Significant Reductions in Opioid Prescribing MetricsThe following opioid ordering behaviors were substantially reduced between December 2018 and December 2018:
Total Opioid Orders Opioid Orders to
All Medication Orders
Opioids Orders w/ MEDD > 80
Opioids w/ Day Supply > 7 days
Total MEDD per pt
Opioids Orders w/ MEDD >30 Acute Pain
7
Presenter
Presentation Notes
Significant Reductions seen in Opioid Prescribing Metrics Data reporting period July 2017 through July 2018
8
Morphine EquivalentsThe key to opioid analytics:
– Analogy of calories to food– Method of quantifying any opioid order
• Potency (conversion factor) X Dose (milligrams) X Frequency per day
– Can also be used at an order, patient, ordering provider, specialty, regional and population level:
• Potency X Dose X Dispense quantity
8
9
Analytics Methodologies - Core Opioid Metrics• Total Opioid Orders: Raw count of narcotic orders within reporting period
• Auth Provider Outlier: Indicates that on any of the 3 Sentinel metrics the provider scores BELOW the 10th percentile
• Avg Percentile for 3 Sentinel Metrics: Mean of the Percentiles of the 3 Sentinel metrics
• Total MEQ RX: Cumulative morphine equivalent burden for all narcotics ordered within reporting period. gold standard takes into consideration potency, dose, frequency, and quantity dispensed
• Percentile Auth Provider Total MEQ RX: This represents the percentile score of the provider compared with peers with lower percentiles (in red shades) being associated with higher MEQ and higher percentiles (in green shades) associated with lower MEQ
Presenter
Presentation Notes
Metrics from opioid cube
10
Analytics Methodologies - Core Opioid Metrics• Rate MEQD GT30 to Acute Opioid Orders: The proportion among narcotic
orders placed for acute pain episodes where the morphine equivalent daily dose exceeded 30
• Percentile Auth Provider Rate MEQD GT 30 to Acute Opioid Orders: Percentile score of the provider compared with peers with lower percentiles (in red shades) associated with higher MEQD >30 and higher percentiles (in green shades) associated with lower MEQD>30
• Rate MEQD GT 80 to opioid orders: Proportion of all narcotic orders where the morphine equivalent daily dose exceeded 80
• Percentile Auth Provider Rate MEQD GT 80 to Opioid Orders: Percentile score of the provider compared with peers with lower percentiles (in red shades) associated with higher MEQD>80 and higher percentiles (in green shades) associated with lower MEQD>80
10
Presenter
Presentation Notes
Metrics from opioid cube
11
Two Opioid Key Performance Indicators for 20181) Morphine Equivalent daily dose limit for acute pain
prescriptions– Numerator: Number of total outpatient mode prescriptions where
morphine equivalent dose per day greater than 30
– Denominator: Acute outpatient opioid orders (in patients with no prior opiate prescriptions in the last 100 days)
2) Opiate Burden– Numerator: Total opiate burden (morphine equivalents)
– Denominator: Total unique patients with one or more selected encounters
11
Presenter
Presentation Notes
