STARTER PACK: Webinar #1 ADE4 - OPIOIDS

Transcription

1 STARTER PACK: Webinar #1 ADE4 - OPIOIDS

2 Welcome to the Starter Pack Webinar #1 Why this is important Establishing a Team Best practices Understanding the Measures Completing a gap analysis First Steps Gap Analysis Tool Webinar #2 How to prioritize the identified gaps Using science of improvement concepts How to create a good action plan Action Plan 2

3 Roy Soto, MD Roy Soto, MD Anesthesiologist, William Beaumont Hospital Royal Oak, Michigan Residency Program Director Professor of Anesthesiology

4 Why is this Important? Statistics More than 100 people die from drug overdoses every day in the U.S. Most deaths are caused by prescription medications. Costs: Healthcare In 2011, more than 1.4 million Emergency Department visits were related to pharmaceuticals. Patients and Families Staff 4

5 Project Goal The HIIN Bold Goal 20% reduction of Adverse Drug Events related to opioids from to The HIIN will assist hospitals with strategies to implement best practices to reduce opioidrelated adverse events, improve appropriate pain management, decrease the usage of opioids and enhance patient expectation management. Hospital baseline and goals 5

6 First Things First Ask: Are we ready? Is there urgency? Is there leadership support? Who owns this effort? What resources are needed? What if we are not ready for full-scale change? Assess the readiness before you proceed 6

7 The MHA Experience/Overview Pain & opioids Multimodal analgesia Pain control & value based care Healthcare literacy Expectation management and patient satisfaction MHA pain initiative 7

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9 Consequences of Acute Pain Acute Pain Sympathetic Activity Fear, Anxiety Splinting, Shallow Breathing Tachycardia, Hypertension Sleeplessness, Helplessness Atelectasis, Hypercarbia, Hypoxia O 2 Consumption Regional Blood Flow Myocardial Ischemia Infection, Ischemia Impaired Rehabilitation Pneumonia 9

10 Pain Control Warfield 1993 Apfelbaum 1999 Gan Pateints (%) Any Pain Slight Moderate Severe Extreme 10

11 HCAPHS & Pain HCAHPS Component Pearson Coefficient of Pain Control and Specific HCAHPS Components Coefficient of Correlation Good communication with doctors 0.90 Good communication with nurses 0.92 Good communication about medicines 0.85 Good nursing service 0.81 Global satisfaction with hospital Gupta A, Daigle S, Mojica J, Hurley RW. Patient perception of pain care in hospitals in the United States. J Pain Res 2009; 2: Taylor R. Interpretation of the correlation coefficient: a basic review. JDMS 1990; 1:

12 Vila. Anesth Analg

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14 Opioid Monotherapy 2012 Premier database 8,023,591 surgical and nonsurgical inpatients and outpatients received IV opioids 4,081,079 (51%) received opioid monotherapy Opioid Monotherapy MMA Used 14

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16 Opioids, acetaminophen, alpha 2 agonists 16

17 Non-Pharmacologic Techniques Ice, PT, massage, stretching, acupuncture, counseling Acetaminophen Alpha-2 agonists Gabapentinoids acetaminophen clonidine dexmetatomidine gabapentin pregabalin Local anesthetics bupivacaine lidocaine liposomal bupivacaine NMDA receptor antagonists ketamine NSAIDs celecoxib ibuprofen ketorolac Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet 2011; 377:

18 Patient Education on Pain Management Apfelbaum. Anesth & Analg

19 MHA Pain Initiative Gap analysis MOSS tool Process & outcomes measures Drug disposal tool Education 19

20 Michigan Opioid Safety Score 20

21 Measuring Progress Adverse Drug Events (ADE) related to Opioids: Patients receiving naloxone after treatment with opioids (any route) Numerator: Number of patients treated with opioids (any route) who received a reversal agent (naloxone) Denominator: Number of patients who received an opioid Hospital Reported: Submit to the MHA Keystone Data System (KDS) Opioids: (any form of, including combinations): codeine, fentanyl, hydrocodone, hydromorphone, levorphanol, meperidine, methadone, morphine sulfate, oxycodone, propoxyphene, tapentadol Performance reports for above measures are available in KDS for all GLPP hospitals 21

