Pain Management and Safe use of opioids in hospitals. Kyoung-Sil Kang, PharmD, BCPS Scott Tam, PharmD Lauve Casimir, RN, MSN

Transcription

1 Pain Management and Safe use of opioids in hospitals Kyoung-Sil Kang, PharmD, BCPS Scott Tam, PharmD Lauve Casimir, RN, MSN

2 Bronx Care Health System Bronx Lebanon Hospital Concourse/ Fulton division, Nursing home, Outpatient clinics 972 beds teaching hospital and health care system Two hospital divisions: Acute and Psychiatric *General Acute Care: 32,121 Discharges/year *90% Occupancy Rate Emergency Room visits 141,000 visits/year Ambulatory Care visits- Over 1million annually All electronic medical record

3 Introduction Opioid abuse and resulting increased morbidity and mortality has received much attention from FDA, CMS, CDC, Joint Commission, State organizations, and the healthcare community recognizing that abuse of these drugs has increased. Healthcare organizations and professionals are trying to take steps to minimize patient harm. This presentation provides a snapshot of what one hospital organization has done.

4 0 Hospitals NYSPRP Rate Hospital Rate Denominator Numerator Dec Dec Nov Nov Oct Oct Sep Sep Aug Aug Jul Jul Jun Jun May May Apr Apr Mar Mar Feb Feb 2017 Jan 2016 Jan ,556 13,471 14,220 13,399 13,741 13,084 13,783 14,464 13,737 15,188 13,129 15,226 14,370 13,378 14,680 14,019 14,634 14,723 14,073 14,907 14, NYPFP Opioid Data

5 Monitored Naloxone use since 2012 TJC Sentinel event alert Monitor naloxone use and track and trend service and patterns

6 Pain management NEW 2018 Joint Commission Standard On January 1, 2018, The Joint Commission implemented new and revised pain assessment and management standards for accredited hospitals. The new and revised pain assessment and management standards are reflected in the Leadership; Medical Staff; Provision of Care, Treatment, and Services; and Performance Improvement chapters of The Joint Commission hospital accreditation manual. Pain Management: A Systems Approach to Improving Quality and Safety The standards require a Joint Commission accredited hospital to establish policies and procedures that address comprehensive clinical assessment of pain; treatment or referral for treatment; and reassessment for patients as it designates, based on patient population and scope of services provided. The additions and revisions require hospitals to: Establish a clinical leadership team Actively engage medical staff and hospital leadership in improving pain assessment and management, including strategies to decrease opioid use and minimize risks associated with opioid use Provide at least one non-pharmacological pain treatment modality Facilitate access to prescription drug monitoring programs Improve pain assessment by concentrating more on how pain is affecting patients' physical function Engage patients in treatment decisions about their pain management Address patient education and engagement, including storage and disposal of opioids to prevent these medications from being stolen or misused by others Facilitate referral of patients addicted to opioids to treatment programs Read more: Standards Development

7 What have we done: 1. Pharmacy reviews and monitors the use of opioids and naloxone 2. Implemented mandatory Opioid staff education for Doctors, nurses, and pharmacists. 3. Built required Opioid risk assessment into the MD prescribing workflow that populates the nursing and pharmacy workflow. 4. Made opioids a High Risk Drug within the Drug delivery workflow.

8 Cause of Opioid Adverse Drug Events Lack of knowledge about potency differences among opioids Improper prescribing and administration of multiple opioids and modalities of opioid administration Inadequate monitoring of patients on opioids

9 Opioid Safety Module: Annual Mandatory : All clinical staff

10 Opioid Dose Conversion Table Drug IV/IM (mg) Oral (mg) Morphine Hydromorphone Oxycodone Hydrocodone Codeine Fentanyl Meperidine Tramadol High alert medication notice: 1 mg IV HYDROmorphone is approx. equal to 7 mg IV morphine

11 What have we done: Opioid Safety Measures High Alert Medications High Alert HYDROmorphone Applied Hospital Locations Ambulatory Inpatient Emergency Storage, Prescribing and Ordering Special alert is added to Pyxis and MAXIMUM dose alert is set up in our computer system. HYDROmorphone: 1mg Injection is equivalent to Morphine 7mg Injection. Look-alike and Sound-alike Medications Potential Problematic Drug Names HYDROmorphone (DILAUDID) and Morphine (DURAMORPH) Applied Hospital Locations Ambulatory Inpatient Emergency Potential Errors and Consequences Some health care providers have mistakenly believed that HYDROmorphone is the generic equivalent of morphine. However, these products are not interchangeable.