1) Numerator authorizing provider specialty exclusions: Addiction medicine, Clinical nurse oncology, Gynecologic oncology, Hematology and oncology, Hospice, Hospice and palliative care, Medical oncology, Oncology, Palliative care, Palliative medicine, Pediatric oncology, Radiation oncology, Surgical oncology Numerator exclusions patient level (either problem list or HMM): hospice, palliative care, cancer, life expectancy less than 1 year, Numerator encounter level/visit specialty exclusions: hospice and palliative care, hematology oncology, OP oncology, gyn oncology, radiation oncology, addiction medicine, palliative care, pediatric oncology, pediatric radiation oncology, surgical oncology 2) Numerator exclusions patient level (either problem list or HMM): hospice, palliative care, cancer, life expectancy less than 1 year, Numerator encounter level/visit specialty exclusions: hospice and palliative care, hematology oncology, OP oncology, gyn oncology, radiation oncology, addiction medicine, palliative care, pediatric oncology, pediatric radiation oncology, surgical oncology, infusion therapy Numerator authorizing provider specialty exclusions: Addiction medicine, Clinical nurse oncology, Gynecologic oncology, Hematology and oncology, Hospice, Hospice and palliative care, Medical oncology, Oncology, Palliative care, Palliative medicine, Pediatric oncology, Radiation oncology, Surgical oncology Denominator encounter inclusions: follow up, home visit, hospital, hospital encounter, initial consult, initial prenatal, OB office visit, office visit, orders only, post op telephone, postpartum visit, procedure visit, refill routine prenatal, prescription refill authorization
(Total MEDD for opioid prescriptions to number of unique patients)
17
Rate Morphine Equivalents >30 (Opioid naïve patients, Ohio law 8.31.17)
17
Presenter
Presentation Notes
Updated 8/1/18
18
Opioid Burden: Total Morphine equivalent divided by patient
18
Presenter
Presentation Notes
Updated 8/1/18
19
2018 Opioid Prescribing Metrics by Month
19
*Red box = Two strategic initiatives
20
Provider Dashboard (Over time with drill down to orders)
20
21
Provider-level Graphs21
22
Medication Assisted Therapy (MAT)22
Presenter
Presentation Notes
Updated 8/1/18
23
Prevention: Provider-Facing Tools to Reduce Opioid Prescribing
23
24
State Level Responses to the Opioid Crisis
• August 31, 2017 (Ohio)
– “7/5/30”• No more than 7 days of opioids can be prescribed for adults and 5 days of opioids can be
prescribed for minors & only after the written consent of parent/guardian
• The total MEDD of a prescription for acute pain cannot exceed 30
• Rules apply to the first opioid analgesic prescription for the treatment of an episode of acute pain
• November 15, 2017 (Kentucky)
– Limit of 3 day supply on C-II for acute pain
• December 29, 2017 (Ohio)
– Require diagnosis association on all opioid prescriptions
– Require indication of days supply on all controlled substance and gabapentin prescriptions
• June 1, 2018 (Ohio)
– Require diagnosis association on all controlled substances
24
Presenter
Presentation Notes
Jed
25
Preference List CustomizationCreation via import of opioid specific facility preference list containing fully configured compliant orders for selected common acute opioids.
25
Presenter
Presentation Notes
Created a preference list entries via import of most commonly prescribed opioids Format: generic // (BRAND) // strength // disp qty // frequency// MEDD // day supply If used as provided in fully configured and compliant state, provider will not receive downstream day supply or morphine equivalence alerts
26
Preference List CustomizationProviders can use either fully configured orders or select a less configured choice.
