AHA/HRET HEN 2.0 RURAL/CAH AFFINITY GROUP WEBINAR REDUCING HARM THROUGH ADVANCING OPIOID SAFETY

Transcription

1 AHA/HRET HEN 2.0 RURAL/CAH AFFINITY GROUP WEBINAR REDUCING HARM THROUGH ADVANCING OPIOID SAFETY August 29, :00 a.m. 12:00 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Lauren Kaderabek, Program Manager, HRET 11:00 11:05 2

3 UPCOMING WEBINARS HRET/HEN 2.0 Leadership Engagement Webinar September 1 11:00 12:00 p.m. CT HRET/HEN 2.0 CAUTI Webinar September 8 11:00 12:00 p.m. CT HRET/HEN 2.0 Spread & Sustainability Webinar September 13 11:00 12:00 p.m. CT View all upcoming events 3

4 ENCYCLOPEDIA OF MEASURES (EOM) Catalogued measure information available on the HRET HEN website HEN Core Topics (evaluation measures) HEN Core Process Measures HEN Additional Topics 4

5 SIGN UP TODAY: RURAL/CAH LISTSERV Rural/CAH Listserv is available for: Sharing of: HRET resources Publically available resources Best practices Learnings from Subject Matter Experts Troubleshooting for data reporting and analysis Sign Up Here 5

6 AGENDA FOR TODAY 6

7 HEN DATA UPDATE Paul Cholod, Data Analyst, HRET 11:05 11:10 7

8 EXISTING AND NEW DATA SOURCES HEN Webpage Data & Informatics Team link Encyclopedia of Measures (EOM) Improvement Calculator Improvement Calculator Demonstration CAH Rural Tool Recordings of past webinars Keep checking back for new things 8

9 FACILITIES BY THE NUMBERS Based on active HEN facilities on August 10, 2016 Type of facility Percent CAH (not Rural) 9.17% Rural (not CAH) 14.47% CAH and Rural 25.58% Not CAH and Not Rural 50.78% 9

10 HOW ARE WE DOING? Improvement based on facilities with a preferred baseline and at least 3 consecutive months of monitoring data starting October 2015 Measure N Improvement Excessive Anticoagulation with Warfarin % Hypoglycemia in Inpatients Receiving Insulin % Adverse Drug Events due to Opioids % CAUTI rates for inpatient units % Catheter Utilization Rate % Central Line rates for inpatient units % Central Line Utilization Rate % All Documented Patient Falls with an Injury Level of Minor or Greater % Readmission within 30 Days (All Cause) % 10

11 FRONTIER COMMUNITY HEALTH INTEGRATION PROJECT DEMONSTRATION (FCHIP) UPDATE Casey Brewington, Project Director, Montana Hospital Association 11:05 11:10 11

12 BACKGROUND Three year demonstration project to develop and test new models for the delivery of health care services: Acute care Extended care Other care Goals: Improve quality of care Increase patient satisfaction Reduce costs 12

13 FCHIP PARTICIPATING CAH S 13

14 DETAILS Aim is to increase access to services that are often unavailable in frontier communities to reduce the need to transfer patients to hospitals in larger communities Meet community needs in: Telemedicine Nursing facility care Ambulance services 14

15 QUESTIONS? Visit the Frontier Community Health Integration Project Demonstration website for more information 15

16 CROSS-CUTTING IMPACT OF ADDRESSING OVERSEDATION Steven Tremain, MD, FACPE Improvement Advisor, Cynosure Health 11:15 11:30 16

17 #1 OPIOID AND SEDATION MANAGEMENT ADE FTR Delirium Falls AS VTE VAE WAKE- UP 17

18 W A K E Warn Yourself: This is high risk. Assess: Use tools (STOP BANG, POSS, RASS, PA-PSA). Know: Your drugs, your patient. Engage: Patients and families to set realistic pain expectations, use of non-sedating analgesics, risks of opioids. - U P Utilize: Dose limits, layering limits, soft and hard stops. Protect: The patient our ultimate job. 18

19 PAIN RELIEF AND SEDATION Are they the same? Different? How? 19

20 DIFFERING GOALS: PAIN MANGEMENT 20

21 DIFFERING GOALS: SEDATION Calm; assess and treat for pain first Comfort; assess and treat for pain and dyspnea first Communicate; see whether patient is able to communicate clearly Reduce anxiety and agitation Facilitate mechanical ventilation Decrease traumatic memory of ICU stay and procedures

