Re: Version 2 of the National Safety and Quality Health Service Standards

Transcription

1 30 October 2015 Ms Margaret Banks Program Director Australian Commission on Safety and Quality in Health Care GPO Box 5480 SYDNEY NSW 2001 By to: Dear Ms Banks Re: Version 2 of the National Safety and Quality Health Service Standards The RANZCP welcomes the opportunity to provide feedback to the Australian Commission on Safety and Quality in Health Care s (ACSQHC) consultation on the Version 2 of the National Safety and Quality in Health Services (NSQHS) Standards. We support the broad safety and quality agenda adopted by the ACSQHC and the commitment to reducing harm to all involved in healthcare, from the consumer to the clinician. In the submission attached we provide a number of recommendations for the Standards, as well as a comprehensive recommendation for how the issue of pain management and opioid stewardship could be added to the Standards. Overall the feedback from our members indicated that Version 2 of the Standards is clearly laid out, easy to understand and containing important actions for delivering healthcare at the highest level of safety and quality. If you would like to discuss any of the information outlined in this submission, please contact Rosie Forster, Senior Manager, Practice, Policy and Partnerships via rosie.forster@ranzcp.org or by phone on (03) Yours sincerely Prof Malcolm Hopwood President Ref: La Trobe Street, Melbourne VIC 3000 Australia T F ranzcp@ranzcp.org ABN

2 Australian Commission on Safety and Quality in Health Care consultation on the National Safety and Quality in Health Services Standards Version 2 30 October 2015 setting and supporting standards for medical practice 309 La Trobe Street, Melbourne VIC 3000 Australia T F ranzcp@ranzcp.org ABN

3 Royal Australian and New Zealand College of Psychiatrists submission About the Royal Australian and New Zealand College of Psychiatrists The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is a membership organisation that prepares doctors to be medical specialists in the field of psychiatry, supports and enhances clinical practice, advocates for people affected by mental illness and advises government on mental health care. The RANZCP is the peak body representing psychiatrists in Australia and New Zealand, and as a binational college has strong ties with associations in the Asia-Pacific region. The RANZCP has more than 5000 members, including around 3700 fully qualified psychiatrists and almost 1200 members who are training to qualify as psychiatrists. Psychiatrists are clinical leaders in the provision of mental health care across a variety of settings and using a range of evidence-based treatments to support a person in their journey to recovery. Executive summary This submission has been developed in close consultation with a number of our key committees, and with Fellows who have expertise in this area. The first section of this submission includes contributions from members of the RANZCP s Community Collaboration Committee (CCC) which is made up of a combination of psychiatrists and community members, including carers and consumers. The CCC supports the RANZCP to partner with people who have a lived experience of mental illness, as well as their carers, in ensuring a person-centred and recovery-oriented approach is always at the centre of RANZCP work. The RANZCP also received input from members of its Practice, Policy and Partnerships Committee (PPPC) and Faculty of Old Age Psychiatry (FPOA). The Opioid and pain management section of this submission is the culmination of efforts from both the binational and Queensland Faculty of Addiction Psychiatry committees, including external consultation with addiction medicine and pain medicine specialists. Overall we welcome the clear and accessible format of the document, and the work ACSQHC has invested in updating the NSQHS Standards to reflect current best practice. In particular, naming the Standards with abbreviated letters to represent each standard makes it easy to follow, and emphasises the equal importance of each standard, rather than allocating a hierarchical number system. The abbreviations also makes reference to standards clearer and easier, and also makes the various standards easier to remember. Key recommendations Reflect quality and safety goals for people with mental illness at the governance level. Add a standard that ensures that the provision of nutrition is not harmful, i.e. refeeding. Reword RH6 to ensure that it does not inadvertently lead to the inappropriate cessation of psychotropic medication in older people. Incorporate the issue of pain management and opioid stewards into the Standards. RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 2 of 11

