Christopher T. Ducko, M.D., FACS

Brigham and Women’s HospitalSouth Shore Hospital

Mass Chapter ACS Meeting, September 21, 2016

Take narcotics off the street.

Why?Substance abuse is on the rise in our neighborhoods

South Shore Hospital ED Chief Complaint: Overdose CY 2013 - YTD 2015 (January - September)

Post-Procedure Narcotic PrescribingWhat is our Goal?

SSO Pain Management CommitteeCo-Chairs:

» Michael Ayers, MD

» Leslie Stenbeck (former)

» Stacey English (current)

Members:

• Michael Marchetti, MD

• Bernard Hendrickson, PA

• Angelica Duczakowski, PA

• Gerda Sullivan, RN

• Ellen Howard, RN

• Laurie Falvey

• Debra Sullo

• Quay Baker, RN

• Lorraine Campbell, RN

• Kim–Phung Lai, RPH

• James Green

• Richard Bello, MD

• Ann Marie Materna, RN

• Lynne O'Connell

• Maura Gallery

» South Shore Orthopedics Pain Management Committee was formed in early Spring of 2014

» Goals included:

• Standardization: Reduce variability in opioid prescribing for post-op pain among surgeons at 2 Pond Park

• Education: Improve patient & family education on appropriate use and disposal of opioids.

• Limit # of pills on the street: Tackle the growing opioid drug problem on the South Shore.

GuidelinesStandardization: Education: All surgeons to give prescriptions

day of surgery.

Prescribe primarily OXYCODONE/TYLENOL/ANTI-INFLAMMATORY

DILAUDID when allergic to OXYCODONE

AVOID combination drugs such as PERCOCET

DECREASE quantity of pills (quantity dependent upon

surgical procedure)

Pain medication education starts in physician office during preoperative visit

Nurse in PACU will educate the patient and family on the pain medications prescribed by physician. (i.e. drug, schedule, side effects etc.)

Committee developed a discharge teaching sheet for OPIOIDS

Discharge sheet given to all patients upon discharge

All patients receive a Post-Op call to reiterate pain medication education

SSO Early Results

Measure Target

March,

2014

(Baseline)

October,

2014

%

change

from

baseline

Number of physicians who

prescribe pain med pre-op

Source: Internal survey at 2

PP

0 45% 18% 60%

Number of physicians

prescribing pain med day of

surgery (DOS)

Source: Manual count

100% 54% 82% 52%

Standardize on the

combination of pain meds

prescribed DOS to be

Tylenol and/or Motrin and

Oxycodone (Eliminate

Vicodin, Percocet)

Source: Manual count/audit

100%

compliance

with

standard

0%

no

standard

95%

compliance 95%

Standardize on the number

of pain meds prescribed DOS

(Excludes complex cases)

Source: Manual count/audit

100%

compliance

with

standard

17% 92% 441%

Patient Pain Management

Satisfaction rank score

Source: Press Ganey, Day

Surgery Pond Park, Ambulatory

NA 98% 96% -2%

Positive early resultsbut not all targets were met

Combo Pills by ProcedureComparison of 2014 and 2015 Surveys and Chart Audits

October 2014 October 2015

# MDs Prescribing Combo Pills by Procedure

0123456789

Vicodin

Percocet

Tylenol#30123456789

Vicodin

Percocet

Tylenol#3

Average # Pills Rx’d by ProviderComparison of 2014 and 2015 Surveys and Chart Audits

October 2014 October 2015

0

2

4

6

8

10

10 12 15 20 25 30 40 >40

MDs Grouped by Av. # of Pills Prescribed

Av # of Pills

# of MDs that Rx each pill amt

0

2

4

6

8

10

10 12 15 20 25 30 40 >40

Other Data Additional survey data from October 2015:

HPSO Is Spreading SSO InitiativeTracking Summary SS Urology Gen Surgery Podiatry Thoracic Ortho Breast Surgery

Owner L. O'Connell,

MD E. Kwasnik,

MD

C. Locke, MD & S. Sheehan,

RN C. Ducko,

MD

M. Ayers, MD & S.

English, RN

L. Leveille, NP & S. Nimbkar,

MD

Identify procedures 11/2015 2/2016 2/2016 1/2016 10/2015 1/2016

Collect current prescribing data (via survey, chart review or database)

11/2015 1/2016 via SSO survey

11/2015 2/2016 11/2015 1/2016

Present current state Rx data to practice/dept

11/2015 2/2016 12/2015 2/2016 12/2015 1/2016

Develop prescribing standards for each procedure

12/2015 2/2016 5/2016 2/2016 1/2016 1/2016

Develop patient materials (pt contract & education)

