Narcotic Stewardship Project Right Size Prescribing Surgical - - PowerPoint PPT Presentation

Narcotic Stewardship Project

“Right Size” Prescribing

Surgical Services Clinical Program Douglas S. Swords MD Shelly Brimhall MSN Barbara Ostlund MSN Sathya Vijayakumar MBA-MS Jeannette Prochazska MSN Prem Narayanan MS David Skarda MD

Prescription Misuse is a Serious Problem

• Opioid overdose now the leading cause of

injury related deaths in the United States (surpassing MVA’s)

• Opioid overdose deaths quadrupled in the last

15 years

• 55% of opioid users received pills for free from

a family member or friend who had excess pills

• Persistent opioid use after surgery - 6%

Surgeons: Gatekeepers to Prescription Opioids

Annals of Surgery April, 2017 Issue.

Surgeons

• Swinging pendulum
• Law of unintended consequences
• No refills
• No call-in prescriptions
• Patient satisfaction scores
• Overprescribe
• Want to control pain
• Trust patients
• Don’t want to be called for more at 10:00 pm
• Difficult to give second prescriptions
• HCAHPS scores matter
• Mix narcotic naïve and narcotic exposed patients

“We might prescribe fewer if we knew how many patients take.”

Challenge Accepted

• Opioid Summit
• Opioid Community Collaborative
• Medication disposal drop boxes
• Naloxone rescue kits
• Increased caregiver training
• Pain Services Clinical Service
• New prescribing recommendations -

40% reduction

• Increased education – alternative

pain management strategies

How Intermountain is addressing Utah’s opioid epidemic: “It’s time for courage and leadership on our part…”

• Surgical Services Clinical Program
• Narcotic Initiative – Surgical Patient Pain Med Survey
• “Right Size” opioid prescribing recommendations - by

procedure/procedure type (based on data collected)

Current Process:

Rolled out to all Intermountain facilities

• n iCentra
• Began Jan. 9, 2017
• Patient provides email address
• 2 weeks postop – survey sent out
• Exclusions for now
• C-Sections (L&D), Endoscopy & CT Patients
• Averaging 31% survey response rate

Education…

How do we let patients know they will receive a survey?

• Address in Preop (PAT) phone call (scripting provided)
• Address in Post-op (discharge) phone call (scripting provided)
• Provide patients with a rack-card
• Rack-cards in OR waiting area for family members
• Inpatients – Included on MAWDS discharge teaching sheet &

can also print info with discharge teaching sheets

iCentra additions initiated March 9, 2017

SDS/PACU – Scripting about the Narcotic Survey now displays on the Preadmission Assessment and the Postop/Procedure phone call pages. The nurse making the phone call uses this verbiage to inform patients that they will receive a survey about their narcotic usage after surgery.

Scripting dialog

Rack-Card

Intermountain Pain Medication Patient Survey Example

 2017 Goal: Increase opioid stewardship, reduce excess opioids in the community, and decrease opioid misuse/abuse.

Method:

• Use patient-reported feedback to discover the quantity of opioids used by patients and their
• pioid-naïve status.
• Cross-reference patient-reported data with enterprise data warehouse opioids prescribed and

surgical records to discover use and procedure comparisons.

• Propose ideal opioid prescription quantities (ranges by procedure/procedure types)
• As of Wednesday, November 29, 2017:
• We sent 36,415 initial surveys
• Patients completed 11,113 surveys
• Average Initial survey response rate of 30.52%

Survey responses – Duration of Opioid Use Prior to Surgery?

Do you feel your pain was well controlled?

Survey Responses – Was Your Pain Well Controlled?

Pain Control Response Opioid Naïve Opioid Exposed Strongly Agree 77.50% 22.50% Agree 71.29% 28.71% Neutral 69.12% 30.88% Disagree 54.55% 45.45% Strongly Disagree 40.00% 60.00%

Pain Control Responses

What have you done with leftover tablets (or liquid) of your opioid pain medication?

Did you receive instructions after your surgery or from the pharmacy regarding how to properly dispose of any unused opioid pain medication?

 Intermountain drop boxes yield over 6,400 lbs. unused meds as of August 17, 2016

http://useonlyasdirected.org/

For your safety and the safety of your family and the community, we recommend that you Take any remaining pain medication to a safe disposal drop box located at Intermountain Community Pharmacy locations or other sites across the region. Use the Safe Disposal: Drop-off Locator to find a drop-off location near you: http://useonlyasdirected.org/throw-out/

Clinician Education Has Started:

• Mid November sent out first dosing

recommendation letters to:

• Gen Surg
• ENT
• Gyn
• Urology
• Addition of Obstetric

(C-sections & Vag-deliveries) population to the Patient Pain Medication Survey

Urology

GYN

ENT

Surgeon Messaging Now

• “Right Size” Prescribing
• Know how many doses patients use

after the operation

• Know if you patient has been taking

narcotics before your operation

• DOPL CSD
• Consider Naloxone for patients who

have been taking narcotics before the

• peration and may have a

respiratory/pain tolerance development differential

Surgeon Messaging Future

• “Right Size” Prescribing
• Prescribe the 2x the mean consumed

with a partial fill of 1x the mean consumed

• Tailor opioid prescriptions to patient’s

genetic phenotype

• Further pain medication prescriptions

should be from the PCP

Success

Consequences

Intended:

• Decrease deaths
• Decrease the development of

new addiction

• Decrease cost

Unintended:

• Increase the value of

prescription narcotics

• Supply/demand
• Drive current misusers to

alternatives

• Injection
• Impurities

Jay Bishoff

Acknowledgement/Credit

Questions