4 Contents About the Royal Australian and New Zealand College of Psychiatrists... 2 Executive summary... 2 Section 1: General feedback... 4 Standard GS: Governance for safety and quality...4 Recommendations...4 Standard PC: Partnership with consumers...4 Recommendations...4 Standard RH: Reducing Harm...4 RH5 Malnutrition and dehydration...4 RH6 Cognitive Impairment...4 RH8 Challenging behaviours and self-harm...5 Recommendation...5 Section 2: Pain management and opioid stewardship... 6 Rationale...6 NSQHS Version Recommendations Based on Standard RH: Reducing Harm Based on Standard IP: Healthcare-associated infection prevention Based on a combination of the RH and IP standards...9 RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 3 of 11

5 Section 1: General feedback Standard GS: Governance for safety and quality Version 2 of the NSQHS Standards emphasises the importance of responding to the increased risk faced by people with mental illness in the healthcare system. We recommend that the also be reflected in the governance section, committing governance systems to addressing this. In particular, reference should be made to peoples of Aboriginal and Torres Strait Islander origin. Recommendations An additional statement similar with wording similar to GS1.2, which commits to reflecting safety and quality goals for Aboriginal and Torres Strait Islander peoples in governance. Standard PC: Partnership with consumers Feedback the RANZCP has received from community members of the CCC indicates that Standard PC has clarity and effectively highlights the importance of a maintaining a person-centred approach and delivering services that enable partnerships, collaboration and effective connection. Recommendations Wider and more robust reference to the importance of incorporating the consumer s carer, and also family, supporters and friends is essential. This is particularly in the context of the fact that not all supporters identify with the title carer. Standard RH: Reducing Harm Overall, we welcome the issues covered in this section. Feedback from our CCC community members suggests that Standard RH is important and welcomed. However, it was noted that part of reducing harm for consumers with mental illness is to ensure that essential supports are in place. This may mean selfdirected supports; family, friends or carers in supporting roles, or substitute supports. The presence of such supports are often of the utmost importance to consumers in making everyday decisions while receiving care, and their presence can significantly reduce the risk of harm to the consumer. RH5 Malnutrition and dehydration In this section we believe it is essential to also ensure that providing nutrition is not harmful, namely explicitly addressing the need to assess for refeeding risks and provide the correct and appropriate amount of nutrition. This is important given the fact that refeeding syndrome can be a serious and potentially fatal medical complication (Hay et al, 2014). RH6 Cognitive Impairment: Wording in this section risks leading to inappropriate cessation of psychotropic medications for older people. While acknowledging the importance of reducing inappropriate use of these medications in treating older people, we believe that this should be balanced with the importance of ensuring that each patient receives individualised assessment and intervention as deemed clinically appropriate by the practitioner or multidisciplinary team. RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 4 of 11

6 RH8 Challenging behaviours and self-harm Feedback from the CCC suggests that the use of the phrase challenging behaviours in this section may be considered inappropriate. While inclusion of the issues of seclusion and restraint raised under this section are welcomed, we suggest Challenging behaviours and self-harm is not the appropriate subheading for this information. Further, in referencing seclusion and restraint, it is essential to be mindful of the fact that, while the principle of the least restrictive level of care is paramount, in instances when such interventions are applied it is when clinically necessary and with the aim of enhancing safety and minimising the level of risk posed to the patient, families, carers and staff. Recommendation Acknowledgement of the role of carers, family, friends and others in playing a supporting role, and the importance of this in reducing the risk of harm to the consumer. Add provisions in RH5 to ensure that providing nutrition is not harmful and that serious complications such as refeeding syndrome is avoided. Add the word inappropriate to RH6.1c (in italics below): RH6.1 Where care is provided to consumers at risk of delirium, or with cognitive impairment, the health service organisation has systems that: a. incorporate best-practice strategies for early recognition, prevention, treatment and management of cognitive impairment in the care plan b. recognise and minimise consumers distress while they are receiving care c. avoid the inappropriate use of antipsychotics and other psychoactive medicines, in accordance with best practice and legislation Remove the term challenging behaviours from RH8. Reformat RH9 Restraint and RH10 Seclusion so that they are separated from the overarching subheading of Challenging behaviours and self-harm. For RH9.1 consider wording as follows: RH9.1 Where the use of restraint is deemed clinically necessary and appropriate for the management of a patient, the health service organisation has systems that ensure that: a. The use of restraint is minimised and, where possible, eliminated b. restraint is undertaken in the least restrictive manner possible c. require clinicians to undertake the appropriate authorisation procedures for, and document, all instances of restraint, including the rationale for why it has been considered a necessary management practice for that patient at that time d. rates of restraint are reported to the highest level of governance e. require clinicians to undertake appropriate education and training to optimise their capacity to maximally preserve the dignity and compassionate care of any patient requiring restraint. For RH10.1 consider wording as follows: RH10.1 Where the use of seclusion is deemed clinically necessary and appropriate for the management of a patient. The health service organisation has systems to ensure that: RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 5 of 11