26
Presenter
Presentation Notes
Providers can still select less configured orders However, use of a custom preference list type and sort column order configuration allows for configured orders to appear above less-configured orders
27
In-Line MEDD Calculation• All opioid containing medications possess a visual indicator of the calculated
MEDD within the order composer• Dynamically calculates based on order dose and frequency
– Does not calculate with free-text sigs
27
Presenter
Presentation Notes
Epic released in-line morphine equivalence calculation based of your morphine equivalence table setup Feedback received from providers is to support highlighting and an in-line look at what this order would do to the patient’s total morphine equivalence Downfall is that this will not calculate when provider elects to utilize free-text sigs
28
MEDD Calculation
Calculated Morphine Equivalent Daily Dose (MEDD)• Have added a hyperlink in the upper right corner of our
Prescription Monitoring navigator section• Cannot calculate with free-text sigs
28
Presenter
Presentation Notes
Again Epic released morphine equivalence calculation report based of your morphine equivalence table setup Similar to in-line calculation, downfall is that this will not calculate when provider elects to utilize free-text sigs We will continue to circle back to the free-text sig issue
29
Day Supply Limitations
Day Supply Designation• Hard Stop• Number of days will be dynamically
appended to sig when using discrete sigs (default)
• Issue: Long-term meds, PRN frequency, dispense qty, and duration may not always align
29
Presenter
Presentation Notes
Ohio also implemented a day supply indicator requirement on controls and gabapentin How do you do this? Wildcard or SmartList inside Notes to Pharmacy that a provider can just clear out? We elected to set the order composer to require a durations where number of days will be dynamically appended to sig when using discrete sigs Providers will be responsible for indicating a day supply on any opioid order when electing to utilize free-text sigs Issues: Free-text sigs do not have a duration field Based on your system setup, long-term meds may fall of list once duration is reached PRN frequencies will not calculate a dispense qty based on duration despite therefore prescribed duration and calculated day supply at the pharmacy for insurance adjudication purposed may not always align as a provider’s intended day supply the same as written prescription duration
30
30 Order Validation Alerts: MEDD
Threshold of 80 MEDD c
cThreshold of 30 MEDD
Order Validations fire at the END of the ordering workflow• Content ONLY – provides stage directions for what is
suggested but no follow up actions via the popup• If providers select “Accept” the order is placed
***Both MEDD and Days Supply can fire simultaneously
Presenter
Presentation Notes
Anna Lendl –
31
31Order Validation: Days Supply
Ohio Adolescent: Days Supply = 5
Kentucky Patient: Days Supply = 3
c
Ohio Adult: Days Supply = 7 c
Presenter
Presentation Notes
Anna Lendl –
32
32 Unsigned Order BPA: MEDD
Threshold of 80 MEDD c cThreshold of 30 MEDD
Unsigned Order BPA fires at the BEGINNING of the ordering workflow.
• It provides follow up actions such as removing orders, placing Naloxone prescription, and links to document flowsheet values.
• If providers select “Accept” the order is NOT placed
Presenter
Presentation Notes
Anna Lendl –
33
33Unsigned Order BPA: Days Supply
Ohio Adolescent: Days Supply = 5
Kentucky Patient: Days Supply = 3
c
Ohio Adult: Days Supply = 7 c
Presenter
Presentation Notes
Anna Lendl –
34
Controlled Substance Monitoring SmartForm, Phase IAs a result of 2015 Ohio legislation, a SmartForm was implemented into Mercy’s EHR for quick documentation that could be utilized for reports.• Provided attestation button to document within the EMR that the PDMP report was reviewed -
a compliance requirement from PDMP• Any documentation within the form could be pulled into the providers note via a SmartPhrase• Provided a hyperlink out to the PDMP website to perform a manual query
34
Presenter
Presentation Notes
Showing Phase 1 of our Controlled Substance Monitoring SmartForm in response to 2015 Ohio Legislation Flowsheet in background of attestation documentation for data collection and reporting as a compliance requirement SmartPhrase created to pull data into documentation Hyperlinks out to state specific PDMPs
35
Controlled Substance Monitoring SmartForm Phase II: New Limits on Prescription Opioids• Effective August 31, 2017, Ohio passed new limits for prescribing opioids for acute pain• SmartForm versatility allows additional documentation to the SmartForm already in use• With provider guidance, the SmartForm was expanded to accommodate documenting the
new limits and exceptions on prescription opioids
35
Presenter
Presentation Notes
With new Ohio regulations for opioid prescribing we added in additional documentation sections to our attestation form. Answers here were used in CDS suppression rules
Phase 3 brought PDMP integration and enhanced reporting and auditing tools Here is a quick look at our current iteration of our controlled substance monitoring report. Recall that first phases were SmartForm based with hyperlinks out to PDMPs Providers still had to log in, took too many clicks Now Integrated a new custom report with Appriss for improved reporting and auditing Pull in EMR data that we feel was appropriate for an at a glance look Provide links above are for action to be taken at PDMP integrated site or Mercy’s SmartForm Highly recommended
37
Phase III: NarxCare Report
• The NarxCare report is the report display from Appriss
