Running Head: PICOT-D ASSIGNMENT 1 NURS 610: PICOT-D Assignment Peggie L. Powell VCU School of Nursing DNP Program
PICOT-D ASSIGNMENT 2 PICOT-D Component Component Wording (P)atient population Among providers who prescribe chronic opioid therapy, (I)ntervention does use of the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) assessment tool, (C)omparison intervention / Current State compared to not using a risk-screening tool, Evidence-base Search Terms prescribing, opioids, chronic opioid therapy RIOSORD, tool, overdose, opioid-induced respiratory depression (O)utcome / Desired State increase the prescribing practice of naloxone naloxone, prescribing practice (T)imeframe over a six-month period (D)ata when looking at the frequency of naloxone prescribing prior to and after utilization of the RIOSORD tool? PICOT-D Question Among providers who prescribe chronic opioid therapy (P), does use of the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) assessment tool (I), compared to not using a risk-screening tool (C), increase the prescribing practice of naloxone (O) over a six-month period (T) when looking at the frequency of naloxone prescribing prior to and after utilization of the RIOSORD tool (D)? Organizational/System Data Measures PICOT-D Component Data Measures Type of Source Location of Data Data Steward Extract Format (P) 1. Providers who prescribe opioids for 90 days or longer in patients with chronic pain (pain lasting 3 months or beyond the expected duration of healing): Electronic EMR VCU owner); will need to have a Student Affiliate Agreement on file and permission Extract data manually and enter data into a Microsoft Excel file Data obtained from: Daily schedule for each provider (plain Demographic data from EMR (plain text file)
PICOT-D ASSIGNMENT 3 Date of visit Visit providers name Patient Chart ID# Date of Birth Gender Race Date of Onset of chronic pain Length of time on opioid therapy Name of prescribed opioid(s) Opioid dose(s) from the IT department to access EMR data this applies to all below Date of onset of chronic pain and length of time on opioid therapy: new patient forms filled out by patient and scanned into EMR (paper document) Medication list (plain (I) 1. Provider use of the RIOSORD tool to assess risk for overdose or opioidinduced respiratory depression in patients with chronic pain on opioid therapy for 90 days or longer: Date of visit/ RIOSORD assessment Visit providers name Patient Chart ID# Gender Race Onset of chronic pain Length of time on opioid therapy RIOSORD score Risk Class Average Probability of OSORD Responses to questions on tool (yes/no) Morphineequivalent dose in Electronic Electronic version of RIOSORD (if available for use when I initiate project; otherwise I will use the paper version) Visit provider and VCU owner) Extract data manually and enter data into a Microsoft Excel file Data extraction will occur 6 months after project start date Data obtained from: Demographic data from EMR (plain text file) Date of onset of chronic pain and length of time on opioid therapy: new patient forms filled out by patient and scanned into EMR (paper document) RIOSORD components: Microsoft Excel file if using electronic version of RIOSORD Paper document if paper tool is used, then manually transfer data to a Microsoft Excel file
PICOT-D ASSIGNMENT 4 mg/day (C) 1. Provider not using an overdose or opioid-induced respiratory depression riskscreening tool in patients with chronic pain on opioid therapy for 90 days or longer: Date of data extract Number of eligible patients Number of times prescribed Contributing factors that influenced naloxone prescribing (O) 1. Number of times prescribed prior to use of the RIOSORD tool for 6 months Number of eligible patients for 6 months Number of times prescribed in the prior 6 months 2. Number of times prescribed after use Electronic EMR VCU owner) Electronic EMR VCU owner) Retrospective chart reviews to extract data manually and enter data into a Microsoft Excel file Extract data for the 6 months prior to project start date to serve as comparison data Obtain data from: Daily schedule for each provider (plain Medication list to determine if patient was eligible (prescribed opioids) and if prescribed (plain text file) Review of office notes (HPI/plan) to infer contributing factors (free text fields); performed by one reviewer to maintain consistency in data collection, may require input from visit provider Obtain data for 6 months prior to project start date and 6 months after project start date and enter into a Microsoft Excel file. Obtain data from: Daily schedule for each provider (plain Medication list to determine if patient was eligible (prescribed opioids; plain Special Report from Greenway (PMS) designed to track naloxone prescribing
