saving & changing lives: ochsner’s opioid stewardship program · apr may jun jul aug sep oct...
TRANSCRIPT
7/6/2018
1
Saving & Changing Lives:
Ochsner’s Opioid
Stewardship Program
What Sparked our Interest
– How common opioid dependency was becoming
– How worrisome the morbidity and mortality in becoming in
patient populations
– How disruptive Opiod patients were in the hospital (contributing
to burn-out of providers and nurses, as well as therapeutic
uncertainty)
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2
Starting Out
• As we began our work, our approach was
– 1. Preventing Opioid Dependency
– 2. Treating It
• It became clear we needed a small army
– As we began to recruit participants, we found a plethora of
professionals who were extremely engaged with the issues
themselves, and our ability to make a difference
Building the Right Team • Identified Executive Sponsor: Chief Quality Officer
• Allocated Resources: Project Management Support
• Initial Goal to Change Provider Behavior
– Enlisted Provider Participants: Representatives from Each Campus
Who Expressed Interest
• Supplemented Team with Pharmacy, Nursing, Legal, Compliance
and Security
• Initially Identified 3 Components for Project Strategy:
– Education for MDs and Patients
– Data Transparency, Practice Improvement, Patient Resources
– Subsequent Work Groups Developed
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3
Team Lead
Hospital Opioid Stewardship
Strategic Program Manager
Clinic Opioid Stewardship
Opioid Stewardship
Opioid
Management
ED Opioid Stewardship Dependency Treatment
and Recovery
Pain Treatment
Opioid Stewardship Org Structure
Support Diversions
Our First Big Win: ED Data Transparency
• Provided Blinded, and Eventually Un-Blinded, Data to Each
ED Leadership Team:
– Prescription Volumes and Rates by Provider and Unit
– The Average Prescription Morphine Equivalent (MEQ) of Each
Provider- Converted More Than 200 Opioids to Normalize the Potency
Across Different Drugs
– Information on What Drugs Each Provider and Unit Were Prescribing
• Also: – Established Guidelines and defaulted quantities in Epic prescribing function
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Initial Resistance: HCAHPS Physicians Who Prescribe Less Have
Same Patient Experience
70
75
80
85
90
95
100
0% 5% 10% 15% 20% 25% 30% 35% 40%
Pat
ien
t Ex
per
ien
ce M
ean
Sco
re
Opioid Prescribing Rate
Opioid Prescribing Rate vs. Press Ganey Mean Score by Physician
To Ease Fears, Removed Patient Satisfaction for Pain Despite
Lack of Correlation
Setting Expectations for Our Patients
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5
2,500
3,000
3,500
4,000
4,500
5,000
5,500
6,000
90.00
100.00
110.00
120.00
130.00
140.00
150.00
160.00
170.00
180.00
190.00
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2017
To
tal R
x
Rx
/Da
y
Opioid Prescribing in the ED
Rx/Day Total Rx
ED Opioid Prescriptions
Blinded
Data
Began
Un-blinded
Data
75.00
80.00
85.00
90.00
95.00
100.00
105.00
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2016 2017 Guideline % Average of MEQ/RX
ED Compliance To Guidelines
Blinded
Data
Began
Un-blinded
Data
Formally
Published
Guidelines
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50.3%
52.4%
48.4% 49.8%
51.0%
55.1% 55.7%
61.6% 61.9%
65.8% 65.8% 67.1%
170.00
175.00
180.00
185.00
190.00
195.00
200.00
205.00
210.00
40%
45%
50%
55%
60%
65%
70%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2017
OB Compliance with Guidelines
Guideline % Average of MEQ
Expanding to Other Specialties
• OB
– Quantity Standardization (14 Tablets)
– % of Patients Receiving Opioids
(Vaginal vs. C-section Delivery)
• Rheumatology
– Quantity Standardization
– New Patients Receiving Opioids
– Opioid Risk Tool
• Transplant Un-blinded
Data
Epic
Default
Quantities
Using our EHR to Help
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Opioid Risk Tool (ORT)
• Assesses patient’s risk of
abusing opioids
• Series of yes/no questions
• Answers can be pulled in
from other areas of chart
(PMH, problem list, etc.)
