Department Collaborative June 25, 2018 Welcome! Agenda for today: - - PowerPoint PPT Presentation

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Department Collaborative June 25, 2018 Welcome! Agenda for today: - - PowerPoint PPT Presentation

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Opioid Light Emergency Department Collaborative June 25, 2018 Welcome! Agenda for today: Welcome Presentation on Opioid Light Order Sets and Data Team sharing/Q&A Resources IHI Open School THA Opioid-Light ED Pilot

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Opioid Light Emergency Department Collaborative

June 25, 2018

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Welcome! Agenda for today:

  • Welcome
  • Presentation on Opioid Light Order Sets

and Data

  • Team sharing/Q&A
  • Resources
  • IHI Open School
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SLIDE 3

THA Opioid-Light ED Pilot

June 2018 Webinar

Dawn M. Waddell, PharmD, BCPS Clinical Pharmacy Manager Baptist Memorial Hospital - Memphis

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Webinar # 1: Objectives

  • Provide background supporting multi-modal pain

medications

  • Review order set pathways for 5 indications
  • Review state-wide metrics
  • Discuss next steps and potential topics for July

webinar

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THA Opioid-Light ED Pilot Participants

  • CHI Memorial Healthcare
  • CHI Memorial Hixson
  • Henry County Medical Center
  • Maury Regional Medical Center
  • Methodist Germantown Hospital
  • Methodist North Hospital
  • Methodist Olive Branch Hospital
  • Methodist South Hospital
  • Methodist University Hospital
  • NorthCrest Medical Center
  • Parkridge East Medical Center
  • Parkridge Medical Center
  • Parkridge West Medical Center
  • Regional One Health
  • Saint Thomas Midtown
  • Southern Tennessee Regional

Health System – Lawrenceburg

  • Starr Regional Medical Center

(Athens and Etowah campuses)

  • TriStar Ashland Medical Center
  • TriStar Centenniel Medical Center
  • TriStar Hendersonville Medical

Center

  • TriStar Horizon Medical Center
  • TriStar Skyline Medical Center
  • TriStar Southern Hills Medical

Center

  • TriStar Stonecrest Medical Center
  • TriStar Summit Medical Center
  • Vanderbilt University Medical

Center

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SLIDE 7

Break the Pattern

Patient reports PAIN OPIOID Rx

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Alternatives to Opioids (ALTO)

Multi-modal approach to target various pain receptor pathways; examples:

  • Cox inhibitors: NSAIDs/APAP
  • Sodium channel blockers: Lidocaine
  • NMDA receptor antagonists: Ketamine
  • GABA agonists/modulators: BZDs/Gabapentin
  • Inflammatory cytokine inhibitors: Steroids

Opioids as “rescue” or second-line

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FIVE Pathways

  • Headache / Migraine
  • Musculoskeletal Pain
  • Extremity Fracture / Dislocation
  • Renal Colic / Kidney Stones
  • Gastroparesis / Chronic Abdominal Pain
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Headache / Migraine

  • Usually requires synergistic therapy with different

mechanisms of action

– Block glutamate, dopamine, histamine – Enhance GABA, serotonin – Decrease CNS inflammation – Hydration

  • Opioids less effective

– May decrease efficacy of alternatives – May promote chronic migraine/medication overuse headaches

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Headache / Migraine

  • Immediate/First-line Therapy

– 1 L 0.9% NS + high-flow O2 – Ketorolac 15 mg IV – Metoclopramide 10 mg IV – Dexamethasone 8 mg IV – Trigger-point injection lidocaine 1%

  • Cervical
  • Trapezius
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Headache / Migraine

  • Alternative Options

– APAP 1000 mg PO + Ibuprofen 600 mg PO – Sumatriptan 6 mg SC – Promethazine 12.5 mg IV or Prochlorperazine 10 mg IV – Haloperidol 2.5 mg - 5 mg IV – Magnesium 1 g IV (esp. if +aura) – Valproic acid 500 mg IV – Propofol 10-20 mg IV bolus

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Headache / Migraine

  • Tension Component

– Cyclobenzaprine 5 mg – Diazepam 5 mg PO/IV – Lidoderm transdermal patch

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Musculoskeletal

  • Examples:

