7/6/ ANNUAL MEETING Pain Stewardship and Pharmacist s Role in HCAHPS OBJECTIVES. Hospital Consumer Assessment of

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1 Pain Stewardship and Pharmacist s Role in HCAHPS David S. Craig PharmD Moffitt Cancer Center August 6 th, 2016 Composite Topics Nurse Communication (Question 1, Q2, Q3) Doctor Communication (Q5, Q6, Q7) Responsiveness of Hospital Staff (Q4, Q11) Pain Management (Q12, Q13, Q14) Communication About Medicines (Q16, Q17) Discharge Information (Q19, Q20) Individual Items Cleanliness of Hospital Environment (Q8) Quietness of Hospital Environment (Q9) Global Items Overall Rating of Hospital (Q21) Willingness to Recommend Hospital (Q22) OBJECTIVES Discuss the HCAHPS process and the impact this has on pharmacy services Describe techniques related to pain management that may be useful for pharmacists to improve patient care and achieve better HCAHPS outcomes Explain various patient related variables that can influence or improve pain related outcomes Summarize important opioid monitoring tools (capnography, pulse oximetry) that can improve the safety of opioids in hospitalized patients Review how the Florida Prescription Drug Monitoring Program (E-FORCSE) can be used to improve hospitalized patient safety 3- Pain Related Questions #12 - During this hospital stay, did you need medicine for pain? Yes No If No, Go to Question 15 #13 - During this hospital stay, how often was your pain well controlled? Never Sometimes Usually Always #14 During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? Never Sometimes Usually Always Hospital patient satisfaction survey administered by CMS Administered to inpatient adults (excludes psychiatric patients) who spent at one night in a US hospital Survey results publically available at ( Hospital Value Based Purchasing (VBP) includes Experience of Care Domain which uses HCAHPS to determine hospital reimbursement (currently up to 1.5%, but planned to increase to 2% in 2017) Poor performance on HCAHPS leads to reductions in reimbursement Positive Influence White ethnicity and level of education strongly predict favorable overall scores Government owned hospital - pain scores Critical Access Hospital (CAH) pain scores Negative Influence Hospital size and primary language (non-english speaking patient population) strongly predicts unfavorable overall scores Private (for profit) hospital ownership pain scores Acute Care Hospital (ACH) pain scores 1. McFarland DC, Omstein KA, Holcombe RF. Demographic factors and hospital size predict patient satisfaction variance implications for hospital valuebased purchasing. J Hosp Med Aug;10(8): Gupta A, Lee LK, Mojica JJ, et al. Patient perception of pain care in the United States: A 5-year comparative analysis of HCAHPS. Pain Physician Sept-Oct;17(5):

2 How can Pharmacists improve HCAHPS scores? Work with interdisciplinary rounding teams (nurse, pharmacist, others) Focus on medication adherence/education and pain related outcomes (pain intensity, side effects, opioid safety) Medication reconciliation (using E-FORSCE) at admission and discharge Create and improve existing pain related hospital policies and treatment strategies Work with existing teams (anesthesia, internal medicine) to improve acute pain Develops patient triggers for patients who have complex needs (i.e. Suboxone, IT pumps, Chronic Pain, etc.) that require in depth review or specialty consultation Be proactive versus reactive (pre-emptive analgesia, etc.) Talk to patients about their pain control (Is it satisfactory?) Important Patient Variables Positive Influence Opioid naïve Older age Acute post-operative pain No Tobacco/Alcohol use Patient has regional analgesic strategies Negative Influence Opioid tolerance Younger age (adult) Chronic pain history Tobacco/Alcohol use Substance abuse or Psychiatric diagnosis Patient not candidate for regional analgesia How can Pharmacists improve HCAHPS scores? Have a dedicated pain management FTE or dedicated team member Work with others to improve the overall patient experience Identify floors/hospital areas who are poor performers looking for ways to improve Work with bedside nurses on the importance of pain assessment & reassessment through education and policy development, evaluate gaps in knowledge Evaluate naloxone utilization to gain information on who, what, why, and when. Use trends to inform improvements in safety and pain. Maximize non-opioid analgesics Conduct internal QI (quality improvement) that evaluates gaps in knowledge, naloxone utilization, and use other hospital quality projects to gain momentum Look beyond opioid dose conversions and drug acquisition costs for solutions Important Patient Variables Negative Influence Opioid tolerance Chronic pain history Tobacco/Alcohol use Substance abuse or Psychiatric diagnosis Patient not candidate for regional analgesia Strategies Identify tolerant patients prior to surgery or admission (when possible) account for tolerance, adjust doses accordingly. Use the PDMP to identify drug/dose. Identify patients with chronic pain and/or tobacco and alcohol use prior to hospitalization, or at admission, and develop treatment strategies to prevent withdraw and improve pain control. Maximize non-opioid analgesic strategies (NSAIDs + Acetaminophen, Ketamine, etc.) Inaccurate Assessments of HCAHPS and Joint Commission The cause of the opioid epidemic We should stop asking people about their pain which will improve the safety of hospitalized patients Pain is subjective and nobody can measure it so stop doing it Pain assessment and measurement tied to increases in opioid prescribing in attempts to manage pain Safety of hospitalized patients is compromised by aggressive pain management techniques (opioids) Is a catch 22 for hospitals (safety versus satisfaction) Genetic Variability and Opioid Analgesia Pain perception/processing COMT, MC1R (melanocortin-1receptor) Mu, Kappa, Delta receptors OPRM1 polymorphism (Mu 118A>G) Drug metabolism Phase I (CYP P450 2D6) Phase II (Glucuronidation, UGT 2B7) Drug transporters ABCB1 (aka P-glycoprotein) 2