12 What have we done? Use of Non-Opioid Drugs Non-Opioid Pain Medications Ibuprofen, Ketorolac, Naproxen, Acetaminophen Antidepressants (For Neuropathic Pain) Amitriptyline Duloxetine Anticonvulsants (For Neuropathic Pain) Gabapentin Pregabalin Muscle relaxants (For Musculoskeletal Pain) Baclofen Cyclobenzaprine Tizanidine

13 Patient Characteristics who are at higher risk for over-sedation and respiratory depression Sleep apnea or sleep disorder Snoring Morbid obesity No recent opioid use Older age risk is 2.8 times higher for individuals aged times higher for age times higher for aged over 80 Post-surgery, particularly if upper abdominal or thoracic surgery Long length of time receiving general anesthesia Receiving other sedating drugs Pre-existing cardiac or pulmonary disease or organ failure Smoker

14 Removed all Pain Med from Order Browse and Utilized Pain Medication Order Set

15 Added Bowel Regimen

16 Copyright 2012 Allscripts Healthcare Solutions, Inc. Hydromorphone injection is separated and made dedicated column

17 Risk Assessment incorporated to Pain medication order screen Medical mlm will Logic look for Module the pt age. will look If >71 for the will patient s check the age. box If >71 will check the box There are 6 checkboxes that dictate if the sentinel alert appears

18 What have we done: Bronx-Lebanon process to assess Safe use of Opioids. Screen patients for respiratory depression MD assess risk factors for opioid-induced respiratory depression while ordering opioids

19 Sentinel Alert Appears The User must pick the selection in the drop down box

20 What have we done: Bronx-Lebanon process to assess Safe use of Opioids- Alert in EMAR for nurses Avoiding Accidental Opioid Overuse At Bronx Lebanon Hospital: If patient has a risk for over sedation alert will appear in EMAR for nurses

21 What have we done: Use of Opioid Long-Acting Drugs versus Opioid Short- Acting (PRN) Drugs Opioids with pain assessments: o Morphine Controlled Release Percocet (Oxycodone + o Oxycodone Extended Release acetaminophen) o Fentanyl transdermal patch Morphine oral immediate release o Methadone Morphine Injection Tramadol oral Oxycodone immediate release HYDROmorphone oral HYDROmorphone Injection Pain Management Note: If short acting pain medications are required frequently or pain is not controlled with short acting opioids please consider adding or increasing long acting controlled opioids Nursing Note: Do not give breakthrough opioid if patient is drowsy or asleep.

22 Previous Breakthrough Pain PRN (as needed) orders: Not scheduled Only gave when patients in Pain

23 Objective To demonstrate how we use successful communication, pain assessment and reassessment to reduce level of opioid dependent among patients at Bronx Care inpatient area. How we deploy the EMR tools to optimize patient pain management.

24 USE FOLLOWING Pain Assessment PAIN SCALE TO DETERMINE PATIENT S LEVEL OF PAIN SCALE APPLICABLE POPULATION 0 10 Numeric Pain Distress Scale Utilized for adults and children that can engage in self reporting of pain FLACC Scale Children or adults that are unable to engage in self reporting due cognitive impairment or inability to self report Wong Bakers FACES Pain Scale Children or adults who cannot use the numeric pain scale but can identify their pain using the Wong Baker faces on the scale Neonatal Infant Pain Scale Utilized from neonate to two months Critical Care pain Observation Tool (CPOT) Utilized for Assessment of pain in both intubated and non intubated critical care patients

25 What have we done: Pain Assessment and Re-Assessment Nursing Staff Perform initial pain assessment for all patients once a shift Flowsheet

26 Nurses Document Pain Assessment in Vital Signs Flowsheet/Structure note Assess and Document pain assessment within 30 minutes before administer pain Medication Alert Structure Note

27 Pain Reassessment Post Meds Admin Assess and Document pain reassessment 30 minutes after Injectable pain medication 60 minutes after Oral pain medication SAS, CAM-ICU/CCU Post-intervention pain rating Compare to tolerable pain score Complete all documentation and communicate with the physician

28 Pain Reassessment Alerts in Work List Manager & Action List

29 Documentation of Pain Reassessment

30 Reassessment Completed in Flowsheet and Also Update the Worklist Manager

31 Conclusion Patient Education, communication and efficient EMR documentation is integral to reducing opioid crisis and maximize patient comfort and quality care. Pain management success 1. Communication 2. Teamwork 3. Patient engagement 4. Monitoring and Follow-up