• Access tool – Opioid Management activity
– Banners
© 2018 Epic Systems Corporation. Used with permission.
Opioid Health Maintenance Plan
• Four Opioid Health Maintenance Plans based on patient’s risk level • Unknown or Low Risk
• Pain contract
• Opioid Risk Tool (ORT) • Moderate
• Above plus
• Urine drug screen every year • High
• Above plus
• UDS every 6 months
• Prescribe naloxone
© 2018 Epic Systems Corporation. Used with permission.
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Morphine Equivalent Daily Dose (MEDD)
• MEDD calculated for opioid outpatient prescriptions
• Normalizes various opioid potencies and doses
• Appears in workflows where providers prescribe
medications
© 2018 Epic Systems Corporation. Used with permission.
Louisiana Prescription Monitoring Program (PMP)
one
click
© 2018 Epic Systems Corporation. Used with permission.
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Opioid Management Activity - Links
© 2018 Epic Systems Corporation. Used with permission.
Opioid Management Activity
© 2018 Epic Systems Corporation. Used with permission.
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Pain Contract
• Provider prescribing opioids should initiate with chronic
opioid users
• Patient and provider sign contract
• Contract includes various requirements for the patient – Main requirement – Can only have opioids prescribed by contract provider
• Banner to alert other providers patient is on pain contract
© 2018 Epic Systems Corporation. Used with permission.
Preventing Patient Overdoses
Identify High-Risk Patients
• Epic Alert to Help Identify Patients
at High Risk for Overdose: – Patient Takes an MEQ >90/day or
– Patient is Currently Prescribed Both an
Opioid and a Benzodiazepine or
– Patient has a Diagnosis of Substance
Abuse or Opioid Dependence.
• If MD Enters Opioid Rx and Patient
Meets Criteria, Epic Alerts Provider
to Consider Writing Naloxone
Order
Increase Naloxone Availability
• Established Naloxone Standing
Orders in All Ochsner Pharmacies – At the Time, Only 4 LA Pharmacies Had
Naloxone Standing Orders
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Doing Our Part:
Drug Diversion Response Team
• Use Data Analytics to Audit Internal
Controlled Substance Utilization
• Investigate Any Reports of Drug
Diversion or Loss of Controlled
Substances
• Monthly Interdepartmental Meeting
– Representation from Pharmacy,
Nursing, Compliance, Legal, and Pain
Management
• In Pilot Phase- Plan to Expand to All
Ochsner Sites in 2018
Innovative Approaches to Pain Treatment • Healthy Back Program
– 10 Week Program- Two Times Per
Week
– Patients Reported a 62.5%
Decrease in Pain After 10 Weeks of
Treatment
• Medicaid Grants to Provide
Services Not Usually Covered:
PT
Paravertebral Facet Joint Blocks
• Virtual Reality to Reduce Initial
Exposure to Opioids
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Functional Restoration Program
• Outpatient, Multidisciplinary, Three-Week
Program Includes:
– Pain Medicine, Pain Psychiatry Specialists,
Physical & Occupational Therapists, Social
Workers & Nutrition Coaches
• Focus on Reclaiming Function & Patient-
Centered Goals
• Program Currently Completing 6th Cohort,
30-days After Program, Patients Report: – 51% Decrease in Disability Due to Pain
– 32% Improvement in Sleep
– 63% Improvement in Mood
Opioid Free Cases
• Opiate Free Protocol
– Cases > 2 Hours
– Pre-operative IV
Acetaminophen and IV
Ibuprofen
• Started with Colorectal &
Urology Procedures
• Other Procedures to Limit
Opioid Use: Knee & Hip
Replacements
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Engaging With Our Community
Supply Naloxone to Police
Departments
Education to Middle School
& High School Students Drug Take-Back Bins
Future Partnership with LSU Vet School
Worked to Successfully Pass
Louisiana Legislation Act #82
(House Bill 192)
Act #88
(House Bill 490)
Act #76
(Senate Bill 55)
• Requires Accessing a
Patient’s PMP Every 90
Days for Patients on
Opioids >90 days.