3 PATIENT VARIABLES = PHARMACOGENETICS Positive impact CYP 2D6 poor metabolism may prolong oxycodone analgesia 1 Avoiding CYP dependent opioids (codeine, oxycodone, etc.) Negative impact Use of codeine as an analgesic 2 OPRM1 (118 A>G polymorphism) µ opioid receptor mutations (approximately 24 identified) 1. Samer CF, Daali Y, Wagner et al. Genetic polymorphisms and drug interactions modulating CYP 2D6 and CYP 3A activities have a major effect on oxycodone analgesic efficacy and safety. Br J Pharmacol 2010:160(4); Eissing T, Lippert J, Willmann S. Pharmacogenomics of codeine, morphine, and morphine 6-glucuronide. Mol Diagn Ther 2012:16(1):45-53 Latch J, Gunslinger G. Are Mu-opioid receptor polymorphisms important for clinical opioid therapy? Trends Mole Med 2005;11:82-9 Interpatient Variability Comorbidities (cardiovascular, psychiatric, etc) End organ function (renal, hepatic) Pharmacogenetic CYP 2D6, OPRM1 (118 A > G polymorphism) Drug interactions (CYP 2D6, 3A4) Overlapping CNS depression Pain type(s) Neuropathic, neuralgic Somatic, visceral (nociceptive) Previous history (analgesic use) PATIENT VARIABLES = DRUG INTERACTIONS Positive impact Prolonged oxycodone analgesia via CYP 2D6 and CYP 3A4 by quinidine + ketcoconazole 1 Ritonavir inhibition of fentanyl metabolism resulting in reduced clearance 2 Negative impact Rifampin induces CYP 3A4 causing reduction of oxycodone analgesia 3 1. Samer CF, Daali Y, Wagner et al. Genetic polymorphisms and drug interactions modulating CYP 2D6 and CYP 3A activities have a major effect on oxycodone analgesic efficacy and safety. Br J Pharmacol 2010:160(4); Olkkola KT, Palkama VJ, Neuvonen PJ. Ritonavir s role in reducing fentanyl clearance and prolonging its half-life. Anesthesiology 1999;91(3): Nieminen TH, Hagelberg NM, Saari TI, et al. Rifampin greatly reduces the plasma concentrations of IV and PO oxycodone. Anesthesiology 2009;110(6): PATIENT VARIABLES = COMORBIDITIES Positive impact TCA in patient with insomnia, anxiety, and depression Opioid use in patient with chronic diarrhea, or short gut syndrome Negative impact Methadone or TCA use in patient with previous MI Antidepressant use in a patient with suicidal ideation PATIENTS DON T SUDDENLY DETERIORATE. CLINICIANS SUDDENLY NOTICE. -ANONYMOUS 3

