Beyond Morphine: Creating an Institutional Environment of Comfort - PowerPoint PPT Presentation

Beyond Morphine: Creating an Institutional Environment of Comfort for Children Experiencing Pain

Text the designated surveyor ID to 22333: Main Campus lisadavenpor389 West Campus tamaradubose684 The Woodlands dionnewalker380 Once you’ve joined, you’re ready to participate in the survey! J 2

CARE PROCESS TEAMS

Care Process Teams Standardize the management and care of patient conditions Measurable outcomes Collection and use of meaningful data Strategic alignment towards managing populations across the continuum of care

Pain Care Process Team Opioid Stewardship Workgroup Assessment Workgroup Treatment Workgroup Patient and Family Engagement and Education Workgroup

Opioids are Given to Patients System-Wide Number of Unique Patients 6,000 4,000 2,000 Data for Academic Year 2018 (July 1, 2017 – June 30, 2018), All Campuses

Opioids are Given to Patients System-Wide Number of Unique Patients 12,000 9,000 6,000 3,000 Data for Academic Year 2018 (July 1, 2017 – June 30, 2018), All Campuses

Opioid Stewardship in a Pediatric World Jennifer Placencia, PharmD, BCPPS Rohit Shenoi, MD

https://www.hhs.gov/opioids/sites/default/files/2019-01/opioids-infographic_1.pdf 9

The Opioid Crisis https://www.npr.org/2019/01/14/684695273/report-americans-are-now-more-likely-to-die-of-an-opioid-overdose-than-on-the-ro

Opioid Stewardship Utilize the Prescription Monitoring Plan (PMP) § Utilize PMP for every patient an opioid is prescribed Sticky-Notes for outpatient § Ensure use of PMP Drug Monitoring Program § Every patient needs a PMP assessment for opioid RX Risk assessments to identify potential opioid § Hard stops for opioid prescriptions to check PMP abuse/diversion Hard stop in Epic ordering PMP before prescribing § § Risk assessments for all preoperative patients opioids § Identify at-risk patients and/or families for potential opioid abuse/diversion Teach/Offer opioid storage/disposal § Risk assessment tool for families as well as § Counsel patients on how to dispose of leftover patients opioids including providing them with a bag to mail it § Risk assessment for high risk patients in when received from our pharmacy § Risk assessment § Educate patient and/or family about proper § Risk assessment tool for patients at risk for opioid security/storage of opioids and disposal risk § Education for disposal of medications in the § Initiate risk assessment tool for patient/family outpatient setting § Opioid stewardship - opioid recapture/retrieval at ortho surgical f/u appt, bring in unused medication to f/u appt 11

Texas Prescription Monitoring Program (PMP) ▪ PMP AWARxE § An electronic database used to collect and monitor prescription data for all controlled substances dispensed by a pharmacy – In Texas – Or to a Texas resident from a pharmacy located in another state ▪ The PMP also provides a venue for monitoring patient prescription history for practitioners and the ordering of Schedule II Texas Official Prescription Forms. ▪ Nurses may be listed as a delegate to check the patient’s PMP https://www.pharmacy.texas.gov/index.asp 12

House Bill 2561 (The Sunset Bill) § Currently, pharmacists and prescribers are Opioids Benzodiazepines encouraged to check the PMP to help eliminate duplicate and overprescribing of controlled Morphine Lorazepam substances, as well as to obtain critical controlled Hydromorphone Diazepam substance history information. Oxycodone Clonazepam Hydrocodone Alprazolam Fentanyl Clobazam § Passed During 2017 Legislative Session Tramadol Midazolam – Beginning September 1, 2019 , pharmacists and Methadone Carisoprodol Barbituates prescribers (other than a veterinarian) will be required to check the patient’s PMP history Phenobarbital before prescribing or dispensing certain controls. This date has now been changed to March 1, 2020 . https://texas.pmpaware.net/login https://www.pharmacy.texas.gov/index.asp 13

