Implementation of an Opioid Withdrawal Pathway in an Acute Care Setting

Description • Opioid-related inpatient hospital stays nationwide increased by 64%

between 2005 and 2014 (Weiss, et al., 2016)

• Opioid withdrawal (OW) treatment is unaddressed in most health care systems

• Unidentified and poorly treated OW may be associated with inpatients leaving against medical advice (AMA)

• Christiana Care (CCHS) implemented a standardized clinical pathway to screen, identify and treat inpatients experiencing OW

Aim To screen, identify and treat hospital inpatients experiencing

opioid withdrawal and reduce AMA rates

Actions Taken • A universal screening instrument was created and administered to

identify patients at risk for OW

• Clinical Opiate Withdrawal Scale (COWS) was used to assess OW severity

• Buprenorphine/naloxone treatment protocol was created for providers through the physician order entry system

• Implementation included a pilot phase, EHR programming changes and provider education

Summary of Results • 72% of admitted patients have been screened since Pathway

implementation

• 3% of screened patients were at risk for OW

• 22% of at risk patients experienced OW and

• 47% of patients with OW received buprenorphine/naloxone treatment

• From Dec 2016 to May 2017, the overall AMA rate for patients with OW diagnosis was 7.7% for CCHS and 11.4% for Peer Hospitals.

© 2017 Christiana Care Health Services, Inc., All rights reserved

Next Steps • Validate Opioid Withdrawal Risk Assessment Screening tool

• Evaluate OW Clinical Pathway impact on 7 and 30 day re-admission rates

• Measure the effectiveness of Project Engage peer counselors to connect patients with substance use disorder treatment after discharge

• Develop real time proactive nursing education at the bedside

• Solicit feedback from physicians, nurses and patients

Weiss AJ (Truven Health Analytic), Elixhauser A (AHRQ), Barrett ML (M.L. Barrett, Inc.), Steiner CA (AHRQ), Bailey MK (Truven Health Analytics), O’Malley L

(Truven Health Analytics). Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. HCUP Statistical Brief #219. December 2016.

Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb219-Opioid-Hospital-Stays-ED-Visits-by-State.pdf.

Beverly Wilson, MS; Jo Melson, MSN, RN, FNP-BC; Kimberly D. Williams, MPH; Erin Booker, LPC; Sherry Hausman, MPH; Jeff Reitz, Pharm D; Terry Horton, MD

OW Risk Assessment Screening Questions

1. Have you used heroin or prescription pain medicines other than prescribed in the last week?

2. Do you get sick if you can't use heroin, methadone or prescription pain medications?

IF patient answers YES to either question, they are “At Risk for Opioid Withdrawal”

Pathway Leaders • Dr Linda Lang, Chair of Psychiatry, Behavioral Health

(BH) Service Line Leader

• Dr Terry Horton, BH Service Line Associate Physician Leader

• Beverly Wilson, MS, Project Engage Senior Program Manager

• Jo Melson, MSN, RN, FNP-BC, Wilmington Step-Down Unit

• Krystal Coles, Organizational Excellence Sr. Consultant, Six Sigma Master Black Belt

Team Members

• Erin Booker, BH Service Line Corporate Director of Operations Leader

• Dr Kathy Willey, BH Service Line CCQP Leader

• Aliesha Rivera, MSN, RN-C, BH Staff Development Specialist

• Bonnie Osgood, MSN, RN-BC, NE-BC, Nurse Manager W4N

• Jeff Reitz, Pharm. D., Pharmacy

• Dr James Ruether, Internal Medicine CCHP

• Michelle Kane, MSN, RN, Data Informatics & Analytics

• Leslie Stevens-Johnson, IT BRM, BH Service Line

• Carmen Pal, MSN, MBA, Information Technology

• Rob Oakes, Power Chart Analyst, Information Technology

• Kimberly Williams, MPH, Research Associate, Value Institute

• Chris Anderson, Patient Advocate

• Cheryl Botbyl, Project Engage Program Assistant

Ad Hoc Team Members

• Dr Tom Sweeney, Emergency Department

• Karen Toulson, RN, MSN, MBA, CEN, NE-BC, Emergency Department

• Dr Elizabeth Zadzielski, Women’s & Children Service Line Associate Leader

• Claudine Jurkovitz, MD, MPH, Senior Physician Scientist, Value Institute

• Erin L. Dzuriak, Pharm. D., Informatics Pharmacist

• Sherry Hausman, MPH, CHES, Data Informatics & Analytics

Track

Behavioral Health

Hospital

Discharge

Month

Total

Cases

AMA

Cases AMA rate

CCHS Dec-16 16 3 18.8%

CCHS Jan-17 21 2 9.5%

CCHS Feb-17 25 2 8.0%

CCHS Mar-17 15 0 0.0%

CCHS Apr-17 19 1 5.3%

CCHS May-17 21 1 4.8%

CCHS Total 117 9 7.7%

Peer Hospitals Dec-16 1,057 142 13.4%

Peer Hospitals Jan-17 1,124 134 11.9%

Peer Hospitals Feb-17 1,070 113 10.6%

Peer Hospitals Mar-17 1,184 124 10.5%

Peer Hospitals Apr-17 1,166 132 11.3%

Peer Hospitals May-17 1,270 136 10.7%

Peer Hospitals

Total 6,871 781 11.4%