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

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 June 2018 Webinar Dawn M. Waddell, PharmD, BCPS Clinical Pharmacy Manager Baptist Memorial Hospital - Memphis

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

THA Opioid-Light ED Pilot Participants • • CHI Memorial Healthcare Southern Tennessee Regional Health System – Lawrenceburg • CHI Memorial Hixson • Starr Regional Medical Center • Henry County Medical Center (Athens and Etowah campuses) • Maury Regional Medical Center • TriStar Ashland Medical Center • Methodist Germantown Hospital • TriStar Centenniel Medical Center • Methodist North Hospital • TriStar Hendersonville Medical • Methodist Olive Branch Hospital Center • Methodist South Hospital • TriStar Horizon Medical Center • Methodist University Hospital • TriStar Skyline Medical Center • NorthCrest Medical Center • TriStar Southern Hills Medical • Parkridge East Medical Center Center • Parkridge Medical Center • TriStar Stonecrest Medical Center • Parkridge West Medical Center • TriStar Summit Medical Center • Regional One Health • Vanderbilt University Medical • Saint Thomas Midtown Center

Break the Pattern Patient OPIOID Rx reports PAIN

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

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

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

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

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

Headache / Migraine • Tension Component – Cyclobenzaprine 5 mg – Diazepam 5 mg PO/IV – Lidoderm transdermal patch

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

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)

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

Extremity Fracture / Joint Dislocation • Goal to provide immediate treatment while setting up for blocks • Short-acting for joint reduction • Longer-acting for fracture pain

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)

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)

Renal Colic / Kidney Stones • Immediate/First-line Therapy – APAP 1000 mg PO – Ketorolac 15 mg IV – 1 L NS 0.9% NS bolus

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

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

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

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

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

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)

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

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

DATA COLLECTION

Baptist Memphis Opioid-Light ED Initiative 2017-2018 Morphine IV equivalents per 100 patient visits 123.2 120.0 ↓ 73% 100.0 92.7 p<0.01 85.1 81.3 81.3 78.5 MME (IV) / 100 patient visits 80.0 74.0 69.6 60.3 60.0 53.6 51.4 49.7 47.4 44.7 42.3 40.0 36.5 32.8 20.0 0.0

Provider Specific MME(IV)/100 Visits: August 2017 200.0 200 178.8 180 69.6 MME(IV)/100 visits 160 MME(IV)/100 visits 138.9 140 124.6 125.0 127.6 120 109.2 97.7 100 94.4 82.7 77.9 80 66.3 64.6 64.1 62.6 60.1 60 54.4 53.6 47.2 46.1 45.3 45.5 40.4 40 33.7 30.1 22.2 20 0 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 Provider 31

Provider Specific MME(IV)/100 Visits: March 2018 mME/ #pts 100 visits 450 396 391 400 379 42.3 MME(IV)/100 visits 350 337 329 323 318 309 303 MME(IV)/100 visits 299 290 300 273 271 257 256 254 250 193 200 188 177.3 180.7 177 150 135 131 107.6 100 88 79 69.7 71.6 74.1 78.7 73.0 63 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 52 47.1 50 22 14 7 8.2 7.2 0 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 Provider 32

Provider Doses Per Patient: August 2017 40 35 13% of Patients Received an Opioid 30 25 Patients (%) 20 15 10 5 0 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 Provider 33

Provider MME (IV) per Opioid Type: August 2017 Morphine 5-10 mg Morphine 4 mg Morphine 2 mg Hydromorphone 2 mg Hydromorphone 1 mg Hydromorphone 0.5 mg 250 200 MME (IV) 150 100 50 0 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 Provider 34

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

Questions

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