Texas Prescription Monitoring Program (PMP) § Standard related to Pain Management ▫ LD 04.03.13 – The hospital facilitates and practitioner and pharmacist access to the Prescription Drug Monitoring Program databases. https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF

Question Do you have any opioids in your medicine cabinet at home that are not currently being used? – Yes – No https://www.polleverywhere.com/multiple_choice_polls/xJeYPQO9u2VaLNdsrYRS8?preview=true&contro ls=none 15

Opioid Storage and Disposal § Standard related to Pain Management ▫ PC.0.1.02.07 – The hospital educates the patient and family on discharge plans related to pain management including the following: - Safe use, storage, and disposal of opioids when prescribed https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF

Sources of Abused Opioids Ages 12 or Older; 2013 and 2014 Other From more than one doctor Bought from drug dealer or 4% 3% other stranger 5% Stole from friend or relative 4% Bought from friend or relative 11% From a friend or relative for free 51% From one doctor 22% From a friend or relative for free From one doctor Bought from friend or relative Stole from friend or relative Bought from drug dealer or other stranger From more than one doctor Other SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2013 and 17 2014.

Medication Disposal https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#household 18

FDA Flush List Household Trash Disposal https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#household 19

The Pendulum Effect § The theory holding that trends in culture, politics, medicine, etc. tend to swing back and forth between opposite extremes. https://kerririchardson.com/the-pendulum-principle/ 20

Assessment Workgroup Lisa Davenport MSN BS RN RNC-NIC Corrie Chumpitazi MD MS Outcomes & Impact Better data, better decisions

Pain Assessment Team Our Journey… 22

Therapeutic Duplication – Pharmacy • Citation during 2017 JC Survey ▫ PC.01.02.07 – The hospital assess and manages the patient’s pain. EP3: The hospital reassess and responds to the patient’s pain, passed on its - reassessment criteria. • Tracer Findings: ▫ During a tracer, it was noted that the organization did not conduct a pain reassessment within the time frame as per the pain policy for the organization. ▫ During a tracer, it was noted that Fentanyl was given for pain and the patient was not reassessed per organizational policy. ▫ During a tracer, it was noted that a pain assessment was not conducted as required by organizational policy. ▫ Hycet was ordered for pain. There was no associated assessment or reassessment of pain associated with the medication administration as required by organizational policy.

Therapeutic Duplication – Pharmacy • Citation during 2017 JC Survey – MM.04.01.01 – Medication Orders are clear and accurate. ▫ EP 13 The hospital implements its policies for medication orders. • Tracer Findings: – There was an oral and IV narcotic ordered for a post-operative patient. Both were ordered for pain and there was no further guidance as to which medication to use. This is an example of therapeutic duplication which is not in accordance with the organization’s therapeutic duplication policy. – There was an order for Fentanyl for pain or sedation. The order was not clarified with the prescriber. – There was an order for diazepam rectal gel and Midazolam injection as needed for seizures. The order did not indicate the parameters for administration of either medication. – During tracer activities during record review, it was noted that two medications were written for the same indication without differentiation as to when each should be used in multiple records.

Identified Gaps per JC Citation • No policy existed to guide the nursing staff on which pain scale to use based on age, sedation status and cognitive status • How are the pain score results currently used? • How do the current scales in use translate to the clinical picture of the patient? • Are we using the most current evidenced based scales for our different populations and age groups?

Pain Assessment Care Process Team Goals ▪ To adopt the latest EBP Pain tools for usage at TCH ▪ To support staff and patients by way of a policy to guide pain assessment and reassessment at Texas children's ▪ To standardize and guide the usage of pain tools based upon age & Cognitive status ▪ To leverage technology to improve compliance for pain assessment and reassessment

Pain Assessment Care Process Team § Pain Assessment – Self report is the gold standard – Healthcare providers and parents universally underestimate pain 27

Pain Assessment Care Process Team § How do we use pain assessments? – For symptom evaluation and assessment – To direct treatment decisions – To indicate efficacy of treatment 28

FIRST THINGS FIRST …. 29