HRET HIIN Adverse Drug Events Virtual Event. Final Opioid Fishbowl Event! Catch and Release September 26, 2017

Transcription

1 HRET HIIN Adverse Drug Events Virtual Event Final Opioid Fishbowl Event! Catch and Release September 26,

2 Shereen Shojaat, MS Program Manager, HRET WELCOME AND INTRODUCTIONS 2

3 Webinar Platform Quick Reference Mute computer audio Today s presentation Chat with participants Download slides/resources Register for upcoming events 3

4 Poll: How did you get here? How did you hear about today s virtual event? a. HRET HIIN flyer b. HRET HIIN website c. HRET LISTSERV d. State hospital association e. QIN-QIO f. Your organization/colleague g. Other, please specify 4

5 Today s Agenda 11:00-11:05 a.m. Welcome and Introductions Introduction to today s event and agenda overview. Shereen Shojaat, MS Program Manager, HRET 11:05-11:07 a.m. HIIN ADE Data Update The HRET HIIN ADE data will be shared inclusive of opioid baseline and monitoring data. 11:07-11:40 a.m. Catch and Release! Let s hear from the fish as they apply their learnings to new process designs for post-op, post-cabg, med-surg and endoscopy sedation safety. Mariana Lesher, MS Director, Data, HRET Steven Tremain, MD, FACPE Maryanne Whitney, RN, CNS, MSN Improvement Advisors, Cynosure Health 11:40-11:47 a.m. Reflections All Speakers 11:47-11:57 a.m. Open Dialogue All Attendees 11:57 a.m-12:00 p.m. Action Items and Next Steps Close today s event with a discussion on designing small tests of change. Shereen Shojaat, MS Program Manager, HRET 5

6 Mariana Lesher Data Director, HRET ADE DATA UPDATE 6

7 ADEs due to opioids PRELIMINARY RESULTS The 2Q 2017 aggregate rate of 0.44 represents a 12.2% reduction from the 1Q HIIN (Oct Dec 2016) rate of 0.50 Rate definition: (number of patients treated with opioids who received naloxone/number of patients who received an opioid agent)*100

8 Steve Tremain and Maryanne Whitney Improvement Advisors, Cynosure Health CATCH AND RELEASE! 8

9 Polling Question I have joined A. All 4 Opioid Fishbowl events B. 2 of the 4 Opioid Fishbowl events C. 1 of the 4 Opioid Fishbowl events D. This is my first Opioid Fishbowl event 9

10 Polling Question The fishbowl events have A. Stimulated our team to refine and focus our aim for opioid safety. B. Assisted our planning and doing one or more tests of change. C. [Both A and B above] D. Did not have much affect on our efforts. 10

11 Chat! 11

12 Last Day in the Hatchery! 12

13 Medical West Bessemer, Alabama 200+ Community Hospital Team Members Meredith Lutz, Chief Quality Officer Demetrios Holmes, Director, Pharmacy 13

14 Rapid Cycle PDSA Updates Overall Aim: Reduce post-operative respiratory failure associated with over-sedation from opiates Aim statement for small tests of change: Reduce over-sedation among patients with OSA who receive PCA post-operatively 14

15 Rapid Cycle PDSA Project Summary What We Tried and Measured Provider education Use of post-op CPAP in patients with known OSA Screening for OSA Completion of screening questions CPAP/BiPAP Protocol Post-op Respiratory Failure 15

16 Rapid Cycle PDSA Project Summary Results 50 Post-operative Respiratory Failure Among Patients Receiving Opioids 40 Rate /2015-6/ / / /2016 1/2017 2/2017 3/2017 4/2017 5/2017 6/2017 7/2017 8/2017 Medical West All Hospitals Improvement Target Trendline 16

17 Rapid Cycle PDSA Project Learnings What didn t work Reliance on humans to order CPAP, even with knowledge of OSA dx What worked Automated standard work CPAP protocol What we learned Knowledge without processes = system failure Processes without knowledge = system failure Data documented data used 17

18 Reflections + Even though we started out below the project average, we were able to improve systems - Although we reduced post-operative respiratory failure, we did not see improvement in the rate of oversedation ADE 18

19 Next Steps This Project Procedural sedation in high risk ICU patients And Beyond Glycemic management 19

20 Slidell Memorial Hospital Slidell, Louisiana 229 bed community hospital Team members Kisha Gant, Clinical Coordinator Pharmacy Michael McKendall, Director of Pharmacy Teri Ramon, Clinical Nurse Auditor Jeanne Wilson, CHSP, Director, Quality 20

21 Rapid Cycle PDSA Updates Overall Aim: By September 2017, reduce naloxone administration by 20% on the Med-Surg units with the implementation of the Pasero Opioid-induced Sedation Scale (POSS) Aim statement for small tests of change: Increase the number of nurses using the POSS to 50% 21

22 Rapid Cycle PDSA Project Summary What We Tried and Measured Implemented use of the Pasero Opioid- Induced Sedation Scale (POSS) on the Med- Surg Unit Measured: Number of completed documentation sheets Number of naloxone administrations to patients taking opioids 22

23 Rapid Cycle PDSA Project Summary Results Number of Opioid-Related Naloxone Administrations on Med-Surg April May June July August 23

