Treating Emergency Room Opioid Withdrawal with Buprenorphine Monday, February 11th (3:45pm 4:30pm) Room W314B Christine Bucago, Advanced Practice Clinical Leader (Nursing), CAMH Jane Paterson, Director, Interprofessional Practice, CAMH 1
Conflict of Interest Christine Bucago RN, MN, CPMHN(C); Advanced Practice Clinical Leader (Nursing), Acute Care Program AND Jane Paterson, MSW, RSW; Director, Interprofessional Practice Have no real or apparent conflicts of interest to report. 2
Agenda Introduction to CAMH Origins Transformation Data-Driven Organization Achievements Buprenorphine Treatment was used 3
Learning Objectives Review the clinical benefits of prescribing buprenorphine rather than other medications to ease opioid withdrawal symptoms Outline how to design a clinical workflow, which standardizes how care is delivered to patients in opioid withdrawal visiting an emergency department. Describe how to construct the key elements to embed clinical decision support in the form of a buprenorphine order set to ensure that patients in opioid withdrawal receive the most effective care at the right time 4
CAMH Overview 5
Location Toronto CAMH is located in downtown Toronto, Canada 6
CAMH Transforming Lives Largest mental health and addictions hospital in Canada University of Toronto - affiliated teaching hospital World leader in brain science 3 main sites with 30+ locations 90 distinct clinical services: eg. emergency department, inpatient, outpatient, day treatment, forensic, partial hospitalization programs and other specialty services 7
CAMH Clinical Programs Acute Care Complex Care and Recovery (CCR) Child, Youth & Emerging Adult Clinical Services ED (Emergency Department) and Inpatient Services Outreach & Telemedicine Ambulatory Services CCR Inpatient Services CCR Outpatient Services CCR Specialized Services and Research Child, Youth & Emerging Adult Services Clinical Operations Clinical Laboratory and Diagnostic Services Pharmaceutica l Services Medical Services Hospitalist Services Infection Prevention and Control Dental Clinic Podiatry Clinics Dietetic Services Nursing Resource Unit 8
CAMH Origins - 1848 Provincial Lunatic Asylum 9
Merger of Founding Organizations 1999 Donwood Institute Clarke Institute of Psychiatry Addiction Research Foundation Queen Street Mental Health Centre 10
CAMH Key Statistics 2017-2018 Report 11
Roadmap to Data-Driven Care Krembil Centre for Neuroinformatics Performance Improvement / Business intelligence Integrated Care Pathways Enterprise Reporting Clinical Information System Transformation Centralized Intake Process IT Infrastructure Optimization 12
Why the Davies Award? International recognition that CAMH leverages its clinical information system to support excellence in care delivery and identify ongoing improvement opportunities, in support of our overarching strategic vision. 13
Treating Emergency Room Opioid Withdrawal with Buprenorphine 14
Agenda Problem Importance Identification / Importance Problem Identification / Baseline Workflow Baseline Workflow Baseline Data Baseline Data Objectives Solution Selection Solution Selection Interventions Interventions End-User Involvement End-User Involvement Revised Workflow Solution Details Solution Details Effect of Interventions on Data Post- Adherence Data Post- Outcome Data Return on Investment 15
Opioid Crisis in Canada Canada is facing a national opioid crisis Over recent years, there has been an alarming increase in the number overdoses and deaths caused by opioids Number (January to September) and estimated annual rate (per 100,000 population) of apparent opioid-related deaths by province or territory, 16 2017 Source: Health Canada. Apparent opioid-related deaths. Retrieved from: https://www.canada.ca/en/healthcanada/services/substance-abuse/prescription-drug-abuse/opioids/apparent-opioid-related-deaths.html