– Takes the raw controlled substance data received from multiple state pharmacies and creates scores and graphs
– Providers can quickly tell the patient's history with opioids and likelihood for abuse
37
Presenter
Presentation Notes
Example NarxCare Report output from Appriss
38
Issue: Free Text Sigs
Solution: Require discrete sig for opioids
• Over 104,600 free text orders in early 2 years window
• Most can be accommodated directly with discrete frequency
38
Presenter
Presentation Notes
Free-text sigs Some examples of the over 100K free-text sigs in past 2 years Yes there was a sig with only a period Data drill down shows that over 90% could be accomplished with discrete sigs
39
Issue: Free Text Sigs
Solution: Dose and Frequency Range Education• Many providers were
unaware of ability to use range doses on outpatient prescriptions
• Created four new discrete frequency range choices:
– Q3-4H PRN– Q4-6H PRN– Q6-8H PRN– Q8-12H PRN
39
Presenter
Presentation Notes
Educated provider on ability to use range doses on OP prescriptions Created and educated on 4 new discrete range based frequencies
40
• Add additional information to patient sig
– 140 total sig character limit
• Note to pharmacy – 300 hard character limit
Issue: Free Text Sigs
Solution: Education of Conveying Information to Pharmacy
40
Presenter
Presentation Notes
Educated on use of add additional information to patient sig and note to pharmacy fields
41
Concomitant Benzodiazepine & Opioid Prescribing Highest Risk for Overdose and Death
• Actionable CDS for Concomitant Benzodiazepine & Opioid Prescribing
41
Presenter
Presentation Notes
Actionable CDS on opioid and benzo co-prescribing black box warning Not just you have a benzo and I’m prescribing an opioid True at same time I am prescribing both In addition to providing mechanism to remove an offending order and/or place referrals for sleep med, pain clinic, and/or behavioral health
42
Concomitant Benzo/Opioids: Analytics
42
43
Pain Agreement Status in Order Composer
• Per CMS, starting in 2019, Pain Agreements will expire for an existing controlled substance after 6 months.
• When ordering a controlled substance, the pain agreement status will display in the order composer.
43
Release Note 635758
44
Opioid Speed Buttons—Default of 3 Days
44
45
PDMP Review Information Available on Radar Dashboards
• Help track individual & organization compliance with state regulations from prescription drug monitoring programs.
• Show % of opioid prescriptions where providers didn't review PDMP information in the same encounter.
• Working definition: No preceding opioid order in a 100 day window prior to the incident opioid order.
– Measures not affected by erroneous or absent associated diagnoses or problem list entries.
• All of these metrics were built in a manner that is not dependent on the use of an Epic registry.
– They were set up in a way that was not dependent on, but could leverage Epic’s method of calculating and storing maximum morphine equivalent daily dose (MEDD)
53
54
Diagnosis Requirement Association Order Validation
• Order Validation Point – Hard stop for diagnosis association– Lacks customization options
54
Presenter
Presentation Notes
Ohio law now requires diagnosis association on all controlled substances. Epic quickly developed ability to specify requirement via rule rather than that of the prior all or none capability. Lacks text customization options Provider feedback is to have diagnosis association linkage box within alert itself
55
• Order validation lacks ability to report on firing rate trends and ability to measure success of learned behavior
– Less alerts over time by way of providers associating upstream
• Created a robust tabular cube to monitor opioid prescribing overall allowed us to identify an issue where some opioid orders were not requiring diagnosis
– Data sharing moved Kentucky market to elect to participate in requirement
Diagnosis Requirement Association Order Validation
55
Presenter
Presentation Notes
Our feedback is that Order Validation unfortunately lacks ability to report out on firing rate trends to help measure success and learned behavior Note how Kentucky did not have a law requiring diagnosis association but us beginning to publish data across ministry magically show that market self elect to align with their Ohio counterparts
56
Actionable Alert: Special Consent (Ohio HB 314)
• Clinical Decision Support (CDS) for special consent form for opioid prescribing to minors
56
Presenter
Presentation Notes
Actionable CDS on opioids for minors and parental/guardian consent
57
Strategies to Decrease Emergency Department Opioid Use
57
58
0%10%20%30%
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Emergency Department Outpatient Opioid Prescription
Trend…
“Opioid-Free” Emergency Department Provider Outreach
58
Presenter
Presentation Notes
Initiative’s “Official” Kick-off in 2016 and began with provider outreach Educational materials were created and began holding discussions with providers about the problem as well as the how and why we are taking action We actually see a decrease occurring in later half of 2015 following initial discussions with providers and the “hey, we have a problem” effect. Marked decrease in second half of 2016 when patient and community outreach began
59
“Opioid-Free” Emergency Department: Community and Patient Outreach
59
Presenter
Presentation Notes
First weeks resulted in numerous patient complaints from our familiar faces Counseled patients and provided educational materials around chronic pain, concerns for their safety, opportunities to ALTO, pain management, behavioral health, and sleep medicine referrals.
