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CHRISTIANA CARE HEALTH SYSTEM  VALUE INSTITUTE

Implementation of an Opioid Withdrawal Clinical Pathway

• n an Inpatient Medical Service

Kimberly D. Williams, MPH Christiana Care Health System, Value Institute 10th Annual Conference on the Science of Dissemination & Implementation in Health December 4, 2017

Christiana Care Team

Kimberly D. Williams, MPH

Senior Research Associate, Value Institute

Beverly Wilson, MS

Senior Program Manager, Project Engage

Jo Melson, MSN, RN, FNP-BC

Nurse Practitioner, Unit 6 South

Erin Booker, LPC

Corporate Director, Behavioral Health

Sherry Hausman, MPH, CHES

Biostatistician, Data Informatics & Analytics

Terry Horton, MD

Chief, Division of Addiction Medicine Medical Director, Project Engage

All authors report no conflicts of interest or funding for this research.

Special thanks to entire team…

 Behavioral Health  Linda Lang, MD, Chair of Psychiatry, Behavioral Health (BH) Service Line Leader  Terry Horton, MD, BH Service Line Associate Physician Leader  Erin Booker, LPC, BH Service Line Corporate Director of Operations Leader  Kathy Willey, MD, BH Service Line CCQP Leader  Aliesha Rivera, MSN, RN-C, Nursing Professional Development Specialist I  Beverly Wilson, MS, Project Engage Senior Program Manager  Cheryl Botbyl, Project Engage Program Assistant  Internal Medicine  James Ruether, MD, Internal Medicine CCHP  Jo Melson, MSN, RN, FNP-BC, Wilmington Step-Down Unit  Bonnie Osgood, MSN, RN-BC, NE-BC, Nurse Manager Unit 4N  Emergency Medicine  Tom Sweeney, MD  Karen Toulson, RN, MSN, MBA, CEN, NE-BC  Women & Children’s Health  Elizabeth Zadzielski, MD, Women & Children’s Service Line Associate Leader  Patient Advocate  Chris Anderson, Patient Advocate  Pharmacy  Jeff Reitz, PharmD, Clinical Pharmacist Specialist  Erin Dzuriak, PharmD, Informatics Pharmacist  Data Informatics & Analytics  Sherry Hausman, MPH, CHES, Data Informatics & Analytics  Michelle Kane, MSN, RN, Data Informatics & Analytics  Organizational Excellence  Krystal Coles, Organizational Excellence Sr. Consultant, Six Sigma Master Black Belt  IT  Leslie Stevens-Johnson, IT BRM, BH Service Line  Carmen Pal, MSN, MBA, Information Technology  Rob Oakes, Power Chart Analyst, Information Technology  Value Institute  Kimberly Williams, MPH, Senior Research Associate  Claudine Jurkovitz, MD, MPH, Senior Physician Scientist

Opioid Epidemic in the Health System

Between 2005-2014

opioid-related ED visits increased by ~100%1 opioid-related inpatient visits increased by 64%1

Unidentified/ poorly treated opioid withdrawal may be associated with inpatients leaving against medical advice (AMA)2 Health care organizations well positioned to identify and treat patients with opioid use disorders at the point of care3

1. Weiss AJ et al. 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. 2. Lianping Ti, Lianlian Ti, Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review, American Journal of Public Health 105, no. 12 (December 1, 2015): pp. e53-e59. 3. US DHHS, Office of the Assistant Secretary for Planning and Evaluation. Opioid Abuse in the U.S. and HHS Actions to Address Opioid-Drug Related Overdoses and Deaths. ASPE. Published November 23, 2015. Accessed August 15, 2017.

Pathway Objectives

 Developed and implemented “Clinical Pathway” – care process model algorithm – to standardize clinical process and reduce variation in care for

• pioid withdrawal

 Developed pathway to: Proactively screen and identify admitted patients at risk for opioid withdrawal Better understand the prevalence of opioid withdrawal among medical service inpatients Provide at risk patients with timely medication- assisted treatment (MAT) and psychosocial support Improve clinical outcomes including AMA rates

Pathway Planning

Development of automated pathway included programming changes to inpatient EHR and physician order entry system Providers received education about new process and opioid withdrawal symptoms by addiction medicine specialist

Specialist continually available for consults after Pathway went live

Piloted on four medical units for five months through Nov. 2016 Scaled-up in all medical units throughout health system in Dec. 2016

Pathway Process Overview

Hospital Discharge

Referral to community-based treatment via provider, peer counselor, social worker

Inpatient Treatment

Medication Assisted Treatment: 72-hour Suboxone (buprenorphine & naloxone) treatment protocol Psychosocial Support: consult with social worker, peer counselor, psychiatrist

Exclusion Criteria

UDS + for benzos

• r methadone

Critically ill Admission to ICU within 24 hrs Scheduled for surgery Under chronic pain mgmt. Experiencing severe acute pain Pregnancy

Clinical Opioid Withdrawal Scale (COWS)*

COWS* score ≥ 8 is considered eligible for pathway

At Risk Patients Receive

Urine drug screen (UDS) for opioids, methadone, benzodiazepines, etc. Clinical Opioid Withdrawal Scale (COWS)* to monitor withdrawal symptoms & severity (Q8 x4)

2-item Risk Assessment

“At risk” patients answered yes to Q1 or Q2

*Wesson, D.R. & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs, 35(2), 253-9.

