Hospitals in Action: Creating Safer Post-Operative ...

#Rx Summit www.NationalRxDrugAbuseSummit.org

Hospitals in Action:Creating Safer Post-Operative Management

to Reduce Opioid-Related HarmAsokumar Buvanendran, MD, Professor, Department of Anesthesiology, Rush University Medical Center, Committee on Pain Medicine Chair, American Society of Anesthesiologists

Roshni Ghosh, MD, MPH, Vice President and Chief Medical Information Officer, Premier, Inc.

Lynda Martin, RN, BSN, MPA, Senior Director Clinical Operations, Government Services, Premier, Inc.

Clinical Track

Moderator: Carla S. Saunders, DNP, APRN, NNP-BC, Advance Practice Coordinator, Pediatrix Medical Group, Neonatal

Nurse Practitioner, East Tennessee Children’s Hospital, and Member, National Rx Drug Abuse & Heroin Summit Advisory Board

MODIFIED FROM LIVE VERSION


Disclosures

Roshni Ghosh, MD, MPH; Lynda Martin, RN, BSN, MPA; and Carla S. Saunders, DNP, APRN, NNP-BC, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Asokumar Buvanendran, MD – Consulting fees: Recro


Disclosures

All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

The following planners/managers have the following to disclose:- Kelly J. Clark, MD, MBA, FASAM, DFAPA –

Consulting fees: Braeburn, Indivior


Learning Objectives

Describe a unique program geared toward hospitals and health systems to decrease opioid use in the post-surgical setting for patients undergoing common surgeries.

Summarize the preliminary findings related to the pilot program and what this means to hospitals and the overall impact on the national opioid epidemic.

Explain the systematic planning, data collection, use of standardized processes/outcomes, harm and cost avoidance measures, peer-to-peer learning, and continuous monitoring, evaluation and refinement of implemented strategies that drove the results of this program.


Hospitals in Action: Creating Safer Post-Operative Management to Reduce Opioid-Related HarmRoshni Ghosh, MD, MPH, Vice President, Chief Medical Information Officer, Premier Inc. Asokumar Buvanendran, MD, Professor, Department of Anesthesiology, Rush University Medical Center, Committee on Pain Medicine Chair, American Society of AnesthesiologistsLynda Martin, RN, BSN, MPA, Senior Director Clinical Operations, Government Services, Director Premier HIIN, Premier, Inc.


Disclosures Asokumar Buvanendran, MD, wishes to disclose he is the President of

American Society of Regional Anesthesia and Pain Medicine (ASRA) and has Research funding: NIH, Halyard. He will present this content in a fair and balanced manner.

Roshni Ghosh, MD, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Lynda Martin, RN BSN MPA, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.


Session ObjectivesUPON COMPLETION OF THIS COURSE, PARTICIPANTS WILL BE ABLE TO:

Describe a unique program geared toward hospitals and health systems to decrease opioid use in the post-surgical setting for patients undergoing common surgeries.

Summarize the preliminary findings related to the pilot program and what this means to hospitals and the overall impact on the national opioid epidemic.

Explain the systematic planning, data collection, use of standardized processes/outcomes, harm and cost avoidance measures, peer-to-peer learning, and continuous monitoring, evaluation and refinement of implemented strategies that drove the results of this program.


Premier is one of 16 Hospital Improvement Innovation Networks (HIIN) for the Centers for Medicare & Medicaid Services (CMS) National

Partnership for Patients Initiative

Two overarching goals:• 20% reduction in all-cause harm • 12% reduction in 30 day all-cause readmissions

Premier HIIN provides hospitals with:• Initiatives and strategies to improve patient safety• Safety Across the Board programmatic approach• Collaborative learning and networking opportunities

Hospital Improvement Innovation Network

Across 11 Harm Event Areas Other Topic Areas of Focus• Adverse Drug Events (ADE)• Catheter-Associated Urinary Tract

Infections (CAUTI)• Central Line Associated Blood Stream

Infections (CLABSI)• Clostridium difficile Infections (CDI)

and Antibiotic Stewardship

• Injury from Falls• Pressure Ulcers• Preventable Readmissions• Sepsis and Septic Shock• Surgical Site Infections (SSI)• Venous Thromboembolism (VTE)• Ventilator-Associated Events (VAE)

• All Cause Harm• Airway Safety• Methicillin-Resistant Staphylococcus

aureus (MRSA)• Person and Family Engagement (PFE)• Health Disparities• Leadership and Safety Culture


