Safe use of opioids at Capital & Coast District Health Board (DHB)

Transcription

1 Safe use of opioids at Capital & Coast District Health Board (DHB) Caroline Tilah Acting Director (Operations), Quality Improvement and Patient Safety (QIPS) Directorate CCDHB 21/10/ Safe Use of Opioids National Collaborative Learning Session Zero - Central Region

2 Background Opioids are used for rapid pain management in hospital settings and are considered a high risk medication group as when errors are made there is more likely to be harm, and consequences for the patient are more serious. Recent national data has found that opioids (33 percent) were most commonly implicated for causing adverse drug events. As such opioids have been identified as a key medication safety work stream at Capital & Coast DHB. The Health Quality & Safety Commission have estimated the cost for surgical harm as $770 per additional occupied bed day (OBD). This estimate can be applied to additional OBDs for medication events and shows that the DHB can make significant savings by preventing medication related harm. Let me tell you a story...

3 Actions already in place early 2013 Patient Safety Opioid newsletter released February 2013 (2 SAC2 s associated with renal failure). The release of the Management of Adult Inpatients Acute Pain Guideline on PML & Capital docs February The CCDHB Medicine Review Committee starting opioid safety education programme for RMOs 2013.

4 The opportunity Commission sponsorship for the 10 month IHI Improvement Advisor (IA) Professional Development Programme (June 2013 to March 2014). Required to focus on a project that would provide an opportunity to apply the theory and methods learned in the IA program and be strategically important to Capital & Coast DHB

5 The method (IHI Model for Improvement)

6 What were we trying to accomplish? The initial Project Aim: To eliminate adverse drug events associated with opioid use at Capital & Coast DHB by 31 March 2014.

7 MDT working group A MDT working group was established in August 2013: Chris Cameron Medical Consultant Paul Hardy Specialist Anaesthetist Pain Service Paul Glover Specialist Anaesthetist Jonathon Adler Palliative Care Specialist Janice Young Pharmacist Belinda Bennett Associate Director of Nursing SWC Julia Barton Acute Pain Clinical Nurse Specialist Claire Atkins Acute Pain Nurse

8 13 data capture PDSA cycles Data Capture PDSA s PDSA4 Reviewed data from reportable events PDSA 8 Assess current junior medical staff understanding of safe opioid use House Surgeons(new to CCDHB) will have gaps in their understanding of opioids yes 12 %wrong Registrars (Employed at CCDHB) will have a good understanding of opioids no worse than HS- 16% wrong. PDSA2 - Reviewed data from ICU Data base/ SAC reviews moved PDSA3 - Reviewed data from Coding PDSA 7 Identified patients not being given CCDHB PCA Patient Information Sheet, or had S&S explained to them PDSA 6 Identified that we have an Acute Pain Management Guideline booklet but outdated and not circulate PDSA1 Source potential areas for opioid related data ICU Data base, SAC reviews, Coding, RL PDSA 5 Assessed PYXIS naloxone data and agreed with working group target ward 7 North

9 7 Nth specific and Community PDSA 12 Information provided to patient by community pharmacies re opioids - Nothing standard, some use patient information leaflets on their computer systems which are very generic, most counselled patients verbally on the potential side effects To test a standard information sheet (in development by group currently) and placed article in Community Pharmacy Newsletter PDSA11 Audit of naloxone events from Nov 2012 to Nov 2013 showed highest contributors were poly pharmacy and increased opioid intake first 24 hours post surgery (PACU and Ward) PDSA10-7 North Nurse knowledge of opioids good understanding & to promote RE when naloxone given as part of safety culture PDSA 9 Inpatients who receive naloxone while an inpatient have this documented on their discharge summary 20% documented PDSA13 7 North Medical staff current prescribing practices of opioids: APPROPRIATE CHOICE - 93% were considered to be an appropriate choice APPROPRIATE DOSE - 83% appropriate dose/18% prescriptions did not have an appropriate dose in light of egfr MULTIPLE OPIATE USE - Multiple opiate use was seen for about 50% of patients prescribed prn opiates TRAMADOL USE - Tramadol prn was often prescribed with opiates