PICOT-D ASSIGNMENT 5 of the RIOSORD tool for 6 months Number of eligible patients Number of times prescribed for 6 months after use of the RIOSORD tool. (plain (T) 1. After six-months of using the RIOSORD tool: Date of visit Visit providers name Patient Chart ID# Was naloxone prescribed (yes/no) Electronic EMR VCU owner) Extract data manually and enter data into a Microsoft Excel file Data obtained from: Daily schedule for each provider (plain Medication list (plain, or Special Report from Greenway (PMS) designed to track naloxone prescribing (plain Narrative Summary: Opioid Risk Assessment in Patients on Chronic Opioid Therapy Chronic pain and the treatment of chronic pain are public health challenges faced by healthcare providers across the nation. Over 100 million people suffer from chronic pain in the United States, and for some, chronic opioid therapy (COT) may be appropriate (Volkow, 2014). The prescribing of opioid pain relievers has quadrupled since 1999 and has increased in parallel with overdoses involving commonly used prescription pain relievers (Dowell, Haegerich, & Chou, 2016). Zedler et al. (2015) note that 80% of opioid-related deaths are due to unintentional overdose. The addictive nature of opioids makes them vulnerable to misuse and abuse. Persons who take opioids for their
PICOT-D ASSIGNMENT 6 intended purpose can risk significant adverse events if they do not take them as prescribed (e.g., taking more than prescribed and taking them in combination with other psychotropic medications and/or alcohol). Opioids can depress the central nervous system and result in serious, life-threatening consequences such as respiratory depression, sedation, coma, and potentially death. Considering such potentially fatal consequences, there is much concern in regards to the safety of opioid prescribing. In 2014, opioid overdose death from prescription opioids increased to approximately 19,000 deaths in the United States; this is more than three times the number reported in 2001 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Such statistics are staggering and indicate a need for action to help curb this epidemic. These findings also demonstrate the importance of utilizing strategies in clinical practice to reduce or prevent overdose deaths from prescription opioids. The Centers for Disease Control and Prevention and SAMHSA recommend that clinicians consider a co-prescription for naloxone when prescribing opioids for patients at high risk of overdose as a risk mitigation strategy. Naloxone is an opioid antagonist that can reverse respiratory depression and save lives when administered to a person suspected of an opioid overdose whether intentional or unintentional. The recommendation to prescribe naloxone for patients at increased risk of opioid overdose raises the clinical questions of how to determine which patients are at increased
PICOT-D ASSIGNMENT 7 risk and how to measure risk of accidental overdose in patients on COT. The only published tool with this ability is the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD; Zedler et al., 2015). The RIOSORD tool provides a real-time quantitative risk assessment for opioid overdose or opioid-induced respiratory depression that is evidence-based and intended to provide clinical decision support (Zedler et al., 2015). Clinicians can utilize results obtained from the RIOSORD to determine predicted probability of overdose and serve as a guide for co-prescribing naloxone in patients on COT. The RIOSORD is useful as a baseline risk evaluation as well as continued risk monitoring at future appointments. Use of the RIOSORD tool also provides an excellent opportunity for patient education regarding their individual risk assessment. Patients identified as high risk for overdose are likely to benefit from lifesaving interventions such as the co-prescribing of naloxone. Implementation of risk mitigation strategies such as the RIOSORD tool demonstrates safety in opioid prescribing and provides for improved patient outcomes. References Dowell, D., Haegerich, T. M., & Chou, R. (2016, March 18). CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recommendations and Reports; 65(1): 1-49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1 Substance Abuse and Mental Health Services Administration. (2016).
PICOT-D ASSIGNMENT 8 SAMHSA opioid overdose prevention toolkit (HHS Publication No. SMA 16-4742). Retrieved from http://store.samhsa.gov/product/opioid-overdose-prevention-toolkit- Updated-2016/SMA16-4742 Volkow, N. D. (2014, May 14). America's addiction to opioids: Heroin and prescription drug abuse. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimonyto-congress/2016/americas-addiction-to-opioids-heroin-prescriptiondrug-abuse Zedler, B., Xie, L., Wang, L., Joyce, A., Vick, C., Brigham, J., Murrelle, L. (2015). Development of a risk index for serious prescription opioidinduced respiratory depression or overdose in veterans' health administration patients. Pain Medicine, 16(8), 1566-1579. doi:10.1111/pme.12777