24 Rapid Cycle PDSA Project Learnings What we learned Asking RN s to fill out data collection sheet is cumbersome Incorporating POSS into current workflow via the emar is more practical Sharing project with senior management is vital What worked Consulting: RN Champion RN Leadership Nursing Informatics Group IT Senior Management Team What didn t work Incorporating the data collection sheet into the RN s workflow 24

25 Reflections + Implementing intervention to improve patient safety and outcomes Working with HRET staff, RNs, Quality, Pharmacy and IT Learning from other fish and webinar participants Participating in fishbowl - Slow process Did not accomplish AIM statement 25

26 Next Steps This Project Incorporate POSS scale into emar for use on non-icu units Educate RN s on POSS Purpose How to use it Monitor Patient safety Naloxone use Areas for improvement And Beyond Expand to include nonopiate medications Incorporate into pharmacy duplicate PRN opioid protocol Educate 26

27 Newton-Wellesley Hospital Newton Lower Falls, Massachusetts 350 Bed Community Hospital part of Partners Healthcare System Team members Cheryl Bardetti, Manager, QI and IC Jeanne Guerin, Q &S RN Specialist Dave Berkowitz, Assistant Director Pharmacy David Marshall, Q &S Specialist 27

28 Rapid Cycle PDSA Updates Overall Aim NWH will decrease Naloxone use by 20% in the Adult GI unit by October 1, 2017 Aim statement for small tests of change NWH will remove Meperidine for one month starting September 1 NWH will add restrictive criteria for use of Meperidine by September 1 28

29 Rapid Cycle PDSA Project Summary What We Tried and Measured Overall Aim-NWH will decrease Naloxone use by 20% in the Adult GI unit by October 1, 2017 Data Analysis-Naloxone Rate in GI Unit- 0.1% (12 patients received Naloxone between May 1, 2016 and April, ) Detailed case analysis of each of the 12 patients Discovery of high rate use of Meperidine in these patients by 2 providers (50% of these providers total patients) 29

30 Rapid Cycle PDSA Project Summary Actions/Results Data presented to Medication Safety Committee Detailed data presented to Chair of Pharmacy and Therapeutics Committee (also a GI MD) for potential removal of Meperidine from Conscious Sedation Policy/ Order Set and he spoke with GI Chair Agenda item at July 19th quarterly Adult GI QI Meeting, GI Chair and Nurse Manager received un-blinded data, MDs received blinded data with their own code-ongoing now that we have the reporting capability Observation of active cases in Endoscopy unit-notes of processes, trends and questions/answers from RNs on cases Add qualifying usage limitations/criteria for Meperidine indications Consideration of removal of Meperidine for one month RN Focus Group Discussion use highlights to update nursing process and assessment tool, and add Naloxone to Recovery Room via smaller Omnicell Removal of Meperidine from the Anesthesia kit box 30

31 Rapid Cycle PDSA Project Learnings What we learned Data available in Epic and will present quarterly at GI QI Rate of Meperidine use in the GI unit is much higher than realized, by 2 providers only Detailed operations of the GI Unit by observations, focus group, manager meetings and reversal patient case reviews What worked Presented the findings and recommendations and received full support from Pharmacy, P&T Chair, GI Nursing, GI Unit Manager, and Anesthesia What didn t work Automatic removal of Meperidine from the hospital formulary and from conscious sedation protocol 31

32 Reflections + We have a strong list of safeguards to improve opioid use safety Multiple order sets for opioid use EMR system (Epic) sets dosing limits on certain opioid orders (PCAs) Standard opioid analgesic conversion tables Policies in place to limit IV opioid doses for acute pain Use of Pasero Opioid-Induced Sedation Scale Ongoing education for clinicians Free naloxone kits and lock boxes for patients Substance use disorder (SUD) screening tools in our EMR Pain management service and SUD services/task force - The new measure is helping us to identify where we can focus our improvement efforts Outcome measure: (HIIN-ADE-1 c) Total number of patients treated with naloxone over the number of opioid withdrawals 32

33 Next Steps This Project And Beyond Continue to incorporate safety measures in the process of conscious sedation in the adult GI unit as we strive for a goal of reversal reduction by 20% or more Assess other units for opioid safety as we refine ways to identify the improvements needed 33

34 Fishbowl Teams REFLECTIONS 34

35 All OPEN DIALOGUE 35

36 Time for Release! 36

37 Polling Question In the future, I would like A. Fishbowl Events focused on hypoglycemia B. Fishbowl Events focused on warfarin C. More lectures on ADEs D. Other...please chat in your answer 37

38 Shereen Shojaat Program Manager, HRET ACTION ITEMS AND NEXT STEPS 38

39 Continuing Education Credits Launch the evaluation link in the bottom left hand corner of your screen. If viewing as a group, each viewer will need to submit separately through the CE link. 39

40 ADE Resources Change Package ADE Change Package Link 40

41 ADE Resources - Checklist ADE Top Ten Checklist Link 41

42 ADE Resources - LISTSERV Join the LISTSERV Ask questions Share best practices, tools and resources Learn from subject matter experts Receive follow-up from this event and notice of future events 42

43 Thank You! Find more information on our website: Questions or Comments: 43