Safer Post-Operative Pain Management WHY: National opioid epidemic that needs to be tackled from multiple angles. The Premier HIIN provided an opportunity to address decreasing opioid usage from an inpatient setting

WHO: Premier HIIN and American Society of Anesthesiologists partnering with 32 Premier HIIN participating hospitals

OVERARCHING GOAL: Measurably reduce and/or prevent opioid-related harm among adult surgical patients having hip or knee arthroplasty or colectomy procedures to improve the safety of opioid-related post-operative pain management by providers, clinicians and patients/caregivers

MEASURABLE GOALS: Reducing opioid-related ADEs among adult inpatients undergoing elective hip and knee

arthroplasty or colectomy procedures. Improving safety with the appropriate, patient-centered and coordinated use of opioid-

related pain management across the perioperative continuum. Preventing misuse and potential for abuse of opioids post-discharge. Reducing and/or avoiding healthcare associated costs from opioid-related ADEs.

TIMEFRAME: September 2017 – March 2018


Opioid Pilot Driver Diagram


Rationale for Opioid Pilot Design N=147 (only opioid naïve patients) and followed 5 common outpatient surgery

procedures at academic medical center Postoperative opioid prescriptions entered into the EMR, refill data, and patient

outcomes were tabulated. A phone survey was then conducted on all patients who were operated on and received

an opioid prescription from June through December 2015.

Hill et al. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Annals of Surgery. Sep 14, 2016

Prescribed

Prescribed

Taken

Taken


Opioids, Surgery and Postop Pain Pills

Study Results: Of the 127 patients with completed phone survey data: 117 had excess pills 9% of these patients disposed of their excess opioids in an FDA approved fashion 5% returned them to a DEA approved collection site 4% flushed them down the toilet > 50% of the patients didn’t recall a disposal method or still had them in their

possession

An “ideal” number of pills to prescribe for each operation was calculated by determining the #of pills that would satisfy about 80% of patients’ postoperative use. Partial mastectomy = 5 pills Partial mastectomy with sentinel node biopsy = 10 pills or less Laparoscopic cholecystectomy = 15 pills Laparoscopic inguinal hernia repair = 15 pills Open inguinal hernia repair = 15 pills

Hill et al. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Annals of Surgery. Sep 14, 2016


Why Did Hospitals Participate? Recognition for the the hospital as a leader and a driver of change Opportunity to redesign workflow for high reliability Increased focus on partnerships with patients and families Reduce data collection burden Organized forum to educate clinicians with evidence-based practices Anticipate and prepare for regulatory/accreditation requirements


Opioid Pilot Program Specifics Systematic plan for applied performance improvement

- Steering Committee- Rapid-cycle performance improvement with small tests of change- Continuous monitoring, evaluation and refinement of implemented strategies to

drive results Monthly Webinars, Office Hours and Technical Assistance

- Education and access to subject matter experts- Peer to peer networking, sharing and learning- Technical assistance and coaching

Tools and resources- Pre and Post-pilot Assessment Tool- Monthly performance reports demonstrating hospital and cohort progress

Evidence-based guidelines, tools and resources on PremierConnect portal Patient and Family Engagement activities

- Patient and family stories Standardized process, outcome, utilization, cost and harm avoidance

measures

What Pilot Participants Can Expect

16

Multi-faceted project plan coupled with a programmatic approach Access to expert faculty to answer questions or provide guidance Premier HIIN Partner integration of opioid pilot project activities into

hospital’s regular cadence of coach calls and/or site visits Monthly reports demonstrating hospital progress as well as the cohorts

progress, to aid in discussing, planning and developing actions plans to address identified opportunities for improvement


Premier/ASA PartnershipAnesthesiologists play a critical role before, during and after surgery to appropriately treat the acute pain from surgery. They are on the front-lines for the chosen patient population to influence opioid use. ASA is an Educational, Research and Scientific association of physicians

organized to raise and maintain the standards of the medical practice of Anesthesiology and improve the care of the patient with 52,000 members.