– Sprains/strains – Opioid-naïve lower back pain

  • Acute on chronic radicular lower back pain

– Acute neck, joint, soft tissue pain – Tendonitis – Arthritis – Bursitis

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SLIDE 15

Musculoskeletal

  • Non-IV Options

– APAP 1000 mg PO + Ibuprofen 600 mg PO – Cyclobenzaprine 5 mg PO – Diazepam 5 mg PO – Lidoderm transdermal patch – Gabapentin 600 mg PO – Ketamine 50 mg Intranasal – Trigger point injections lidocaine 1% (1-2 mL)

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Musculoskeletal

  • IV Options

– Ketamine 0.2 mg/kg IV – Ketorolac 15 mg IV – Dexamethasone 8 mg IV – Diazepam 5 mg IV

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Extremity Fracture / Joint Dislocation

  • Goal to provide immediate treatment while setting

up for blocks

  • Short-acting for joint reduction
  • Longer-acting for fracture pain
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Extremity Fracture / Joint Dislocation

  • Immediate/First-line Therapy

– APAP 1000 mg PO – Ketamine 50 mg Intranasal – Nitrous oxide (titrate up to 70%)

  • Ultrasound-Guided Regional Anesthesia

– Lidocaine 0.5% perineural infiltration (max 5 mg/kg)

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Renal Colic / Kidney Stones

  • Flank pain radiating to groin caused by kidney

stones in ureter

  • Increased prostaglandin synthesis and release ->

– Diuresis/vasodilation -> increased intrarenal pressure – Smooth muscle spasms of ureter – Edema/inflammation near stone

  • Present in acute distress with severe back/abdominal

pain

Golzari et al. Anesth Pain Med 2014. Feb; 4(1)

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Renal Colic / Kidney Stones

  • Immediate/First-line Therapy

– APAP 1000 mg PO – Ketorolac 15 mg IV – 1 L NS 0.9% NS bolus

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IV Lidocaine for Renal Colic

  • Firouzian et al (Am J Emerg Med 2015)

– Morphine 0.1 mg/kg +/- Lidocaine 1.5 mg/kg

  • 110 patients 18-50 yo
  • Reduced time to pain relief
  • Decreased nausea
  • Sin et al (Am J Ther 2018)

– IV lidocaine 120 mg infused over 10 minutes

  • 3 minutes -> 1/10
  • 5 minutes -> 0/10
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Renal Colic / Kidney Stones

  • Second-line IV Therapy

– Lidocaine 1.5 mg/kg IV (max 200 mg)

  • Alternative Options

– DDAVP 40 mcg Intranasal – Ketamine 50 mg Intranasal

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Gastroparesis / Chronic Abdominal Pain

  • N/V/abdominal pain common repeat presentation to

ED

  • Often associated with diabetes, post-surgical, or

idiopathic

  • Opioids further inhibit gastric emptying
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Gastroparesis / Chronic Abdominal Pain

  • Immediate/First-line Therapy

– Metoclopramide 10 mg IV – Prochlorperazine 10 mg IV – Diphenhydramine 25 mg IV

  • Caution in geriatric population

– Dicyclomine 20 mg PO/IM (NOT IV)

  • Esp. if +cramping
  • Caution in geriatric population d/t anticholinergic effects
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Gastroparesis / Chronic Abdominal Pain

  • Ramirez et al (Am J Emerg Med 2017)

– Comparison of 52 patients who received haloperidol 5 mg IM to previous presentation without haloperidol administration

  • Decreased hospital admission (5/52 vs 14/52, p-value 0.02)
  • Decreased MME (6.75 vs 10.75, p-value 0.009)
  • Roldan et al (Acad Emerg Med 2017)

– Randomized, double-blind, placebo-controlled – 33 patients, conventional therapy +/-haloperidol 5 mg

  • Pain scores 3.13 with haloperidol vs 7.17 with placebo
  • Nausea scores 1.83 with haloperidol vs 3.39 with placebo
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Gastroparesis / Chronic Abdominal Pain

  • Second-line IV Therapy

– Haloperidol 2.5-5 mg IV – Ketamine 0.2 mg/kg IV – Lidocaine 1.5 mg/kg IV (max 200 mg)

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Special Populations

  • Pregnancy

– Generally exclude d/t contraindications – Ex: NSAIDs, haloperidol, valproic acid

  • Geriatrics

– Caution with sedating medications/Beers criteria – Ex: dicyclomine, haloperidol, diphenhydramine, cyclobenzaprine

