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Implementation of an Opioid Withdrawal Clinical Pathway on an Inpatient Medical Service Kimberly D. Williams, MPH Christiana Care Health System, Value Institute 10 th Annual Conference on the Science of Dissemination & Implementation in

  1. Implementation of an Opioid Withdrawal Clinical Pathway on an Inpatient Medical Service Kimberly D. Williams, MPH Christiana Care Health System, Value Institute 10 th Annual Conference on the Science of Dissemination & Implementation in Health December 4, 2017 V CHRISTIANA CARE HEALTH SYSTEM  VALUE INSTITUTE

  2. 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.

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

  5. 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 care 3 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.

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

  7. 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

  8. Pathway Process Overview 2-item Risk Assessment “At risk” patients answered yes to Q1 or Q2 At Risk Patients Receive Urine drug screen (UDS) for opioids, Clinical Opioid Withdrawal Scale (COWS)* methadone, benzodiazepines, etc. to monitor withdrawal symptoms & severity (Q8 x4) Clinical Opioid Withdrawal Scale (COWS)* COWS* score ≥ 8 is considered eligible for pathway Exclusion Criteria UDS + for benzos Admission to ICU Scheduled for Under chronic Experiencing Critically ill Pregnancy or methadone within 24 hrs surgery pain mgmt. severe acute pain Inpatient Treatment Medication Assisted Treatment: Psychosocial Support: 72-hour Suboxone (buprenorphine & naloxone) treatment protocol consult with social worker, peer counselor, psychiatrist Hospital Discharge Referral to community-based treatment via provider, peer counselor, social worker *Wesson, D.R. & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs , 35(2), 253-9.

  9. Pathway Process Begins with 2-item universal screening tool to establish withdrawal risk for all admitted patients: 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? ‘Yes’ to Q1 or Q2 = Positive Screen and patient identified as at risk for withdrawal

  10. Clinical Opiate Withdrawal Scale (COWS) 0 pulse rate 80 or below 1. Resting Pule Rate 1 pulse rate 81-100 (beats per min. _____) 2 pulse rate 101-120 Measured after patient is sitting or 4 pulse rate greater than 120 lying for one min. 0 no report of chills or flushing 2. Sweating 1 subjective report of chills or flushing Over past 1/2 hour not account for 2 flushed or observable moistness on face by room temp. or patient activity 3 beads of sweat on brow or face 4 sweat streaming off face 3. Restlessness 0 able to sit still 1 reports difficulty sitting still, but is able to do so Observation during assessment 3 frequent shifting or extraneous movements of legs/arms 5 unable to sit still for more than a few seconds 0 pupils pinned or normal size for room light 4. Pupil Size 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 0 not present 1 mild diffuse discomfort If patient was having pain previously, 2 patient reports severe diffuse aching or joints/muscles only the additional component 4 patient is rubbing joints or muscles & is unable to sit still because of discomfort attributed to opiates withdrawal is scored 0 not present 6. Runny nose or tearing 1 nasal stuffiness or unusually moist eyes Not accounted for by symptoms or 2 nose running or tearing allergies 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.

  11. Clinical Opiate Withdrawal Scale (COWS) 0 0 no GI symptoms 7. GI Upset 2 2 stomach cramps over last 1/2 hour 3 3 vomiting or diarrhea 5 5 multiple episodes of diarrhea or vomiting 8. Tremor 0 no tremor 1 tremor can be felt, but not observed observation of outstretched hands 2 slight tremor observable 4 gross tremor or muscle twitching 9. Yawning 0 no yawning 1 yawning once or twice during assessment observation 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 Total Score 5-12 Mild 13-24 Moderate 25-36 Moderately severe > 36 Severe withdrawal Wesson, D.R. & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs , 35(2), 253-9.

  12. 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

  13. 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 3.3% (990/30,084) tool Active opioid withdrawal (COWS score ≥ 8) 23.4% (232/990) Data source: Christiana Care data warehouse

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