ASA is the leading authority through their faculty and subject matter experts to help educate hospital care teams on best practices for opioid pain management; regional anesthesia and analgesia with a multimodal approach

Alignment of Premier and ASA Premier is focused on looking at reducing harm, improved outcomes and

cost savings in the inpatient setting ASA is focused on safe perioperative medicine and evidence based

science and how interventions are changing clinical practice in acute pain


Webinar and Office Hours Series#1 Opioid Pilot Kickoff Introduction and onboarding to the opioid

pilot program, goals, monthly audits, and data performance measures

#2 Safer Medication Management Overview of opioid medication guidelines

including strategies to decrease overuse, misuse and inappropriate prescribing

#3 Safe Anesthesia Practices for Management of Post-operative Pain Overview of pre-surgical screenings and

medication management for surgical procedures including nerve-blocks

#4 Multi-modal Practices for Management of Post-operative Pain Overview of the role of the prescriber, pre-

screenings, Assessments, Multi-Modal strategies, and documentation

#5 Multi-modal Practices for Monitoring of Post-operative Pain Overview of capnography monitoring, pain

and sedation screening tools, safe use of PCA, technology, role of nursing response, and handoffs

#6 Discharge Planning for Management of Post-operative Pain Overview of patient education focused on

medication management and discharge planning including safe medication use, storage, disposal and constipation management

#7 Decreasing Addiction Overview of facts and definitions of addiction,

basics of screening, brief intervention and referral for treatment, importance of collaboration and strategies for safe perioperative opioid prescribing, patient/family engagement for prevention of opioid misuse and patient stories

Purpose of Monthly Series Education and access to subject matter experts Sharing of results Peer to peer networking, sharing and learning


Pre and Post-pilot Assessment ToolCompleted by multidisciplinary team Purpose Pre-pilot hospital self-assessment with

evidence-based practices and gap analysis to surface opportunities for improvement

Aggregate results analysis serves as a checks and balances to ensure pilot design aligns with hospitals needs

Post-pilot hospital self-assessment with performance and success with implementing and sustaining best practices

Alignment CMS Conditions of Participation for

postoperative patients receiving opioids The Joint Commission 2018 Pain

Assessment and Management Standards Evidence-based guidelines/standards


Hospital Small Tests of ChangeMultidisciplinary TeamsEngaged EMR team to assist with build of tools neededTeams working to improve and standardize patient/family education when discharged on an opioid

Discharge callsCalling a small sample of discharged patients to assess effectiveness of pain management regimen and ascertain number of pain medications taken since discharge

Discharge Instructions Revising current discharge instructions to include opioid bundle

Electronic Medical Record (EMR)Surgeons championing the use of EMR function for morphine milligram equivalent (MME) dosing

AssessmentsStandardizing use of the ‘STOP-BANG’ assessment within facility and system

ReportsUsing a new report to see who is prescribing and how much is being prescribed

Patient and Family EngagementPiloting a new way to document the pain management plan of care, goal and patient/family involvement

EducationNursing education regarding opioid discharge documentation


Engaged as partners in developing safe post-op pain management plan- Resetting post-operative pain management expectations- Use of MMA and alternatives to opioids

Pre-operative screening - Opioid naïve or opioid tolerant - Substance abuse (past or current)

PFE Subject Matter Experts Patient and family stories – live and video clips Tools and resources

- CDC Rx Awareness Campaign Materials

Patient/Family Engagement


Measures and Reports Process Measures

- Hospital submits – monthly audit and report• Process Bundle measures - near-real time data collection • Rapid-cycle improvement with small tests of change• Reporting on successes, challenges and lessons learned

Outcome measures- Claims-based and AHRQ Patient Safety Indicator (PSI)

• Opioid-related adverse drug events (ADEs)• Naloxone reversal• Postoperative Respiratory Failure (PSI-11)

Opioid utilization measures • Opioid utilization • Average daily dose • High dosage

#Rx Summit www.NationalRxDrugAbuseSummit.org23

GOAL: 100% compliance with performance and documentation of all six elements

Process Bundle Measures


Pilot Hospital Dashboard Reports

Hospitals receive performance dashboard reports Demonstrate the hospital

and the cohorts progress Aid hospital in discussing,

planning and developing action plans to address identified opportunities for improvement


Management of Pain

Evidence Based Science: Clinical Pathway OSA System issues in postoperative

monitoring Anticoagulation Anesthetic technique Concerns over postoperative pain

management

Main Elements of the Pathway: Preoperative patient education Correction of preoperative risk

factors Multimodal analgesia Anesthetic technique Early rehabilitation programs Dealing with outliers

Nabil Elkassabany, M.D. MSCEAssistant ProfessorDirector of Orthopedic and Regional AnesthesiaDepartment of Anesthesiology and Critical CareUniversity of Pennsylvania, Philadelphia, PA


Spinal Cord

Tissue Injury

Inflammatory Mediators

Neuronal Pathway

Arachidonic acid

Regional Anesthesia & Analgesia

X

Multimodal Analgesia

X

Surgery and Pain Mediators


Pain Management ProtocolsCDC Guideline for Prescribing Opioids for Acute Pain: Recommendation #6

Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe

the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. - Recommendation category: A - Evidence type: 4

https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf. Accessed August 2016.http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed August 2016.