  • Heart Failure

– Caution with steroids/NSAIDs

  • Renal Impairment

– Caution with NSAIDs

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Miscellaneous

  • ALTO medications often utilized ‘a la carte’

– Individual orders outside of order set

  • Ketamine

– Caution if significant psychiatric history/PTSD

  • Lidocaine

– Caution with significant cardiac history

  • Trigger point injections/ Ultrasound-guided

anesthesia training

– ACEP and Gulf Coast Ultrasound recommended

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DATA COLLECTION

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123.2 92.7 81.3 85.1 78.5 74.0 81.3 69.6 60.3 53.6 51.4 44.7 49.7 47.4 42.3 36.5 32.8 0.0 20.0 40.0 60.0 80.0 100.0 120.0

MME (IV) / 100 patient visits

↓ 73%

p<0.01

Baptist Memphis Opioid-Light ED Initiative 2017-2018

Morphine IV equivalents per 100 patient visits

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Provider Specific MME(IV)/100 Visits: August 2017

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22.2 30.1 33.7 40.4 45.3 45.5 46.1 47.2 53.6 54.4 60.1 62.6 64.1 64.6 66.3 77.9 82.7 94.4 97.7 109.2 124.6 125.0 127.6 138.9 178.8 200.0

20 40 60 80 100 120 140 160 180 200 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

MME(IV)/100 visits Provider 69.6 MME(IV)/100 visits

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Provider Specific MME(IV)/100 Visits: March 2018

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7.2 8.2 19.8 22.3 22.4 26.7 27.9 33.5 34.3 35.5 37.8 39.8 39.8 42.3 42.8 46.2 49.7 57.8 58.5 69.7 71.6 74.1 78.7 47.1 73.0 107.6 177.3 180.7

254 131 379 396 193 271 318 79 273 337 329 299 88 309 303 391 256 323 135 290 188 257 177 7 63 22 52 14

50 100 150 200 250 300 350 400 450 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA BB

MME(IV)/100 visits Provider

mME/ 100 visits #pts

42.3 MME(IV)/100 visits

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Provider Doses Per Patient: August 2017

5 10 15 20 25 30 35 40 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Patients (%) Provider

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13% of Patients Received an Opioid

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Provider MME (IV) per Opioid Type: August 2017

50 100 150 200 250 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z MME (IV) Provider

Morphine 5-10 mg Morphine 4 mg Morphine 2 mg Hydromorphone 2 mg Hydromorphone 1 mg Hydromorphone 0.5 mg

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Future Webinar Topics?

  • Potential policy updates

– Conscious/Moderate sedation – Ketamine

  • Example ketamine nursing education/competency
  • Provider/Nursing ALTO education
  • Patient education and pain management goals
  • Discharge prescribing options
  • Program goal setting

– Baseline data collection – Leader commitment

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Questions

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SLIDE 39

http://www.tnpatientsafety.com/resources/opioid-light-ed-collaborative

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IHI Open School 2018

  • THA is providing free access to the IHI Open School curriculum to employees and

trustees of our safety partner hospitals.

  • 32 online, self-paced courses including 92 lessons and corresponding resources—

videos, case studies, podcasts, featured articles, exercises, networking

  • Free app for the iPhone and iPad by logging onto iTunes
  • Over 30 contact hours available for CME, CNE, CPHQ and ACPE credit
  • Certificate of completion

1. Register at www.ihi.org/registerfull 2. Log in by going to www.ihi.org/login 3. Once logged in, go to www.ihi.org/enterpasscode and enter “5EE99B34” under “Access an Alternate Catalog using a Passcode”, then click “Get Access” 4. To access course material, go to www.ihi.org/professionalcourses and select Begin Online Learning 5. Click Begin Lesson

Contact Teresa Benedetti at tbenedetti@tha.com or 615-401-7414 for more information.

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IHI Open School Courses

  • QI 102: How to Improve with the Model for

Improvement

  • QI 103: Testing and Measuring Changes with

PDSA Cycles

  • QI 105: Leading Quality Improvement
  • PS 104: Teamwork and Communication in a

Culture of Safety

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Key Contacts

Tennessee Center for Patient Safety Jackie Moreland at jmoreland@tha.com Jennifer McIntosh at jmcintosh@tha.com

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Baptist Memorial Hospital – Memphis Dawn Waddell at dawn.waddell@bmhcc.org Zach Brent at Zachary.Brent@BMHCC.org Julie Bennett at julie.bennett@bmhcc.org