22 Advancing Sedation Hypoxia Apnea Respiratory Arrest Cashman & Dolin, 2004, Davies, et al., 2009, Fecho, Jackson, Smith, & Overdyk, 2009, Joint Commission 2012, Shapiro, Jarzyna et al., 2011 American Society of Anesthesiologists, 2002, Cashman & Dolin, 2004, Considine, 2005, Davies et al., 2009, Jarzyna et al., 2011, Nisbet & Mooney-Cotter, 2009, Weinger & Lee, 2011). The sequelae of opioid-induced sedation progressing to respiratory depression include hypoxia, apnea, and respiratory arrest (American Society of Anesthesiologists, 2002, Cashman & Dolin, 2004, Considine, 2005, Davies et al., 2009, Jarzyna et al., 2011, Nisbet & Mooney-Cotter, 2009, Weinger & Lee, 2011).

23 ARE POST-OP PATIENTS IN FLOOR BEDS SAFE? Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid- induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient s respiration rate, oxygen and sedation levels. Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert- Letter pdf 23

24 INPATIENT OPIOID HARM 1 out of every 6 medication errors Half of preventable opioid ADEs are due to use of multiple opioids and sedatives 0.5% to 1.1% of post-operative patients receiving opioids experience respiratory depression Failure to rescue occurs in approx. 20% of all postsurgical patients experiencing a treatable lifethreatening complication

25 WHY CAN T YOU HOLD YOUR BREATH VERY LONG? Is it because you are running out of oxygen? Is it because your pulse is going to fast? If you panted shallow breaths at 16 per minute would you be fine? Or it because you are accumulating carbon dioxide and have get rid of it?

26 SO ARE THESE MONITORING APPROACHES SENSITIVE? SAFE? Pulse? Pulse oximetry? Respiratory rate?

27 IF NOT THOSE THEN WHAT? Routine use of a validated assessment tool End tidal capnography

28 OPIOID SAFETY: WHAT WORKS PA PSA Opioid Knowledge Assessment fetytools/opioids/documents/assessment.pdf 11 questions No profession scored better than 40 percent

29 OPIOID SAFETY: TOOLS Identify patients at risk: STOP BANG Use effective tools to reduce over-sedation from opioids (e.g. risk assessment tools, sedation assessment tools: POSS, RASS oid-induced_sedation.pdf

30 No discharge from PACU No additional opioids S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25% to 50% 1 or notify primary 2 or anesthesia provider for orders; consider administering a non-sedating, opioid-sparing nonopioid, such as acetaminophen or a NSAID, if not contraindicated; ask patient to take deep breaths every minutes. 4 = Somnolent, minimal or no response to verbal and physical stimulation Unacceptable; stop opioid; consider administering naloxone 3,4 ; stay with patient, stimulate, and support respiration as indicated by patient status; call Rapid Response Team (Code Blue) if indicated; notify primary 2 or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. *Appropriate action is given in italics at each level of sedation. 1 If opioid analgesic orders or hospital protocol do not include the expectation that the opioid dose will be decreased if a patient is excessively sedated, such orders should be promptly obtained. 2 For example, the physician, nurse practitioner, advanced practice nurse, or physician assistant responsible for the pain management prescription. 3 For adults experiencing respiratory depression give intravenous naloxone very slowly while observing patient response ( titrate to effect ). If sedation and respiratory depression occurs during administration of transdermal fentanyl, remove the patch; if naloxone is necessary, treatment will be needed for a prolonged period, and the typical approach involves a naloxone infusion. Patient must be monitored closely for at least 24 hours after discontinuation of the transdermal fentanyl. 4 Hospital protocols should include the expectation that a nurse will administer naloxone to any patient suspected of having life-threatening opioid-induced sedation and respiratory depression. 1994, Pasero C. Used with permission. As cited in Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management, p St. Louis, Mosby/Elsevier,

31 WHEN TO USE END TIDAL CAPNOGRAPHY? Patients above threshold doses Patients for whom you are struggling to manage pain and not over-sedate Patients at risk for obstructive apnea Every inpatient on parenteral opioids?? 31

32 WHAT HAPPENS IS YOU HAVE ONE OVERSEDATION DEATH OR SERIOUS PERMANENT EVENT? Costs in $ Costs to staff Costs to community Costs in trust Outmigration Closure 32

33 STANDARD PROCESSES: EVERY PATIENT, EVERY TIME! 33

34 TO LEARN MORE: Complete WAKE UP webinar Safe use of opioids Multi-model treatment of pain to reduce opioid use/ades 34

