who Are Not Best Served by Receiving Narcotics in the ED Panel Meets Monthly as Needed Patients Nominated by ED Staff Secondary to Concern Over Patients Recurrent ED Presentations with Requests for Controlled Substances Criteria as follows: 6 Discharged ED Visits with Subjective Pain Complaints Criminal Drug History Doctor Shopping (RxSentry ) PROCESS FLOW DIAGRAM Patient Nominated ED Visits NC Rx Monitoring System Review Criminal History Multidisciplinary Panel Review Inclusion Exclusion Indicator Placed Care Plan Committee Multidisciplinary Panel All Patient Identifiers are Blinded Cases Reviewed Rapid Fire Format Selected Patients Not to Receive Prescription Controlled Substances from the ER Unanimous Agreement Needed for Inclusion Attestation with Attendance Roster Included in EMR ED Staff RN Moderator ED Medical Director ED Case Management Risk Manager ED MD ED RN Director VPMA ED RN Clinical Leader ED Social Work FP Physician Addiction Specialist Physician Pain Management Physician Outpt Care Coordinator 7

8 Results: ED Visits Pre- and Post-Intervention n=20 Patients of 20 Pts: With Decreasing Visit Frequency (73%) 12 of 77 Visits Resulted in Reduced CS Rx (93%) (14.5 Visits per Pt 163 scripts written) (3.9 Visits per Pt 12 scripts written) Month Pre-Selection 6 Month Post-Selection Review Example Case #1 21 y/o F hx bipolar, seizure disorder, appendectomy, cholecystectomy, chronic abdominal pain and post wisdom tooth extraction pain. 22 ED visits past 12 months multiple complaints each time requesting narcotics. 4Rx, 4 Providers No Criminal History 8

9 Case #2 25 y/o F hx depression, on methadone maintenance for narcotic dependency, multiple drug related felonies and misdemeanors. 15 ED visits in past 12 months mostly depression and back pain. 6 Rx, 3 providers Case #3 21 y/o F no significant medical hx, recreational methadone OD, multiple pain related complaints. 11 ED visits past 12 months, majority substance abuse related or pain c/o s No drug related criminal record 4Rx, 3 providers Case #4 25 y/o F hx appy, chole, csection mostly presents to ED with chronic abdominal pain or abscesses. No diabetes. No admitted IVDA. 23 ER visits in past 12 months 39 Rx from 12 Providers past 12 months No criminal history 9

10 Case #5 Husband of Case #4. 35 y/o Male hx IDDM, depression, polysubstance abuse 11 visits past 12 months, no clear trend to complaints 1 admission 12/09 for TCA OD + psychosis 59 Rx from 15 providers Challenges to Appropriate Pain Management During Episodic Visits to the Emergency Department Patient Satisfaction Scores are often tied to bonuses and annual goals. In the future our ED s will have ED CAHPS surveys (tied to Value Based Purchasing) that ask patients how well their pain was controlled. A significant information GAP exists between PCP s & ED Providers to communicate treatment plans/pain management contracts for continuity of care. Lack of PCP s for referral and follow-up Resources qlog/pmqaccess.html :NC PDMP (RxSentry) inalquery.html : Search NC Court Calendars o?method=view : Search NC Court Convictions 10

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