60
“Opioid-Free” Emergency Department60
0%5%
10%15%20%25%30%
Jan
'14
Mar
'14
May
'14
Jul '
14Se
p '1
4N
ov '1
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n '1
5M
ar '1
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ay '1
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l '15
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p '1
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ov '1
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ay '1
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l '17
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'18
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18
Emergency Department Outpatient Opioid Prescription Trend
Rate of Opioid Prescriptions to All PrescriptionsSpringfield Market
Year Patient Visits
VolumeReduction
2014 80,916 -
2015 77,945 3.8%
2016 71,696 8%
2017 65,976 8%
Presenter
Presentation Notes
Success from education and aligning entire team prior to go-live Providers were there to support the nursing staff when patients challenged not receiving an opioid in the ED period or a prescription on discharge, or a less-strong opioid, or giving an NSAID that the patient reports does not historically work for them, or not receiving the one that starts with a “D” Drastic drop in ED visit volume (word of mouth) Major gut check for any health system to essentially voluntarily slash you ED visit volume Currently reporting greater satisfaction from ED staff from marked drop in drug seeking behavior Prefer patient to come seeking help and not come seeking drugs
61
Strategies to Decrease Inpatient Opioid Use
61
62
Reducing Opioids in the Inpatient Setting
• As part of an organizational focus on decreasing overall numbers of opioid prescriptions, the following inpatient opportunities were identified:
– Presence of narcotic pain relief options on admission order sets not typically associated with pain
– Lack of a collection of Alternatives to Opioids (ALTO) options in one concise format for ease in ordering
62
Presenter
Presentation Notes
As more and more outpatient opioid ordering requirements were implemented to decrease the amount of opioids being prescribed, we began to discuss what could be done to help stem the tide from an inpatient perspective As we brainstormed, 2 things stood out to us One was the presence of narcotic pain relief options on many of our admission order sets that were for diagnoses not usually associated with pain Another was the lack of Alternatives to Opioids (ALTO) options in an easy to use format that could be accessed by providers
63
Designing a Solution:Removing Pain Medications from Select Order Sets
• In reviewing all admission and focused order sets with IV and oral pain medication, it was determined that over 30 were for treatment of diagnoses not normally associated with pain
– Validated with informatics committees and received nearly unanimous support for removal of these pain medications
– Standard biennial review cycle of all order sets still containing pain medications will be assessed for clinical appropriateness moving forward
63
Presenter
Presentation Notes
As we discussed with the appropriate informatics committees our desire to remove pain medications, we settled on over 30 order sets that would have pain medications removed While this number may seem low, we have a standardized order set build throughout our system, with a single instance of each order set available throughout all of our hospital facilities Beyond the initial order sets that would have pain meds removed, future routine review would evaluate additional order sets and service lines for potential removal
64
Designing a Solution:Creating a Pain Management Focused Order Set
• To supplement the removal of pain medications from many admission order sets and to provide a single location for opioid and non-opioid pain treatment a Pain Management Focused Order Set was created
• Plan to increase number of ALTO options after initial use period and evaluation in conjunction with system Pharmacy and Therapeutics Committee decisions
64
Presenter
Presentation Notes
In conjunction with the removal of pain meds from order sets, we decided to provide a single location where both opioid and non-opioid pain options Out of this our Pain Management Focused order set was created Within this order set we incorporated some initial ALTO options, with the intention of increasing these options over time
