Saving & Changing Lives: Ochsner’s Opioid Stewardship Program · Apr May Jun Jul Aug Sep Oct Nov...

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)

7/6/2018

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

7/6/2018

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

7/6/2018

4

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

7/6/2018

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

7/6/2018

6

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

7/6/2018

7

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


7/6/2018

8

Morphine Equivalent Daily Dose (MEDD)

• MEDD calculated for opioid outpatient prescriptions

• Normalizes various opioid potencies and doses

• Appears in workflows where providers prescribe

medications


Louisiana Prescription Monitoring Program (PMP)

one

click


7/6/2018

9

Opioid Management Activity - Links


Opioid Management Activity


7/6/2018

10

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


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

7/6/2018

11

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

7/6/2018

12

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

7/6/2018

13

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

7/6/2018

14

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









70030 Des Allemands Saint Charles SCLHSA

70031 Ama Saint Charles SCLHSA

70032 Arabi Saint Bernard MHSD


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




70057 Hahnville Saint Charles SCLHSA

7/6/2018

15

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

7/6/2018

16

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?

Date post:	30-Sep-2020
Category:	Documents
Upload:	others
View:	7 times
Download:	0 times

Saving & Changing Lives: Ochsner’s Opioid Stewardship Program · Apr May Jun Jul Aug Sep Oct Nov...

Documents