7 a. the use of seclusion is minimised and, where possible, eliminated b. require clinicians to undertake the appropriate authorisation procedures for, and document, all instances of restraint, including the rationale for why it has been considered a necessary management practice for that patient at that time c. rates of seclusion are reported to the highest level of governance d. require clinicians to undertake appropriate education and training to optimise their capacity to maximally preserve the dignity and compassionate care of any patient requiring seclusion. Section 2: Pain management and opioid stewardship Currently, the related issues of pain management and opioid stewardship are not addressed in the NSQHS Standards Version 2. These are issues that cover a broad spectrum of medical practice, including addiction psychiatry, addiction medicine and pain medicine. The importance of this aspect of healthcare is increasingly being realised, with local and international evidence showing the link between inappropriate opioid prescribing and ineffective treatment of pain, exacerbation of substance use disorders, morbidity and mortality. The RANZCP recommends that the ACSQHC s NSQHS Standards Version 2 should reflect the importance of quality and safety in pain management and opioid stewardship by making specific reference to this area. The following section sets out our rationale for this, and goes on to make recommendations for how this could be actioned. Rationale The correlation between inappropriate opioid prescribing and ineffective treatment of pain and substance use disorders is well established. There is also evidence of significant increases in prescribed and over the counter opioid use over time (Diener et al, 2008; CDC, 2015; Harrison et al, 2012), and of increasing opioid overdose (Roxburgh et al, 2015; Pilgrim et al, 2015). The inclusion of pain management and opioid use within the NSQHS Version 2 would highlight the problem and facilitate safety improvements such as those seen where there has been a concerted approach to improving opioid prescribing (Franklin et al, 2015). The need to incorporate pain management and opioid prescribing as a key priority in the areas of public health and safety and quality is being increasingly acknowledged by health experts. In response to this, the Royal Australasian College of Physicians (RACP) with support from the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (FPM, ANZCA), the Royal Australian College of General Practitioners (RACGP) and the RANZCP produced Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use (RACP, 2009). This policy document identified three areas of particular concerns, as follows: The development of dependence on prescription opioids with subsequent drug seeking behaviour by a proportion, probably small, of individuals taking prescription opioids for chronic non-malignant pain. The use of prescription opioids by individuals with other drug and alcohol problems, often instead of illicit heroin or other drugs. The management of chronic non-malignant pain in opioid dependent individuals (RACP, 2009). RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 6 of 11

