Improving Pain Control and Reducing Opioid Related Adverse Events

Improving Pain Control and Reducing Opioid Related Adverse Events

Improving Pain Control and Reducing Opioid Related Adverse Events Adam Novak Manager, Patient Safety & Quality Michigan Health & Hospital Association Keystone Center February 7, 2017

Objectives Describe the MHA Keystone Center Pain Management activities and tools involved in reducing opioid-related adverse events Discuss the impact of MHA Keystone Center Pain Management Activities MHA Keystone Center: Our Mission Vision

Healthcare that is safe, effective, efficient, patient-centric, timely and equitable. Mission To lead the nation in quality and patient safety through the diffusion of change using patient-centered, evidence-based interventions supported by cultural improvement. Values

Excellence Innovation Compassion Teamwork Opioid Crisis - Background Opioid Crisis Additional Statistics 69% of people who misuse pain medication got them from a friend or relative

80% of heroin users began by misusing pain medication ordered by their doctors Drug overdose is the leading cause of accidental death in the United States o More than car accidents

Opioid Crisis In Our Backyard MHA Keystones Timeline for Opioid Adverse Drug Events and Pain Management 2013-2014 2015 Sept. 2016

Sept. 2016 Sept. 2019 MHA Keystone Surgery IV Opioids Only Surgical Population (Inpatient & Outpatient) Exclusion: OB 29 hospitals submitting data

MHA Keystone Pain Management IV Opioids Only Inpatients, surgical outpatients Exclusion: OB and ED 215 hospitals submitting data Targeted Improvement Opioids (All Routes)

Inpatients, surgical outpatients Exclusion: OB and ED 300+ hospitals submitting data Methods/Timeline of Activities HEN 1.0 and HEN 2.0 CMS PfP Hospital Engagement Network (HEN)

Advisory Committee Opioids called out as high-risk medication needing to be addressed Coupled with MHA Keystone: Surgery efforts around Enhanced Recovery After Surgery (ERAS) Obtained a physician champion for MHA Keystone Convened an advisory committee comprised of an anesthesiologist, director of surgical services,

independent nurse consultant, Michigan Surgical Quality Collaborative (MSQC) abstractor, pain nurse resource specialist, pharmacist, surgeon, and surgical nurses Conducted gap analysis Gap Analysis Roll Out Project launch meeting was held

Educational materials were distributed including the Michigan Opioid Safety Score (MOSS) tool, sample order sets, data dictionaries, and schedule of monthly content webinars and coaching calls Expanded from surgical to inpatient and surgical inpatient and outpatient under HEN 2.0 Procedure Intervention 1: CUSP The Comprehensive Unit-based Safety Project (CUSP) follows a six step iterative program to improve patient safety and the culture that drives safety attitudes and practices.

Intervention 2: Educational program including in-person and multi-media sessions Monthly content webinars, monthly coaching calls (in collaboration with the Armstrong Institute for Patient Safety & Quality, Johns Hopkins University), and an annual conference (in person meeting) with national speakers. Intervention 3: Implementation of a perioperative pain management toolkit Gap Analysis tool, Michigan Opioid Safety Score (MOSS tool), patient and family education templates, pre-op checklist modification recommendations, and a multimodal analgesia tool (with specific recommendations for order sets).

Opioid Adverse Drug Event Prevention Gap Analysis Pain Management Gap Analysis Results 2014 There is a process in place to discuss and agree upon specific pain goals and strategies with the patient prior to a surgical procedure. Collecting a history of snoring, obesity and sleep apnea Defining and identifying if patient is opioid tolerant vs. opioid nave

Reversal protocols are active on all patients' MARS if there is an active order for a narcotic Established dose equivalency conversion tools are readily availale and utilized No Yes 0 5 10

15 20 25 Michigan Opioid Safety Score (MOSS) Goals

Incorporate patient/procedural risk factors Incorporate respiratory rate Incorporate sedation Reinforce need for multimodal analgesia Improve nursing documentation of patient assessment

Soto, Roy; Yaldou, Brandon. The Michigan Opioid Safety Score (MOSS): A Patient Safety and Nurse Empowerment Tool. Journal of Perianesthesia Nursing 2015, June, 30(3) 196-200. MOSS Continued MOSS Continued

Results 2014 (Surgical) Percent of patients who received naloxone during surgical related care 0.50% Percent of surgical patients receiving MOSS assessments 60% 0.45% 0.40%

0.35% 50% 40% 0.30% 0.25%

30% 0.20% 0.15% 0.10% 20% 10%

0.05% 0.00% n = 24 0% MHA Keystone: Pain Management Collaborative

Launched in 2015 Improve appropriate pain management practices Reduce opioid-related adverse events

Decrease the usage of opiates statewide Enhance patient expectation management Focused Interventions 1. All patients will be screened to determine if they are opioid nave or opioid tolerant prior to receiving any opioids. 2. All patients needing pain control will have multimodal analgesia. Providers will follow the World Health Organization (WHO) analgesic pain ladder when prescribing. 3. All patients receiving opioids will be formally assessed via the Michigan Opioid Safety Score (MOSS)

or Pasero Opioid-induced Sedation Scale (POSS) on a regular basis to prevent unintended sedation and respiratory depression. 4. Patients receiving opioids will not receive more than one concomitant sedative. 5. All patients receiving pain medications will be counseled on the medication they are receiving, any potential side effects and expectations of realistic pain management. 6. Policies and procedures will be established for patients who are no longer responding to treatment, directing that those patients receive increased monitoring, level of care, and appropriate pain consultation. 7. Patients requiring a PCA will be monitored via pulse oximetry and/or capnography.

Pain Management Toolkit Comparing 2014 to 2015 Gap Analyses Expectation Management Results 2015-2016 Inpatient and Surgical Patients

26 Additional Programs/Tools MHA Keystone Speak-up! Award The MHA Keystone Center Speak-up! Award is designed to acknowledge the efforts of individuals or teams within Michigan hospitals who speak-up to prevent potential harm to patients or other staff members.

182 nominees 19 hospitals 55% of nominees who spoke up to prevent harm, prevented or mitigated an ADE 29 10 Things Every Patient in Pain Should Know

10 day social media campaign 1 hour Twitter chat 1.5 million impressions Medication Disposal Endorsing and Supporting Organizations

The Future of Keystone and Opioids 2013-2014 2013-2014 2015 Sept. 2016 MHA Keystone Surgery

MHA Keystone Pain Management MHA Keystone Surgery IV Opioids Only IV Opioids Only IV Opioids Only Surgical Population (Inpatient & Surgical Population Outpatient) Inpatients, surgical outpatients (Inpatient & Exclusion: OB

Outpatient) Exclusion: OB and ED 29 hospitals submitting data Exclusion: OB 215 hospitals submitting data

29 hospitals submitting data Sept. 2016 Sept. 2019 Targeted Improvement Opioids (All Routes) Inpatients, surgical outpatients Exclusion: OB and ED 300+ hospitals submitting data

Leading Healthcare Safe Care is what drives us. Collaboration is how we get there. Thank you! Adam Novak, MA | Manager, Patient Safety & Quality MHA Keystone Center

2112 University Park Drive | Okemos, MI 48864 (517) 886-8257 | (517) 323-0946 Fax [email protected]|

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