35 CASE STUDY: MADISON MEMORIAL HOSPITAL Mikel Barr, RN, Director of Quality 11:30 11:45 35

36 ABOUT US BECOMING A VALUE DRIVEN ORGANIZATION Madison Memorial Hospital is a 69 bed, full-service medical facility, and the only selfsustaining county-owned, non-critical access hospital in Idaho. It is a premier, regional healthcare facility serving five counties in Southeastern Idaho. It is comprised of an outstanding administrative staff and healthcare professionals who are dedicated to providing quality care to every patient. 36

37 WHERE WE WERE? Improvement Model Not Effective: Expectation that quality would fix issues Lack of shared governance / No buy-in Focus on value based purchasing measures limited attention on other safety indicators Our approach was reactive: Temporary improvements / No sustainability Hospital centered processes Department silos Not much attention to risks versus efforts 37

38 OUR JOURNEY TO EXCELLENCE Culture Revolution Phase 1 I AM Committed To Excellence o Employee to owner - employee engagement committee, daily huddles o Total harm across the board training modules, total harm score o Patient safety teams change packet checklists (planning calendars) o Employee evaluations - raise criteria based on quality & safety performance Culture Revolution Phase 2 I AM Obsessed with Quality & Safety o Volume to value o Methodologies: LEAN, SIX SIGMA, PDSA Culture Revolution Phase 3 Changing Care Delivery o o o Risk identification ISO improving systems/processes & customer satisfaction Just culture (create a learning culture, an open & fair culture, design safe systems and manage behavioral choices) 38

39 RESULTS 39

40 BOWTIE 40

41 VALUE SUMMARY PREVENTING OPIOID OVER SEDATION Monitor Data Continual design of process improvements until outcomes/data goals met and sustainability achieved - document project updates on next version 41

42 MEASURED RESULTS # of Performance Improvement Projects Total Harm Per 1,000 Patient Days Prior to Revolution Harms/1,000 Patient Days Baseline Goal 0 42

43 LESSONS LEARNED Advice: It takes a lone dancer and one follower Support your followers (spark plugs) Gemba walks leaders must spend time on the front lines (where the work happens) Identify waste ask why? Transparency Proceed until apprehended Shared governance Collaborate with other organizations Are we doing what's right for healthcare? (send the right message) 43

44 QUESTIONS? Mikel Barr RN, Director of Quality Madison Memorial Hospital 44

45 DISCUSSION: TIPS FOR SMALLER HOSPITALS Betsy Lee, MSPH, RN, Improvement Advisor, Cynosure Health Steven Tremain, MD, FACPE, Improvement Advisor, Cynosure Health 11:45 11:55 45

46 BRING IT HOME Lauren Kaderabek, Program Manager, HRET 11:55 12:00 46

47 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Evaluate post-operative order sets for opioids and end tidal capnography use Review use of standardized risk and sedation assessment tools (e.g. STOP BANG, RASS, POSS) What are you going to do in the next month? Identify gaps for targeted tests of change Lead interprofessional team in standardizing processes for sedation and opioid management 47

48 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Review HRET webinars on safe use of opioids and multi-modal treatment of pain Evaluate hospital and unit data on failure to rescue, unplanned transfers to ICU and frequency of post-operative assessment What are you going to do in the next month? Form interprofessional team with representatives from OR, med-surg, RT, pharmacy, nursing, physicians and others to revise order sets and processes to proactively manage pain and sedation Update handover scripts and tools between PACU and med-surg unit to include patient POSS scoring and need for end tidal capnography Evaluate use of naloxone in ambulatory procedure areas 48

49 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Review data for naloxone use across the organization Interview staff to evaluate unit-level practices for assessing and managing pain and sedation What are you going to do in the next month? Assign an executive sponsor from the C-Suite to remove barriers Assess needs and budgetary impact for end tidal capnography Recruit a patient or family member to serve on a quality team Evaluate the impact of community opioid issues with respect to impact on patient sedation and pain management 49

50 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Engage family members in discussions about plans for opioid assessment and management Encourage family members to speak up when they have concerns about patient over-response to pain medications What are you going to do in the next month? Evaluate patient and family education strategies Collect patient stories to emphasize the personal impact of the compounding risks of sedation and pain management Plan with community leaders to address strategies across the region 50

51 QUESTIONS? 51

52 THANK YOU! Find more information on our website: Questions/Comments: 52