• Auto Enroll Prescribers into
the PMP Who Get a New
License and at Renewal
(Every 3 years)
• Require 3 Hours of
Continuing Education Prior
to License Renewal
• Limit Opioid Prescriptions
to Seven Days for a
Patient’s First
Prescription
• Create an Advisory
Council on Heroin and
Opioid Prevention and
Education
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Expanding Opioid Use Disorder
Treatment Options
• Our New Psychiatric Hospital- River Place Behavioral
Health- Will Open a Dual Diagnosis Unit in Early 2018
– Offering Detoxification and Induction with Buprenorphine for
Opioid Dependent Patients with Acute Psychiatric Issues
• Psychiatry's Suboxone Program (OchMAT) is Underway
– Adding Additional Support to Capture a Greater Range of
Disease Severity.
• Intensive Outpatient Program for Substance Use
(Addictive Behavior Unit) is Streamlining its Services for
Opioid Dependent patients
– Providing Easier Access to Outpatient Suboxone Treatment.
Partnerships with Behavioral Health LGEs Zip Code City Parish LGE
70001 Metairie Jefferson JPHSA
70002 Metairie Jefferson JPHSA
70003 Metairie Jefferson JPHSA
70004 Metairie Jefferson JPHSA
70005 Metairie Jefferson JPHSA
70006 Metairie Jefferson JPHSA
70009 Metairie Jefferson JPHSA
70010 Metairie Jefferson JPHSA
70011 Metairie Jefferson JPHSA
70030 Des Allemands Saint Charles SCLHSA
70031 Ama Saint Charles SCLHSA
70032 Arabi Saint Bernard MHSD
70033 Metairie Jefferson JPHSA
70036 Barataria Jefferson JPHSA
70037 Belle Chasse Plaquemines MHSD
70038 Boothville Plaquemines MHSD
70039 Boutte Saint Charles SCLHSA
70040 Braithwaite Plaquemines MHSD
70041 Buras Plaquemines MHSD
70043 Chalmette Saint Bernard MHSD
70044 Chalmette Saint Bernard MHSD
70047 Destrehan Saint Charles SCLHSA
70049 Edgard St John The Baptist SCLHSA
70050 Empire Plaquemines MHSD
70051 Garyville St John The Baptist SCLHSA
70052 Gramercy Saint James SCLHSA
70053 Gretna Jefferson JPHSA
70054 Gretna Jefferson JPHSA
70055 Metairie Jefferson JPHSA
70056 Gretna Jefferson JPHSA
70057 Hahnville Saint Charles SCLHSA
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Hard Decisions: Seek Care Elsewhere
2017 Strategy Review
Education
• Patient Education (1-pager and Packet)
• Patient Video
• Nurse Education Conference
• Finalize Policy
• System Communication
Data Transparency
• ∆ Prescribing Reports (Hospital and
Clinic) – could they be done off of PMP
• Dashboard in Tableau
• Opioid Risk/Benefit Dashboard (Epic)
Improving Practice
• Opioid Risk Tool
• Registry
• ∆ Urine Drug Screen
• Patient Contract
• PMP/Epic
Integration
• High Risk Flags
• ∆ Patients with
Multiple prescribers
• Quantity and
Potency Standards*
Patient Resources
• ∆ Grants – “Safe Pain Management
Program”
• BCBS Partnership – need integration
of governmental, payer, and providers
• Addiction Treatment and Recovery
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2018 Goals
Education
• Opioid Conference
• Monroe Hall Educational Series
• PSO Protection
• Expand CVS Education into Schools
• Opioid Stewardship Website
Data Transparency
• Sharing prescribing data throughout
Primary Care
• Establish Routine metrics for Prescribing
• Multiple Prescribing Letter
• Develop System Metrics
Improving Practice
• 100% Adoption of the PMP
• Inpatient MEQ Calculator
• Pre-Op Opioid Screening
• Opioid Smart Set
• Project ECHO
Patient Resources
• Grants – “Safe Pain Management
Program”
• Addiction Treatment and Recovery More
integrated (Investigate Referral Center)
• More non- pharmacological Chronic Pain
Options
• Pediatric Sickle Cell Initiative
If Not Us, Then Who? If Not Us,
Then Who?