Pathway Process

Begins with 2-item universal screening tool to establish withdrawal risk for all admitted patients:

‘Yes’ to Q1 or Q2 = Positive Screen and patient identified as at risk for withdrawal

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?

• 1. Resting Pule Rate

(beats per min. _____) Measured after patient is sitting or lying for one min.

0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120

• 2. Sweating

Over past 1/2 hour not account for by room temp. or patient activity

0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face

• 3. Restlessness

Observation during assessment

0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 unable to sit still for more than a few seconds

• 4. Pupil Size

0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible

• 5. Bone or Joint aches

If patient was having pain previously,

• nly the additional component

attributed to opiates withdrawal is scored

0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching or joints/muscles 4 patient is rubbing joints or muscles & is unable to sit still because of discomfort

• 6. Runny nose or tearing

Not accounted for by symptoms or allergies

0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks

Wesson, D.R. & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs, 35(2), 253-9.

Clinical Opiate Withdrawal Scale (COWS)

• 7. GI Upset
• ver last 1/2 hour

0 no GI symptoms 2 stomach cramps 3 vomiting or diarrhea 5 multiple episodes of diarrhea or vomiting

• 8. Tremor
• bservation of outstretched hands

0 no tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching

• 9. Yawning
• bservation during assessment

0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/ minute

• 10. Anxiety or Irritability

0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious 4 patient so irritable or anxious that part

• 11. Gooseflesh skin

0 skin is smooth 3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection

Wesson, D.R. & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs, 35(2), 253-9.

Clinical Opiate Withdrawal Scale (COWS)

Total Score 5-12 Mild 13-24 Moderate 25-36 Moderately severe > 36 Severe withdrawal

2 3 5

Metrics

 Process Measures

 Admitted patients screened for opioid withdrawal  Screened patients identified as at risk for withdrawal  At risk patients in active withdrawal as measured by COWS score ≥ 8  Patients discharged with opioid withdrawal diagnosis  Patients received medication-assisted treatment (Suboxone) to manage withdrawal symptoms

 Outcome Measures

 7-day readmission rate  30-day readmission rate  Leaving hospital against medical advice (AMA) rate

Current Rates

Dec 2016 – Sep 2017 % N Total patients admitted to hospital

• 42,952

Patients screened with 2-item risk assessment tool 70.0% (30,084/42,952) At risk for opioid withdrawal per 2-item risk assessment tool 3.3% (990/30,084) Active opioid withdrawal (COWS score ≥ 8) 23.4% (232/990)

Data source: Christiana Care data warehouse

Current Rates

Dec 2016 – Sep 2017 % N Patients with ICD 10 discharge diagnosis, opioid withdrawal*

• 196

Suboxone treatment 45.9% 90/196

Left hospital Against Medical Advice (AMA) 11.7% 23/196 7-day readmissions 2.6% 5/196 30-day readmissions 6.1% 12/196

*Denominator: Medical DRG patients discharged with primary/secondary ICD10 diagnosis of opioid withdrawal:

• F11.23 (opioid dependence with withdrawal)
• F11.93 (opioid use, unspecified with withdrawal)

Data source: Vizient (UHC)

Lessons on Local Adaptation

 Proactive opioid withdrawal screening enables hospital to serve as “reachable moment” where patients can

 Successfully complete medical admission  Engage in substance use treatment (MAT and psychosocial support) as opposed to simply completing detox which increases risk for relapse and

• verdose

 Receive continuity of care with linkage to community- based drug treatment following discharge

 Staff education and leadership buy-in critical

Lessons on Local Adaptation

Opportunities identified

Coding of opioid withdrawal diagnosis potentially underreported (232 patients on pathway vs 196 patients coded) Education must be ongoing after implementation to ensure knowledge does erode over time Continuously assess fidelity to model (e.g., screening rate) to ensure sustainability of process

Next Steps

Evaluation underway to validate 2-item

• pioid withdrawal risk assessment tool

Enhanced data collection from validation study will enable deeper dive analysis of outcomes

Implementing adapted pathway in trauma, surgery, obstetrics, and emergency departments within our own health system In talks with other hospitals to disseminate and replicate opioid withdrawal pathway

Thank you

KimWilliams@ChristianaCare.org @Kim_D_Williams