12/2015 2/2016 12/2015 2/2016 11/2015 1/2016

Educate MDs and APCs on standards 12/2015 2/2016 1/2016 2/2016 11/2015 1/2016

Educate RNs on Rx standards & pt education

12/2015 2/2016 2/2016 2/2016 11/2015 1/2016

Implement Rx standards 1/2016 3/2016

3/2016 1/2016 2/2016

Track adherence (via survey, chart review or Qlik database)

4/2016 5/2016

5/2016 11/2015; 1/2016

2/2016

Collect/analyze data 4/2016 5/2016

5/2016 11/2015 2/2016, ongoing

Assess if targets achieved or not 4/2016:

20% Drop 5/2016;

40% Drop 11/2015;

5/2016:

56% Drop

Track av. # of pills taken by pts (compared to # dispensed) & readjust standard as necessary

Dispensed: 10; taken: 5

3/2016

4/2016 4/2016 1/2016

Results

Prescribed pill numbers have decreased by 20 – 54% across urology, general surgery, thoracic surgery, breast surgery, & orthopedic surgery.

Data from Breast, General, & Orthopedic surgery showed that most patients are taking less pills than the number prescribed (even under the new standards).

Next step: Check and adjust Rx standards accordingly.

HPSO Additions to Original Guidelines

Other guideline considerations:

Routinely utilize the Mass Prescription Awareness Tool (MassPAT)

Prescriber or delegate can check the MassPAT

Previously known as Prescription Monitoring Program (PMP)

Require a Patient Agreement/Contract for Narcotic Use

Develop a Practice Policy and/or Prescriber’s Pledge

MassPAT: Enroll, Use and Delegate

Reducing Variation in Post-Procedure Narcotic Prescribing

Faculty(17)

PAs(11)

Fellows(9)

CumulativeAverage

Range

CervicalMediastinoscopy

8 22 21 170-60

5

ThoracoscopicWedge Resection

41 89 44 580-100

50

VATSLobectomy

53 97 60 70 10 – 120 60

Thoracotomy 65 113 89 89 24-120 80

Lap Nissen Fundoplication

or Hernia35 71 29 45 0-100 30

Chapter Members’ SurveyWhat is your age?

What is your specialty?

o General Surgeryo Bariatric Surgeryo ENTo Hepatobiliary

o Endocrineo Plastic Surgeryo Pediatric Surgeryo Podiatry

o Oral Surgeryo Cardiac Surgeryo Thoracic Surgeryo Orthopedic Surgery

o Urologyo Colorectal Surgeryo Neurosurgeryo Vascular Surgery

When do you prescribe narcotics?

o Before the procedureo Day of surgery

Do you prescribe a combo medication (e.g. Percocet) or straight narcotic (e.g. oxycodone)?

o Comboo Straight Narcotic

Do you write in okay for partial fill?

o Yeso No

Do you provide patients with education regarding narcotic DropBox?o Yeso No o Unaware

o <40o 40 – 60o > 60

Chapter Members’ Survey

Surgeon Questionnaire

Procedure # of Tablets

Appendectomy

Lap Cholecystectomy

Inguinal hernia repair

Umbilical/ventral hernia repair

Lumpectomy/Breast Biopsy

Mastectomy

Port Insertion

Procedure Surgeon

A

Surgeon

B

Surgeon

C

Average

# of pills

New Standard

Target # of

Pills

Appendectomy

Lap Cholecystectomy

Inguinal hernia repair

Umbilical/ventral hernia

repair

Lumpectomy/Breast Biopsy

Mastectomy

Port Insertion

Please circulate this surgeon questionnaire to your group and see what the consensus numbers turn out to be as a baseline for working toward standardization and reduction in post-procedure narcotic prescribing.

Surgeon QuestionnaireHow many pills do you prescribe for the following case types?

Cumulative Numbers for Group

Patient Post Surgical Narcotics Survey

Procedure Baseline Average # of Pills

Prior to Patient Survey

Post-modification # of

pills

After Patient Survey

Appendectomy

Lap Cholecystectomy

Inguinal hernia repair

Umbilical/ventral hernia

repair

Lumpectomy/Breast

Biopsy

Mastectomy

Port Insertion

How many pills were you prescribed after your procedure?Did you fill the prescription?How many tablets did you take?Are you in need of a refill?Are you aware of community drop box for unused narcotic pills?

Based on the patient questionnaire upon initial postoperative visit, can you further reduce your narcotic prescribing?

Pre and Post Numbers for Group