Multimodal Analgesia (MMA)

Role of the Anesthesiologist: Balanced multi-modal approaches

in the context of a multi-disciplinary pathway is likely the best approach

Anesthesiologists can be leaders in writing these pathways

Anesthesiologist can help implement the approaches as well

Why Strategize about Postoperative Pain: National opioid prescribing

reduction goals Growing understanding that

approaches should differ as a function of the type of surgery

Need to group data to better characterize options

Common approaches may not be optimal

Brian D. Sites, MD MSProfessor of Anesthesiology and Orthopedic SurgeryDartmouth-Hitchcock Medical Center

MMA is the combination of different analgesics that act by different mechanism, resulting in additive or synergistic analgesia with lowered adverse effects; compared to sole administration of an individual pharmacological agent


Ketamine, Dextromethorphan,Memantidine Clonidine, Dexmedetomidine, Gabapentin, Pregabalin, COX-1 & 2 inhibitors, Acetaminophen

PAIN

Ketamine, Magnesium, Clonidine, Gabapentenoids, Local anesthetics, COX-1 and COX-2 inhibitors

Clonidine, Steroids, Neostigmine, local anesthetics

Clonidine

Dexamethasone

Local Anesthetics

COX-1 &2 inhibitors

Tissue

MMA for Perioperative Pain


Post Op Regional Anesthesia

Epidural analgesia is the insertion of a needle into the epidural space (outside the spinal canal) with injection of medication to promote pain relief. A catheter (tube) is commonly inserted and used to continuously infuse medication

Edward R. Mariano, M.D., M.A.S.Chair, ASA Committee on Regional Anesthesia and Acute Pain MedicineProfessor of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine


Persistent Post Surgical PainRisk Factors for Persistent Post Surgical Pain (PPSP): Patient phenotypic factors

- Preexisting pain before surgery

- High consumption of analgesic medications preoperatively

- Catastrophizing- Severe acute

postoperative pain Patient genetic factors (~45%) Nerve injury during surgery,

inflammation, and neuronal plasticity

Edward R. Mariano, M.D., M.A.S.Chair, ASA Committee on Regional Anesthesia and Acute Pain MedicineProfessor of Anesthesiology, Perioperative and Pain Medicine Stanford School of Medicine

Richebe P, et al. CJA 2015;62:1329Clarke H, et al. CJA 2015;62:294

Gilron & Kehlet. CJA 2014;61:101


Post- Op: Decreasing Addiction

Addiction is a Disease not Moral Failing: Substance use disorder (SUD) is

defined as a problematic pattern of substance use leading to clinically significant impairment or distress manifested by clinical criteria (DSM-V

Antje M. Barreveld, MDDirector, Substance Use ServicesMedical Director, Pain Management ServicesNewton-Wellesley Hospital, Newton, MA

video.nationalgeographic.com/video/magazine/focal-point/170822-NGM-focal-point-addiction

http://video.nationalgeographic.com/video/magazine/focal-point/170822-NGM-focal-point-addiction


Post- Op: Decreasing AddictionWhat is medication assisted addiction treatment (MAT)?MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders

Common agents use Methadone Mixed agonist anatagonist

(Buprenorphine) Pure antagonist (Naloxone and

Naltrexone)

Safe Pain Management and SUD: Solution?We must rethink the old treatment paradigms as well as provider, patient and family education programs to address and coordinate patients’ multidisciplinary options: Addiction screening and care Non-opioid medication

management Physical therapy Behavioral management Education Interventional management Lifestyle modifications, alternative

therapies, and more

Antje M. Barreveld, MDDirector, Substance Use ServicesMedical Director, Pain Management ServicesNewton-Wellesley Hospital, Newton, MA


Pathway for Positive ScreensAntje M. Barreveld, MDDirector, Substance Use ServicesMedical Director, Pain Management ServicesNewton-Wellesley Hospital, Newton, MA

Proposed Approaches: Utilize best practices in

safe opioid prescribing and maximize non-opioid pain management strategies and education

Provide compassionate care – without judgement and without stigma

Ensure collaboration between the patient, providers, and families

High (8 or higher on audit c or 6 or higher dast 10)

Low risk

Medium (<8, on audit c or <6 on dast 10)