8 The complexity of managing the need to reduce iatrogenic opioid use disorders with the need to treat patients with existing problems has been described as the duelling obligations of opioid stewardship (Coffin & Banta-Green, 2014). These obligations must further be balanced against the imperative to treat acute and chronic pain effectively. In 2013, the National Drug Strategy released its National Pharmaceutical Drug Misuse Framework for Action (the Framework) which identifies national priority areas for actions to minimize the harms to individuals, families and communities from pharmaceutical drug misuse. Among the nine priority areas identified by the Framework of relevance to opioids include: developing a coordinated medication management system; support prescribers, pharmacists and other health professionals; health information and health literacy for consumers; and treatment and harm reduction. The Framework also noted that there had been a substantial increase in opioid supply in Australia in recent years, with a range of associated harms including: pharmaceutical drug-related emergency department presentations and fatal and non-fatal overdoses the risks associated with injection and inhalation of oral pharmaceuticals individuals seeking treatment for prescription opioid or benzodiazepine dependence levels of trafficking in, and police seizures of, pharmaceutical drugs robbery, theft, identify fraud, extortion and the manufacture of illicit drugs (Australian Government, 2013). The National Guidelines for Medication-Assisted Treatment of Opioid Dependence also identify that the issue is growing, with an increasing number of consumers developing harms related to use of pharmaceutical opioids, both prescription and over-the-counter, usually in the context of chronic pain. The marked increase in the prescription of opioid medication in Australia over the past 20 years is resulting in increasing numbers of patients who develop pharmaceutical opioid dependence, and require assistance in the management of dependence in addition to any concomitant medical conditions (Australian Government, 2014). This trend is international, with United States Centres for Disease Control describes the scale of overdose related to prescription painkillers as an epidemic (CDC, 2015). In recognition of the importance of this issues, the Canadian Institute for Safe Medication Practices launched its Opioid Stewardship Program in 2014, and the United States Department of Veteran s Affairs developed an Opioid Safety Initiative Toolkit in the same year (ISMPC, 2014; USDVA, 2014). Since the late 1990s there has been a shift from heroin to prescription opioids as the most common cause of hospitalisations due to opioid poisoning in Australia. A related phenomenon, adverse selection, recognizes that it is often patients who are most at risk of developing problem opioid use who are most likely to receive them, and higher doses where the risks of overdose are greatly increased. These are patients who may have a history of tobacco and other substance use disorders, co-occurring mental health disorders, and who may have the most subjective distress which prescribers may be trying to address (Sullivan, 2010). This highlights the importance of attention to the interrelated areas of pain and opioids to support prescribers in what can be difficult clinical interactions, as recommended in previous opioid and quality prescribing guidelines and implemented in some health systems (RACP, 2009; NPS, 2006, Franklin et al, 2015; USDVA, 2014). RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 7 of 11

9 NSQHS Version 2 The NSQHS Version 2 addresses related areas, in particular in the Reducing harms and Medication safety, as well as some overlap with Partnering with consumers, Communicating for safety and Comprehensive care. It is important to note that the standards currently mention opioids only once as a high risk drug in the glossary, and similarly pain is mentioned only as a type of suffering. We believe that the lack of specificity in relation to opioids and pain does not pay sufficient attention to the significant morbidity and mortality associated with these areas of health care. As a first step to addressing this significant public health problem within the NSQHS Version 2, the standards should refer specifically and jointly to the problem areas of pain, both acute and chronic, and harmful use of opioids. We recommend that this could be done relatively simply in the first instance by adding a criterion to the standard Reducing harm. In the recommendations section below we provide examples that are modifications of existing criteria, one from the Reducing harm standards, the other from the Antimicrobial stewardship section of the Healthcare-associated infection prevention standard, and one which is a combination of elements of from both standards. These examples demonstrate how opioid stewardship and pain management could be incorporated readily into the existing draft of the Standards. While recognising the importance of wider community consultation, including particularly consumers and carers, we would be eager to provide expert input to the ACSQHC to assist in ensuring pain management and opioid stewardship are adequately covered in the NSQHS Standards. This would support health services in improving safety in this important area, which cuts across many clinical specialties, similar to antimicrobial stewardship and other clinical areas addressed in the Reducing harm standard. Recommendations 1. Based on Standard RH: Reducing Harm Care of patients with pain and/ or opioid use disorders Systems are in place for appropriate and effective care of acute pain and chronic pain disorders and for the safe and appropriate prescribing and use of opioids, thereby minimising risk of opioid related harms. Item RHx Pain and harmful use of opioids Action required RHx.1 In relation to pain and/or prescription or provision of opioids, the health service organisation has systems that: a. incorporate best practice strategies for early recognition, prevention and treatment of pain and/or opioid use disorders b. define relevant criteria and guidelines for clinicians to use when treating pain and/or opioid use disorders c. provide ready access to specialist pain, addictions and psychiatric assessment and treatment advice as required d. provide access to supervision and support for clinicians providing care for people with pain and/or opioid use disorders e. review the safety and quality of care of people with pain and opioid use disorders that is provided against the planned goals of care. RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 8 of 11