22 Drug Disposal Tool 22

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24 Beware the Lure of Education 24

25 Gap Analysis Tool 25

26 Gap Analysis Not a must-do list Represents best practices and individualized gut check Gap Analysis located on MHA Community Site Library 26

27 Examples of Areas of Focus/Findings Pharmacy/pain supervision of Rx Range orders OSA identification Reversal protocols Determining opioid tolerance 27

28 A Pharmacist or Pain Provider Provides Oversight for all Dosing of: Methadone 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 69.0% Yes n= % No Fentanyl Patches (At Medication Initiation Only) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 72.4% Yes n= % No 28

29 Recommended Best Practice Institute requirement for pharmacist or pain physician oversight for use of methadone for post-surgical inpatients Institute requirement for pharmacist or pain physician oversight for use of transcutaneous fentanyl for post-surgical inpatients 29

30 The Facility's Opioid Practices Clearly Specify the Following: 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Range Orders are Not Used for Opioids 58.6% 41.4% Yes No n=29 30

31 Recommended Best Practice Range dosing for opioids should not be allowed Specific doses for specific conditions can be used in order sets in a rank-order list to achieve the same effect in a safer way 31

32 OSA Identification The Facility has Standard Policies and Practices in Place for Managing the Initiation of Maintenance of Opioid Therapy Which Include: Collecting a History of Snoring, Obesity and Sleep Apnea 100.0% 80.0% 60.0% 40.0% 20.0% 72.4% 27.6% A Standard Hand-off/Transition Communication Process is in Place for All Patients Receiving Opioids Which Includes the Following Information, at Minimum: 100.0% 80.0% 60.0% 40.0% 20.0% History of Snoring, Obesity and Sleep Apnea 55.2% 44.8% 0.0% Yes 0.0% No Yes n=29 n=29 No 32

33 Recommended Best Practice Obtain a sleep apnea/snoring history from all patients and document appropriately Include this history during all handovers of nursing care 33

34 A Protocol is Followed which Guides the Reversal of Opioids and Includes the Following: 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Reversal Protocols are Active on All Patients' MARs if there is an active order for a narcotic 17.2% Yes Nurses are Allowed to Administer Reversal Agents Without Prior Physician Order 100.0% 82.8% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 35.7% 30.0% 20.0% 10.0% 0.0% No Yes n=29 n= % No 34

35 Recommended Best Practice MAR reversal protocols should be active for all patients with an active order for opioids and benzodiazepines Nurses will be allowed to administer reversal agents per these protocols 35

36 The Facility has Standard Policies and Practices in Place for Managing the Initiation of Maintenance of Opioid Therapy Which Include: 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Defining and Identifying if Patient is Opioid Tolerant vs. Opioid Naïve 27.6% Yes PCA and PCEA Orders Prohibit the Routine Use of Basal Dosing in the Opiate Naïve Patient 100.0% 72.4% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 31.0% 30.0% 20.0% 10.0% 0.0% No Yes n=29 n= % No 36

37 Recommended Best Practice Patients should be identified as either opioid naïve or tolerant on the MAR and during handoffs Basal PCA rates should not be used on opioid naïve patients 37

38 Where are you now? Analyze your hospital s current state Gap analysis Compare your current practices with the listed best practices Honest and non-judgmental: you want to understand variation now Create a list of gaps/opportunities 38

39 Establishing Your Team Successful improvement work relies on a team Project Champion senior leader who will provide support Team Leader a person with authority to make the changes needed Team members staff that do the daily work Pain Champion, physician champion, pharmacy contact, data contact, senior executive sponsor, emergency department contact, surgical services contact, inpatient contact 39

40 Where to find the Resources 40

41 Resources AHRQ Toolkit SAMHSA Opioid Overdose prevention Toolkit AHRQ CUSP Toolkit MOSS The Michigan Opioid Safety Score WHO World Health Organization analgesic ladder Your Guide to Controlling Pain After Surgery Equianalgesic Opioid Calculator 41

42 Next Steps Perform your Gap Analysis Access the resources provided - make notes and ask questions View Webinar #2 How to engage and involve stakeholders Learn about PDSA and Small Tests of Change Keystone Calendar of Educational Events Quality Essential Skills Training (QuEST) 42

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