Opioid Management Change Package 2017/2018

Transcription

1 Opioid Management Change Package 2017/2018 Opioid Prescribing and Management Overall 100% 80% 60% 40% 20% 0% 01/07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/2017

2 Aim: 100% of prescribing for Opioid Derived Analgesia will follow a safe standardised process Practices will randomly sample 10 patients who have been prescribed moderate strong opioid derived analgesia more than once in the past six months, to see if they are reliably receiving the following care Palliative care patients usually have a clear management plan in place from the hospice, but it is important for clinicians to effectively manage all patients on opioid-derived analgesics The choice of moderate to strong opioid-derived analgesia would omit the more common codeine patients who are generally more acute with less follow-up planning. If we omitted tramadol, we may miss a drug of abuse, hence we focus on Tramadol, Sevredol and Morphine-based analgesia Selecting those who have been prescribed opioid derived analgesia more than once, would enable us capture review of these patients. Question One: Is there a clear indication within the clinical record for a moderate to strong opioid derived analgesic to be used/initiated? There needs to be a clear indication within the clinical record. This needs to be apparent to the non-attendant clinician also There may not always be a classification or a specific diagnosis made but there should be evidence that the prescription is justified. Question Two: Is there evidence that the analgesic ladder has been used prior to the patient being prescribed a moderate to strong opioid derived analgesic? BPAC has an excellent resource on the WHO analgesic ladder - it must be clear from the notes that the analgesic ladder has been considered This would also measure whether the appropriate medication has been selected at an appropriate dose for the patient. Question Three: Is there a clear management plan? (side effects, breakthrough pain, self-management) Evidence that side effects, self-management and timely review have been discussed with the patient There should be clear documentation that side effects and their management (especially constipation) has been discussed. We could encourage the ABC approach (antiemetic for the first week, breakthrough analgesia and constipation advice) BPAC again has an excellent resource for this Self-management albeit functional goals or patients attending for investigations or allied health appointments should also be clearly addressed Timely review must be planned at the outset of treatment All three must be met Documentation should be clear for the non-attending clinician.

3 Question Four: Has clinical review occurred effectively prior to the second prescription being issued? This would be Y/N as we are selecting patients who have had more than one prescription in the last three months There should be documented evidence of clinical review (this can be a telephone consult) The measures that must be met are was the review timely (did the patient call in early or did the patient need to be recalled?) and was there a discussion about side effects and pain management. Question Five: Have all measures been met? This will self-populate. Audit Instructions Practices will randomly sample of 10 patients per month who have been prescribed opioid*-derived pain relief in the past three months, to see if they are reliably receiving the following care: 1. Is there a clear indication within the problem list for an opiate to be used? 2. Is there a clear plan in regard to using an opiate that initiator, patient and GP all are aware of? 3. Has there been a clear assessment for and management of common opiate complications? 4. Is the prescribed opiate and dose indicated for the condition treated? 5. Has any evidence of prescription manipulation been addressed e.g. recurrent lost scripts? 6. Has the patient been reviewed by GP or Specialist within the planned timeframe? 7. Have all conditions been met? 1. Identify patients who have received a prescription for opioid derived pain relief* in the previous three months. A query is currently being developed for MedTech and My Practice PMSs to assist with this, and will be available online at: 2. From the identified list, randomly select a sample of 10 patients 3. Print and complete the Opioid Prescribing Data Collection Form (included in the Opioid Prescribing Audit spreadsheet and online at: 4. Transfer the data collected to the Opioid Prescribing Audit spreadsheet. Please make sure the date is entered beside each individual record. The data will automatically be collated and displayed on the run charts that can be printed as needed 5. Save the spreadsheet 6. the completed spreadsheet by or on the 10 of each month (i.e. June data is due on 10 July, July data is due on 10 August). The spreadsheet is to be ed to victoria.brown@middlemore.co.nz. *Includes any medication containing: - Codeine - Tramadol - Sevredol - Morphine

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5 Theory of Improvement

6 Change Ideas Tested Handouts to patients - HEALTH NAVIGATOR HAS EXCELLENT RESOURCES All GPs are prescribing safely according to the analgesic ladder Opioids prescribing process is streamlined Management plan clearly documented in notes Patient given clear instructions about potential side effects and when to report back to GP/nurse Developed PDSA cycles to inform the team of current tramadol prescribing process We hypothesised regarding GP prescribing habits, to identify differences between GP s Attempt to socialise opioid prescribing policy amongst clinicians at the practice Update of locum / registrar orientation document to this effect Ensure whole practice team are familiar with CD handling and Rx processes Controlled drug Rx s to be scanned into patient notes to ensure audit trail Elimination of extra CD Rx audit record New CD Rx pads received, continue to be documented in numerical sequence in CD register Explore possibility of coding for opioid prescribing. Benefits/Positives Audit data slowly improved each month Reassurance that staff are following the process Potential areas for improvement Team implementing pain ladder Our team know what their responsibilities are and what is expected of them. The team is focused and provides resource information for all other practice staff. Involving reception admin in an area not thought to concern them has benefits for the whole practice Reduction in opioid induced side effects Just looking at an area of practice has a way of making things better We now have a process in place that will help us to comply with Cornerstone accreditation Consideration of shifting of drug safe Reduction in amount of opioids prescribed. Issues/Negatives Time consuming Ambiguous starting point Hearing about the existence of a CD prescription audit Finding out that over the years my controlled drug pads had been scraped off my overfull clinical drawer into the space behind my desk I found about seven pads! Buy-in from doctors Patients not keen on other adjuvant treatment.

7 Examples of Opioid Prescribing Template for MedTech Opioid Checklist Name of Opioid Prescribed Basic Information Has breakthrough analgesia been discussed Follow up Script Previous script Date Opioid Indication Side Effects Discussed Fup Was Due Has Analgesic Ladder been used Could Any Adjuvant therapy help Could Patient be a potential drug seeker Constipation Nausea Disorientation Is Dose appropriate for patient Self-Management Discussed Is patient managing ok Authorised by Concurrent systemic diseases assessed Other Medication assessed Follow up Plan Acute Review Date yy Dd/mm/