Problem Identification Problem Identification CAMH provided Clonidine (comfort measure) as a treatment for individuals presenting to the Emergency Department (ED) with opioid withdrawal There is an additional treatment for opioid withdrawal (buprenorphine) CAMH identified new Health Quality Ontario opioid use disorder standards including: Administration of opioid agonist therapy within 3 days of presentation Opioid agonist therapy should be administered within 2 hours Distribution of take-home naloxone kits Why is this Important? As the leading national academic mental health and addictions hospital, CAMH must lead the way with best-practice treatments Buprenorphine has a ceiling effect and slow action onset, meaning minimal overdose risk Patients on a maintenance dose may have a blunted analgesic and euphoric response if they take other opioids concurrently 17
Initial Baseline Workflow Refer to CAMH Medical Withdrawal Service, Addiction Medicine Service, or community non-medical detox Discharge from ED Yes Patient presents to ED with opioid withdrawal Decision to prescribe Clonidine Clonidine order set selected Symptoms relieved? No Continue treatment 18
Percentage of Initiations Baseline Data 2015 Q4 2016 Q3 Clonidine Initiations 20.8% Buprenorphine Initiations 8.5% 50% Percentage of Initiations for Opioid Withdrawal Patients 40% 30% 20% 10% 0% 2015 Q4 2016 Q1 2016 Q2 2016 Q3 Calendar Quarter Suboxone Initiations Clonidine Initiations 19
Objectives Standardize pathway and treatment protocol for buprenorphine Create barrier-free and timely access to continuing care Streamline ordering process to save clinician time and prevent errors Adhere to new Health Quality Ontario standards for opioid withdrawal and opioid use disorder 20
Solution Selection CAMH identified a method to ensure increased use of buprenorphine within the ED. Options reviewed and selected by CAMH Addiction Medicine Service and ED management with staff consultation: -Experience with other order sets showed positive practice change Clinician familiarity Dynamic reporting Communicatio n tools Existing change management Tracking and feedback Standardized practice Existing governance Standardized documentation 21
Interventions Addiction Medicine Service Partnership Education Sessions Order Set And Pathway Partnership between CAMH Addiction Medicine Service and Emergency Department to build capacity for addictions treatments, including buprenorphine (Nov 2016 Mar 2017) Education sessions including benefits, initiation, and administration of buprenorphine for all ED staff (May June 2017) Creation of an interdisciplinary buprenorphine pathway and buprenorphine order set (August 2017 go-live) 22
Strategic Governance High-level Decisions Executive Leadership Team CEO Medical Advisory Committee Physician in Chief Mid-Level Decisions Pharmacy & Therapeutics Dir. Pharmacy Health Information Interdisciplinary Committee Dir. Interprof. Practice Dir. Medical Informatics Clinical Care Committee Dir. Interprofessional Practice Chief Medical Officer Order Sets Sub-Committee Dir. Medical Informatics Pharmacist Physician / Hospitalist User Groups Dir. Medical Informatics Lead Hospitalist Practice Adoption & Optimization Council Manager, Clinical Education Advanced Practice Clinical Lead Collaborative Practice Advisory Committee Chief of Nursing Data and Reporting Governance Committee (ELT Sub-Committee) Exec. Dir. Performance Improvement Med. Dir. Performance Improvement Clinical Applications Change Advisory Board Sr. Manager, Clinical Applications Integrated Health Record Council Dir. Clinical Information Systems APPROVED ** Advisory / Working Groups established as required 23
End-User Involvement Integrated Health Record Committee Chairs: Dir. Interprofessional Practice, Dir. Medical Informatics Includes clinicians and other stakeholders Initial approval of need Pharmacy & Therapeutics Co-chairs: Appointed Physician and Dir. Pharmacy Owners and approvers of Order Set Includes a minimum of 6 physicians, 4 pharmacists Order Sets Sub-Committee Chairs: Dir. Medical Informatics, Pharmacist Assembled subject matter clinical experts for review of order sets Medical Advisory Committee Chair: Physician in Chief High-level review and recommendations regarding the practice of medicine at CAMH 24
Revised Workflow Patient presents to ED with opioid withdrawal Re-assess in 2 hours Administer additional dose No No Does patient agree to buprenorphine treatment? Yes Buprenorphine induction order set selected* Clinical Opiate Withdrawal Scale completed * Result >12? * Yes Administer buprenorphine* Reassess in 2 hours * Symptoms relieved? No Yes Proceed with Clonidine or alternative treatment Discharge from ED Refer to CAMH Addiction Medicine Service, prescribe total daily dose, provide Naloxone kit and information * Total daily dose established Health IT used within intervention*