65
Designing a Solution:Creating a Pain Management Focused Order Set• Key Features:
– Non-customizable– Set as a suggested order set for all admitted patients– In addition to traditional acetaminophen and ibuprofen, added
additional ALTO options– Provider has to navigate through non-opioid options to get to
opioid choices
65
Presenter
Presentation Notes
When designing this order set, there were several Key Features that we decided on: Non-customizable: We wanted to be able to nimbly add or adjust ALTO options over the upcoming months without affecting customized users each time we did, so we suppressed the ability of physicians to customize Set as a suggested order set for all admitted patients to bring greater awareness In addition to the traditional acetaminophen and ibuprofen, added additional ALTO options Configured the layout so the Provider has to navigate through non-opioid options to get to opioid choices
66
Designing a Solution:Creating a Pain Management Focused Order Set
66
Presenter
Presentation Notes
Have separated the ALTO Options out Opioids have specific instructions on if IV and Oral ordered, use Oral if tolerated, etc.
67
SBIRT:Screening, Brief Intervention, and Referral to Treatment
• Prior to SBIRT Implementation:• Alcohol, drug, and depression screenings were inconsistent• Alcohol and drug use screenings were outdated and not
linked to action• Approach to screening was inconsistent with public health
approach• There were no outcomes captured for patients’ drug or
alcohol use
67
Presenter
Presentation Notes
The first inpatient intervention we will discuss today is SBIRT—Screening, Brief Intervention, and Referral to Treatment Prior to SBIRT implementation in late 2015, there was no consistent screening being done for Emergency Department patients’ alcohol, drug use, or depression Alcohol & Drug use screenings, when being done, were outdated and not linked to a specific and evidence based action step Only patients with a chief complaint related to alcohol, drug use, or depression were screened for these problems This approach was inconsistent with a public health approach which suggests screening everyone; not only those with a complaint related to alcohol, drug use or mood There were no outcomes being captured for patients’ drug or alcohol use Identified Solution Our goals were to increase the number of patients screened for substance use and depression, take a public health approach to ensure early detection, intervention and referral for alcohol, drug use, and mood difficulties Choose and implement an efficient, evidence-based and actionable screening process in the Emergency Room (SBIRT) and build these tools into Epic Screen patients regardless of chief complaint Tools Utilized: Prescreen consisted of the: Alcohol User Disorder Identification Test (AUDIT) Drug Abuse Screening Test (DAST-10) Patient Health Questionnaires (PHQ-2 & PHQ-9) - mood screening Desired Outcomes: Decreased the stigma associated with substance use disorder Normalize discussion of a topic that is often difficult for patients and providers to discuss
68
Screenshots: Prescreens
*All patients are asked the prescreen questions at triage
68
Presenter
Presentation Notes
The tools that were built out as seen in the screenshots were built as a brief scripted alcohol or drug use (Brief Negotiated Interview) intervention that will cascade in Epic automatically if triggered by a score on a full screen. Referral information is given to patients for alcohol/drug use and/or mental health treatment based on their scores on the full screens—a Best Practice Advisory (BPA) will fire when referral is indicated All of these processes and scripting are built into Epic Clinicians are able to quickly screen patients, capture data regarding patient scores, and make informed decisions regarding the need for intervention and/or referral. This would not be possible without use of health information technology
69
SBIRT Screening Numbers (2016 - Q1 2018)
0
10000
20000
30000
40000
50000
60000
70000
80000
2016 2017 2018Q1 Q2 Q3 Q4 YEARLY TOTAL
**The large, sustained spike in screenings beginning in Q2 2017 is due to the spread of SBIRT to several additional sites at that time. Additional sites were added in Q1 2018, resulting in another large spike in screenings.