4 Opioid Safety Clinical Assessment Tools CAPNOGRAPHY (END TIDAL CO 2 ) Pasero Opioid-induced Sedation Scale (POSS) S = Sleep, easy to arouse 1 = Awake and alert 2 = Slightly drowsy, easily aroused 3 = Frequently drowsy, arousable, drifts off to sleep during conversation 4 = Somnolent, minimal or no response to verbal or physical stimulation Patient Controlled Analgesia (PCA) Pasero, C. Assessment of sedation during opioid administration for pain management. JOPAN 2009;24(3): Opioid Safety Clinical Assessment Tools Pulse Oximetry Noninvasive and relatively inexpensive Valuable when supplemental oxygen NOT utilized Acoustic Monitoring Pairs continuous pulse oximetry with respiratory rate Likely superior to pulse oximetry alone Capnography (End Tidal CO 2 ) Able to detect desaturation and apnea earlier than other modalities Useful for patients on supplemental oxygen Why Clinical Monitoring Alone Is Inadequate A patient whose vital signs are checked every four hours is unmonitored >96% of the time. The nurse s presence may stimulate the patient, resulting in overestimation of the resting RR, which is often determined by manual respiration counts. Manual counts of RR have been shown to be inaccurate when compared to capnography. ACOUSTIC APNEA MONITORING High Risk Patient Case DC is a 62 y/o Female admitted for ACDF (Anterior Cervical Discectomy and Fusion) at C3-C7 PMH = Rectal cancer, aortic stenosis, chronic neck/shoulder pain, DDD, fatigue, Hodgkin's lymphoma, insomnia, migraine, & obstructive sleep apnea (OSA) Home medications (Documented in Medical Record) Prochlorperazine 10mg po q 8 hrs PRN Pregabalin 75mg po BID (not listed in PDMP) Temazepam 30mg po at HS (Dr. #1) Carisoprodol 350mg po QID (Dr. #2) Alprazolam 2mg po QID PRN (Dr. #4) APAP/Butalbital 325/50mg #2 po q 4 hrs PRN (not listed in PDMP) Xyrem (sodium oxybate, GHB) (Dr. #3) 4

5 High Risk Patient Case - PDMP Using E-FORCSE to Improve Care Provides an additional outside reference to verify patient drug history Helpful both on admission and discharge Reduced need for refills on chronic medications Can be used to identify drug/drug interactions with new + old drug therapy One of the most important safety tools for hospitalized patients Does contain errors, use caution with interpretation Unexpected findings can be opportunities for further discussion Can be a tool to reduce opioid related harms Surgery HOSPITAL COURSE Day #1 SCM Consult Continue Pregabalin, Ketorolac, Methocarbamol, Carisoprodol, Hydromorphone IV, Oxycodone, Primary Continue Temazepam, Xanax, Xyrem Carisoprodol 350mg 2. Hydromorphone IV 1 mg 3. Methocarbamol 750mg 4. Pregabalin 75 mg 5. Topiramate 50mg 2026 Day #2 1.Temazepam 30mg 2.Xyrem (Not charted as given) Patient Self Administered Xyrem SCU Transfer and Intubation Code Blue Called Recommendations to Improve Care Be proactive versus reactive Improving pain care requires effort, education, resources, and teamwork Identify problem areas use to stimulate other improvement projects Better identification of high risk patients may improve overall satisfaction Use multimodal analgesic techniques Use available tools (capnography, E-FORSCE, etc.) to improve care Work with admitting/medical teams to develop pain treatment algorithms (PCA, PCEA, Post-Op, Sickle Cell, Ketamine, etc.) Avoid drug treatment based on pain intensity Joint Commission Sentinel Event Alert Use of Opioids in Hospitals Opioid analgesics rank among the drugs most frequently associated with adverse drug events. Some of the causes for adverse events associated with opioid use are: Lack of knowledge about potency differences among opioids Improper prescribing and administration of multiple opioids and modalities of opioid administration (i.e., oral, parenteral and transdermal patches) Inadequate monitoring of patients on opioids Create and implement policies and procedures that allow for a second level review by a pain management specialist or pharmacist of pain management plans that include high-risk opioids, such as methadone, fentanyl, IV hydromorphone and meperidine Accessed June 10 th, 2016 Conclusions HCAHPS pain scores influenced by patients overall hospital experience Pharmacists are uniquely qualified to make improvements Use patient specific variables to tailor drug therapy Evaluating naloxone utilization can be helpful in improving pain scores Patient safety is paramount, use opioid use (and other drugs) with caution Use objective monitoring (capnography) whenever possible E-FORSCE can be an invaluable patient safety tool Attempts to improve HCAHPS scores solely with opioids can result in bad outcomes/harm 5

6 QUESTIONS/COMMENTS? 6