10 2. Based on Standard IP: Healthcare-associated infection prevention Pain and opioid stewardship Systems are in place for appropriate and effective care of acute pain and chronic pain disorders and for the safe and appropriate prescribing and use of opioids, thereby minimising risk of opioid related harms. Item RHx Pain and harmful use of opioids Action required RHx.1 In relation to pain and/or prescription or provision of opioids, the health service organisation has an opioid stewardship program that: a. includes an opioid stewardship policy that incorporates recommendations and principles from the Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use (2009) of the combined medical colleges (RACP; FPM, ANZCA; RACGP and RANZCP) b. provides access to, and promotes the use of, current, evidencebased Australian therapeutic guidelines and resources on opioid prescribing, including the National Guidelines for Medication- Assisted Treatment of Opioid Dependence c. has an opioid formulary that includes restriction rules and approval processes d. monitors opioid prescribing and use, including use of other psychoactive substances e. evaluates performance of the program, identifies areas for improvement, and takes action to improve the appropriateness of opioid prescribing and use f. uses surveillance data on opioid overdoses to support appropriate prescribing g. reports to clinicians and the highest level of governance in relation to i. compliance with the opioid stewardship policy ii. iii. opioid use and overdoses appropriateness of prescribing and compliance with current evidence- based Australian therapeutic guidelines or resources on opioids. 3. Based on a combination of the RH and IP standards Care of patients with pain and/ or opioid use disorders and opioid stewardship RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 9 of 11

11 Item RHx Pain and harmful use of opioids Action required RHx.1 In relation to pain and/or prescription or provision of opioids, the health service organisation has systems that: a. incorporate best practice strategies for early recognition, prevention and treatment of pain and/or opioid use disorders b. define relevant criteria and guidelines for clinicians to use when treating pain and/or opioid use disorders, including an opioid formulary and approval processes c. provide ready access to specialist pain, addictions and psychiatric assessment and treatment advice as required d. provide access to supervision and support for clinicians providing care for people with pain and/or opioid use disorders e. review the safety and quality of care of people with pain and/or opioid use disorders that is provided against the planned goals of care, including at time of transfer of care f. monitor opioid prescribing and use, including use of other psychoactive substances and surveillance data on opioid overdoses and appropriateness of opioid prescribing. RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 10 of 11

12 References Centres for Disease Control and Prevention (2015) Prescription Drug Overdose: Understanding the Epidemic. Available at: (accessed 14 October 2015). Coffin P, Banta-Green C (2014) The duelling obligations of opioid stewardship. Annals of International Medicine. 160(3): 207. Diener H, Schneider R, Aicher B (2008) Per-capita consumption of analgesics: a nine-country survey over 20 years. Journal of Headache and Pain. 9: Franklin G, Sabel J, Jones C, Mai J, Baumgartner C, Banta-Green C, Neven D, Tauben D (2015) A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. American Journal of Public Health. 105(3): Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N (2014) National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Commonwealth Government, Australia. Harrison C, Charles J, Henderson J, Britt H (2012) Opioid prescribing in Australian general practice. Medical Journal of Australia 196(6): Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W (2014) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry 48(11): Institute for Safe Medication Practices Canada (2014) Opioid Stewardship. Available at: (accessed 8 October 2015). National Drug Strategy (2014) National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Commonwealth Government, Australia. National Drug Strategy (2013) National Pharmaceutical Drug Misuse Framework for Action Commonwealth Government, Australia. National Prescribing Services (2006) Indicators of Quality Prescribing in Australian General Practice. Available at: data/assets/pdf_file/0019/37351/indicators_full.pdf (accessed 14 October 2015). Pilgrim J, Putrianita Yafistham S, Gaya S, Saar E, Drummer O (2015) An update on oxycodone: lessons for death investigators in Australia. Forensic Science and Medical Pathology 11: Royal Australasian College of Physicians (2009) Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention problems associated with prescription opioid use. Sydney, Australia. Available at: (accessed 8 October 2015). Roxburgh A, Hall W, Burns L, Pilgrim J, Saar E, Nielsen S, Degenhardt L (2015) Trends and characteristics of accidental and intentional codeine overdose deaths in Australia. Medical Journal of Australi. 203(7): 299. Sullivan M (2010) Who gets high-dose opioid therapy for chronic non-cancer pain. Journal of the International Association for the Study of Pain. 151(3): United States Department of Veterans Affairs (2014) Opioid Safety Initiative Toolkit. Available at: (accessed 14 October 2014). RANZCP submission to the ACSQHC consultation on the NSQHC Standards Version 2 Page 11 of 11