69
Presenter
Presentation Notes
This slide speaks to the increase in the number of screenings over the past 3 years In CY 2016 approximately 6,700 SBIRT screenings were conducted in Mercy Health ERs In 2017 Mercy Health assembled a systemwide SBIRT implementation team and began a rolling implementation and spread of SBIRT to additional ERs. SBIRT also became a system KPI measure In CY 2017 approximately 68,000 SBIRT screenings were conducted in Mercy Health ERs As of end of Q1, 2018, there has been approximately 31,000 SBIRT screenings conducted in ERs across the Mercy Health system The number of Mercy Health ERs in which SBIRT is active went from 1 in 2015 to 22 in 2018 **2017 YTD – 124,000 screenings completed, met system KPI target in Q1 alone
70
SBIRT Outcomes - ROI
0
1
2
3
4
5
6
7
8
9
10
Alcohol Use Illegal Drug Use
Num
ber o
f Day
s (la
st 3
0 da
ys)
Change in Substance Use for Mercy Patients 6 months post SBIRT screening protocol (n=155)
BaselineFollow-up
The chart illustrates change in number of days of substance use for Mercy patients with both a baseline and follow-up interview (n=155). Mercy patients demonstrated statistically significant reductions in alcohol (p=.002) and illegal drug use (p=.001). Data was collected from December 2015-August 2017
70
Presenter
Presentation Notes
For the SBIRT Outcomes, the data you can see was compiled through post-intervention follow up interviews with 155 patients who had participated in the screening protocol Performed by students from a local university Results showed a 6 month follow-up reduction of 2 days alcohol use in previous 30 days from baseline and over 3 days decrease in illegal drug use
71
Focused Order SetClinical Opiate Withdrawal Scale (COWS)
71
72
Background
• Over the past few years, Mercy Health faced the rising tide of the opioid crisis
• Amid the increasing numbers of opioid-related overdoses and deaths, a growing number of patients with an opioid use disorder were presenting at Mercy inpatient facilities
• There were few evidence-based, standardized tools to help guide their treatment, and any existing tools were not integrated into the EMR
• Lack of ability to manage the symptoms of these patients while admitted to our facilities complicated care
– Increased burden of care on staff– Increased number of patients unable to complete necessary treatment
for co-morbidities
72
Presenter
Presentation Notes
There were few evidence-based, standardized tools to guide treatment Any existing tools were not fully integrated into the EMR
73
Order Set Key Features
• Presence of buprenorphine– Required approval by Mercy Health Formulary Committee for use in
order sets– Limited to 72 hour duration to make available to physicians without
special prescribing authority to exceed 72 hours
• Combination of clonidine as adjunctive medication in linked panel with both buprenorphine and tramadol as treatment options
• Fixed dose strategy– COWS score dictated frequency of reassessment and follow-up doses– Avoided confusion of titrating various doses of medication
• Availability of medications for symptom management
73
Presenter
Presentation Notes
Use of buprenorphine, or having a protocol in place at all, was not without its own challenges There were some pharmacists and providers that did not believe that we should be using buprenorphine, some felt that we should reconsider treating “these people” because they did it to themselves Some nurses and providers felt that patients should detox on their own, it teaches them a lesson Buprenorphine required approval by P&T for use on ordersets We had to work with Board of Pharmacy to help develop and approve guardrails for duration of use as IP to make available to non-waivered physicians. The COWS scale was pre-existing and well-defined but we had to push the literature to arrive at dosing and max levels. Went with a fixed dose strategy where the COWS score dictated the frequency of reassessment and subsequent dosing versus a CIWA-like sliding scale. It was seen early on that a fixed dose with differential reassessment triggers avoided confusion in titrating various doses of medication on a complex scale. Within the orderset itself, we also addressed symptom management as we know the side effects of withdrawal are what drive patients back to the drug