10 Initial PDSA findings Assessed PYXIS naloxone data most reliable data source of measurement data. Specific gaps in opioid knowledge base by HSO & RMO s (improve education programme). No Patient information regarding opioids given on discharge or by Pharmacies Had introduced Acute Pain Management Guideline but access via Capitaldocs (More accessible tools?) Patents given naloxone did not have event routinely documented on discharge summary or RE completed for review Main contributors of harm 18% prescriptions did not have an appropriate dose in light of egfr, multiple opiate use was seen for about 50% of patients prescribed prn opiates, tramadol prn was often prescribed with opiates Poor monitoring of patient on PCA s Increased doses of morphine first 24 hours post PACU/Ward

11 Revised aim: To eliminate inpatient s developing opioid narcosis on 7 North Ward at Capital & Coast DHB by 31 March Pareto Chart - Use of Naloxone by Ward from Jan 2011 to August % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

12 How will I know that a change is an improvement? Our measure? As previously stated we had assessed PYXIS naloxone data as the most reliable data source of measurement data. Goal Measure To eliminate naloxone use (used to treat opioid narcosis) on 7 Nth Ward by 31 March Monthly the number of inpatients requiring naloxone on 7 North.

13 What changes could we make that would result in improvement? Use of the mighty driver diagram... to keep us focussed on specific changes

14 Safe use of opioids at Capital Coast District Health Board (CCDHB) Driver Diagram as at 20/10/2014 Primary Drivers: Secondary Drivers: Specific Changes: Assessment Managing complex elective pain patients Advance pain management planning at pre assessment for Elective Vascular patients Prescribing Acute Pain Management Guideline introduced in 2013 PML Phone app for ready access to Acute Pain Management Guideline awaiting completion by sign writers at present Aim: To eliminate inpatient s developing opioid narcosis on 7 North Ward at CCDHB by 31/03/2014 (has had to be extended to 31/12/2014) Administration Monitoring Current prescribing practices Discharge prescribing Transfer of care Opioids large doses within first 24 hours PACU/Ward. PCA monitoring not occurring hourly as per policy & double up of observation forms Campaign to focus on awareness to launch June Poster & education re - appropriate dose in light of egfr, reduction of multiple opiate use of patients prescribed prn opiates, reduction of tramadol prescribing with opiates. Pharmacy currently completing audit of medications prescribed on discharge summaries Modification of observation charts to identify high risk patients and individual plan Revised EWS chart and incorporation of APMS chart 1 observation Tool. Review of frequency of observations and ability to identify high risk patients and plan observations accordingly. Education Medical Staff knowledge base gaps identified PCA Competencies Modification of in house training to address & re audit Safety Culture Naloxone use not recorded on discharge summary (20%) and RE not completed Naloxone specific incident type set up and RE to be complete when Naloxone administered. Event to be documented on discharge summary and MAP (To be audited) Patient and family No Patient Information regarding Opioids on discharge or when scrip t filled. Opioid Patient information sheet on discharge and when script filled by Pharmacy.

15 How are we doing? Prefer to think we are half way!

16 Progress to date A mobile app for direct access to our PML Set up specific incident type on the reportable event system for naloxone. Modified RMO/HSO teaching programme Revised EWS to include minimum pain monitoring Updated separate prescription chart DO NOT PRESCRIBE PCA MORPHINE IN PATIENTS WITH RENAL IMPAIRMENT. Revised minimum requirement for PCA monitoring Developed a Patient Opioid information sheet (discharge and by the community pharmacy when the script filled).

17 C Chart showing naloxone use on target ward Feb 11 to September 14 (measure)

18 Reflections and advice: As a famous New Zealander once said... It won t happen over night but it will happen While our project is not completed as stated we did take on the equivalent of world peace. However the future imbedded improvements will have a significant positive impact on patient safety, patient experience and cost savings. The IHI Improvement Methodology has been invaluable and the central region Improvement Advisors are here to support you with Prem. KISS - Your aim must be really specific and achievable.