Suboxone Order Set Clinical Opiate Withdrawal Scale Administration guidelines Buprenorphine Order Set Standardized Lab orders Vital signs Clinical Opiate Withdrawal Scale Rapid Access Referral Distribution of Naloxone kits Patient education materials Rapid Access Referral Free Naloxone kit flyer Dosage options 26
Clinical Opiate Withdrawal Scale (COWS) COWS Used in ED for patients presenting with opiate withdrawal symptoms Recommended for use during buprenorphine induction <2 minutes for completion Automated scoring Key 27
Rapid Access Referral Rapid access autopopulates 28
Outcomes Intervention Effect of Interventions on Data AMS Partnership Education Sessions Order Set and Pathway Partnership between CAMH Addiction Medicine Service and Emergency Department to build capacity for addictions treatments, including buprenorphine (Nov 2016 Mar 2017) Education sessions including benefits, initiation, and administration of buprenorphine for all ED staff (May June 2017) Creation of an interdisciplinary buprenorphine pathway and buprenorphine order set (August 2017 go-live) Created clinical awareness Generated familiarity and comfort with prescribing opioid agonist therapy Created practice guidelines to educate staff about buprenorphine and its use within opioid withdrawal and maintenance therapy Created clinical awareness and enforced regulations to standardize practice for buprenorphine patients Provided rapid access referral option to support evidencebased practice 29
Percentage of Initiations Post- Adherence Data 2015 Q4 2016 Q3 2017 Q3 2018 Q2 Clonidine Initiations 20.8% 8.5% Buprenorphine Initiations 8.5% 28.4% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Percentage of Initiations for Opioid Withdrawal Patients AMS Partnership Education Order Set Pre-implementation Post-implementation 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2 Calendar Quarter Suboxone Initiations Clonidine Initiations
Repeat Visits Post- Outcome Data 2015 Q4 2016 Q3 2017 Q3 2018 Q2 Repeat ED Visits within 7 days 5.31% 3.96% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 5.1% 5.0% Repeat ED Visits for Opioid Withdrawal Patients Pre-implementation 3.1% 7.9% AMS Partnership 5.5% 12.9% 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2 Calendar Quarter Education 3.0% Order Set 6.8% Post-implementation 3.0% 0.0% 4.8% Repeat ED Visits Within 7 Days
Average Wait Time (Days) Post- Outcome Data 10 9 8 7 6 5 4 3 2 1 0 Average wait time between ED and CAMH AMS rapid access service for Opioid Withdrawal patients 9.3 4.8 2015 Q4 2016 Q3 2017 Q3 2018 Q2 32
Return on Investment 700000 600000 500000 400000 300000 200000 100000 0 Cost of Treating Patients Presenting in ED with an Opioid Diagnosis who were Admitted to Inpatient Pre Order Set & Rapid Access Referral (August 1, 2016 - July 31, 2017) Savings = $137,462 $628,028 $490,566 Post Order Set & Rapid Access Referral (August 1, 2017 - July 31, 2018) Twenty-four fewer patients with opioid withdrawal diagnoses were admitted to inpatient after improvements in care due to buprenorphine initiations. (Cost of ED visit * # ED visits) + (# admitted to IP * LOS * IP day cost) 33
Return on Investment Able to treat opioid withdrawal onsite in a safe and effective manner Adhere to Health Quality Ontario guidelines for opioid agonist therapy Reduce repeat ED visit rates for opioid withdrawal patients presenting to ED 34
Lessons Learned Streamlining the ordering process has been beneficial to clinicians while emergency volumes increase Ongoing efforts are required to ensure residents and clinicians are confident initiating treatments Buprenorphine is the most supported treatment through research, but other medications are appropriate for some patients 35
Questions Christine Bucago, Advanced Practice Clinical Leader (Nursing) christine.bucago@camh.ca Jane Paterson, Director, Interprofessional Practice, CAMH jane.paterson@camh.ca Please ensure to complete the online survey for this session: 36