Hospital Identified Successes

Pilot Design Pre-pilot assessment and monthly

audit tool provided focus and identified gaps, opportunities and prioritization for action Validated the need to modify current

practice Served as an impetus for change

Opioid Process Bundle Education and monthly monitoring

improved compliance with use of the full process bundle

Multi-modal Analgesia (MMA) Improved use of MMA

Electronic Medical Record (EMR) Added opiate use to the pre-op assessment

Added opioid naïve, tolerant, dependent

Incorporated opioid-related discharge instructions

Multidisciplinary Team Enhanced multidisciplinary team

collaboration

Partnered with Physical Therapy Improved documentation of the pain

management goal and patient/family agreement with the plan

Surgeon-to-surgeon collaboration and education on use of MME and MMA evidence-based practices


Hospital Identified Challenges/Barriers

Multidisciplinary Team Delayed engagement with pilot due to:

Internal infrastructure Forming of new multidisciplinary team Education of staff

Hospital Competing Priorities Staffing constraints

Sufficient time for participation

Multiple opioid related projects occurring within the hospital at the same time

New EMR implementation

Documentation Inconsistent documentation of evidence-

based practices

EMR EMR lacks capabilities to support

documentation of all pilot elements

Knowledge Deficit Definitions of opioid naïve and opioid

tolerant

Appropriate use of evidence-based practices and/or tools Pre-screening tools Pain and sedation assessments Use of MMA and alternatives to opioids


Opportunities and Lessons Learned

Timing of Pilot Milestones Recruitment

Use a hard stop date for ending recruitment to pilot

Pre-pilot activities Allow longer timeframe for hospital

completion of pre-pilot activities

Webinar and Office Hours Selection of time slots to allow for

greater multidisciplinary team participation in live events

Engagement HIIN Partner with hospitals

Begin with pre-pilot phase to provide seamless support and enhanced engagement

Hospital staff Provide separate onboarding for staff

completing the process audit tool to ensure understanding of definitions and process for standardized and accurate completion

Process Audit Process audit tool

Refine process audit tool to ensure capturing of compliance with all process bundle elements


What’s Working…Thus Far Multidisciplinary team participation Educational webinars meeting participant needs Pre-pilot assessment results aligned with program design

and education Patient and family stories Small tests of change Use of shared best practices, resources and tools Use of existing resources and tools


Next Steps Conduct remaining webinars and Office Hours calls Continue technical assistance Measures and evaluation

- Analysis of results• Process, outcome, and opioid utilization measures• Harm and cost-avoidance measures

Conduct post-pilot assessment and formal evaluation of pilot- Qualitative and Quantitative Evaluation

White Paper Plan for scale and spread

39


Conclusion Safer post-operative pain management is a team sport

- Leadership support and championing- Patient and family engagement- Multidisciplinary team collaboration

Key drivers of change- Raise awareness regarding risks of opioid

misuse/potential for abuse- Appropriate pre-operative opioid pain management

planning- Appropriate intra-operative anesthesia management- Appropriate post-operative opioid pain management- Patient and family engagement with pain management

plan


Conclusion (Continued) Use of evidence-based and/or best practices to reduce

opioid prescribing and safer pain management- Assessing patient’s opioid tolerance at multiple points in

the perioperative episode of care- Use of MMA and alternatives to opioids

Preliminary findings are promising for reducing opioid-related adverse drug events and improving safer postoperative pain management among adult inpatients undergoing elective hip and knee arthroplasty or colectomy procedures - These findings are also encouraging as they suggest

some of the processes can be extrapolated to help manage other forms of acute pain


Hospitals in Action:Creating Safer Post-Operative Management

to Reduce Opioid-Related HarmAsokumar Buvanendran, MD, Professor, Department of Anesthesiology, Rush University Medical Center, Committee on Pain Medicine Chair, American Society of Anesthesiologists

Roshni Ghosh, MD, MPH, Vice President and Chief Medical Information Officer, Premier, Inc.

Lynda Martin, RN, BSN, MPA, Senior Director Clinical Operations, Government Services, Premier, Inc.

Clinical Track

Moderator: Carla S. Saunders, DNP, APRN, NNP-BC, Advance Practice Coordinator, Pediatrix Medical Group, Neonatal

Nurse Practitioner, East Tennessee Children’s Hospital, and Member, National Rx Drug Abuse & Heroin Summit Advisory Board

THANK YOU#RxSummit

www.NationalRxDrugAbuseSummit.org

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