74
Opiate Withdrawal Focused Order Set74
Presenter
Presentation Notes
Orderset is what we call a focused orderset in that it does not contain all the required and extra admission content Allows providers to merge into other disease state admission ordersets or even additional related focused ordersets of ours like CIWA, Amphetamine Toxicity, Overdose, etc Orderset contains a Notify Physician order for Clinical Opiate Withdrawal Score (COWS) of 25 or greater or SBP less than 90 Symptom management in place with nicotine replacement Use of Trazadone, Seroquel, Benadryl, or Melatonin for Insomnia Dicyclomine for abdominal cramping NSAIDS for myalgia Gabapentin for neuropathic pain Hydroxyzine for anxiety, lacrimation, or rhinorrhea Promethazine for nausea and RLS Also contains seizure and fall precautions under nurse interventions Michael will now speak to the assessment portion of the nurse intervention Transition to Michael Michael to speak to Nurse Intervention One key feature of the Order Set was the nursing assessment order, which is similar in format to the CIWA assessment order, and lays out the time frame for COWS assessment based on previous scores
75
Designing a Solution:Clinical Opiate Withdrawal Scale (COWS)
• Nursing assessment that evaluates 11 signs/symptoms
• Stratifies severity of opiate withdrawal
• Flowsheet built to auto-calculate score
75
Presenter
Presentation Notes
A standardized assessment tool was needed for nursing to assess symptom severity Settled on the Clinical Opiate Withdrawal Scale (COWS) An evidence based 11 point assessment tool designed for use in both the inpatient and outpatient settings A flowsheet was created to auto-calculate the score, which corresponded to medication interventions as previously noted in the order set
76
Outpatient Opioid Prescribing Data Summary
-12%-16%
-30%
-15
-50%
-20%
Significant Reductions in Opioid Prescribing MetricsThe following opioid ordering behaviors were substantially reduced between December 2018 and December 2018:
Total Opioid Orders Opioid Orders to
All Medication Orders
Opioids Orders w/ MEDD > 80
Opioids w/ Day Supply > 7 days
Total MEDD per pt
Opioids Orders w/ MEDD >30 Acute Pain
76
Presenter
Presentation Notes
Significant Reductions seen in Opioid Prescribing Metrics Data reporting period July 2017 through July 2018
77
Success Stories77
Presenter
Presentation Notes
Some additional success stories We feel that this is more humanitarian and real than pumping the patient full of dilaudid, which we used to do Evidence shows that if you go through this your likelihood of still being in treatment in 6 months is doubled Additional points here are that you cannot initiate as detox unless you are going to then send patient to be under the care of an addiction treatment provider within 72 hours Patient cannot enter electively until they are sent and enrolled through intake with an addiction treatment provider When we started there was no defined network of local addiction treatment providers, so we created the network through the local health collaborative With the orderset and flowsheet, we are fully open to share, and have shared and helped champion. Providers from local competing organizations are reporting that they cannot move quick enough to implement this at their other practice sites to where they have essentially the same protocol no matter where they practice in town We, and other local health systems, have helped fund support of the Narcan Distribution Collaborative providing narcan to high risk abusers. When we started, patients still in medication assisted therapy after 1 year was 6% Last quarter this was 30% Last week 40%, one of the highest percentages of patients still in MAT in the nation Attribute to excellent care coordination Still a newer epidemic but early data is demonstrating that when you are still in MAT at 12 months your likelihood of being sober long-term is significant Lets pause and think about how many ODs, deaths, serious health issues like Hepatitis and HIV are avoided or reduced by going from 6% to 40%
