CHSP and CalHEN Opioid Adverse Drug Event Prevention Gap Analysis: Survey Findings

August 14, 2013, 2013

Welcome

Agenda

• Thank you for participating in the Opiate Adverse Drug Event Prevention Gap Analysis

• Review survey responses • Discussion and Questions

• Opportunities

• Participate in second gap analysis survey: hypoglycemia agents

Survey SectionsSection Header Number of Section

QuestionsNumber of Sub-

section QuestionsI. Prevention and Mitigation Strategies

4 7

II. Assessment and Detection Strategies

1 2

III. Therapeutic Strategies 2 2

IV. Critical Thinking and Knowledge Strategies

1 1

V. Patient Education 1 1

VI. Survey Evaluation 1 1

I. Prevention and Mitigation Strategies

# Sub-section Questions Total Number of Questions

7 31

Number who responded to question= 56 Number who skipped the question= 0

# 1. The facility has process in place to eliminate errors in opioid storage, preparation and dispensing, which include:

# 2. A pharmacist or pain provider provides oversight for all dosing of:

1h) Methadone. 1i) Fentanyl patches (at med-ication initiation only).

1j) Transmucosal immediate release fentanyl patches

(TIRFs) (at medication initia-tion only).

0

10

20

30

40

50

60

26

5

24

28

4924

Yes

No

Number who responded to question= 56 Number who skipped the question= 0

# 3. The facility’s opioid practices clearly specify the following:

Number who responded to question= 53 Number who skipped the question= 3

# 4. The facility has opioid administration and monitoring practice guidelines in place, which include:

Number who responded to question= 48 Number who skipped the question= 8

# 5. The facility has safety mechanisms in place for epidural opioid infusion processes which ensure:

4a) Epidural pumps are used only for epidural infusion

therapy.

4b) Epidural tubing is pre-connected in pharmacy when possible, and is incompatible

with non-epidural pumps.

4c) Epidural bags and bottles are clearly differentiated from IV infusions or piggybacks.

0

5

10

15

20

25

30

35

40

45

7

28

7

34

13

33

Yes

No

Number who responded to question= 44 Number who skipped the question= 12

# 6. The facility uses smart infusion pumps with drug libraries for the IV administration of all opioids (including PCA and epidural infusions), with functionality employed to:

4d) Intercept and prevent wrong dose errors 4e) Intercept and prevent wrong infusion rate errors.

0

5

10

15

20

25

30

35

40

45

50

9 9

35 34

Yes

No

Number who responded to question= 44 Number who skipped the question= 12

# 7. The facility’s nursing practice includes a process to double check opioid pump programming:

4f) At the start of their shift. 4g) With new narcotic infusion and PCA starts.

4h) With setting changes – ini-tiation of bag, bag change, and

shift change.

0

5

10

15

20

25

30

35

40

45

92 5

3140 35

Yes

No

Number who responded to question= 44 Number who skipped the question= 12

II. Assessment and Detection Strategies

# Sub-section Questions Total Number of Questions

2 12

# 8. The facility has a PACU discharge process in place to ensure patient is stable upon transfer which includes:

5a) Holding patients in PACU for at least 15 minutes following narcotic dose.

5b) Holding patients until safely cleared for transport ( at least 30 additional minutes) if

naloxone administered in OR or PACU.

0

5

10

15

20

25

30

35

40

45

711

3230

Yes

No

Number who responded to question= 42 Number who skipped the question= 14

# 9. A standard hand-off/transition communication process is in place for all patients receiving opioids which includes the following information, at minimum:

Number who responded to question= 42 Number who skipped the question= 14

5c) History of snoring, obesity & sleep apnea. 5d) Drug and dose history for the previous shift.0

5

10

15

20

25

30

35

40

45

19

8

1833

Yes

No

# 10. A protocol is followed which guides the reversal of opioids and includes the following:

6a) Reversal protocols are active on all pa-

tients’ MARs if there is an active order for a

narcotic.

6b) Nurses are allowed to administer reversal agents without prior

physician order.

6c) Strategies are in place to guard against

dose stacking.

6d) The facility utilizes a rapid response team to assist with possible narcotic oversedation

events.

05

10152025303540

17 2113

2

20 1623

36

Yes

No

Number who responded to question= 40 Number who skipped the question= 16

# 11. If an over sedation event occurs, the facility has a learning process in place which includes:

6e) All oversedation events are reviewed by expert staff and analyzed to identify improvement oppor-

tunities.

6f) A root cause anal-ysis is completed any time the use of a re-

versal agent results in a transfer to a higher

level of care.

6g) Data are collected and widely available on the rate of nalox-

one-reversal coded as an adverse drug

event.

6h) Collecting and reviewing data to as-sess compliance with dose guidelines and monitoring require-

ments.

05

10152025303540

6

17

6 9

31

20

31 27Yes

No

Number who responded to question= 40 Number who skipped the question= 16

III. Therapeutic Strategies

# Sub-section Questions Total Number of Questions

2 22

# 12. The facility has standard policies and practices in place for managing the initiation and maintenance of opioid therapy which include:

Number who responded to question= 34Number who skipped the question= 22

# 13. Practice guidelines for morphine include:

7j) Starting doses of IV push morphine do not exceed 2 mg IV morphine equivalent in the

opiate naïve adult patient.

7k) Titration guidelines for appropriate and safe clinical response.

0

5

10

15

20

25

30

35

18

10

15

20Yes

No

Number who responded to question= 34Number who skipped the question= 22

# 14. Practice guidelines for hydromorphone include:

7l) Starting doses of IV push hydromorphone do not exceed 0.4 mg

in the opiate naïve adult patient.

7m) Titration guide-lines for appropriate and safe clinical re-

sponse.

7n) Pharmacy repackages hydro-morphone into 0.2, 0.4, or 0.5 mg sy-

ringes.

7o) The facility’s renal opioid dosing program

includes morphine, meperidine (if used)

and oxycodone.

0

5

10

15

20

25

30

35

22

10

23

15

9

20

9

14Yes

No

Number who responded to question= 34Number who skipped the question= 22

# 15. The facility has a pain management process in place, which includes:

Number who responded to question= 32Number who skipped the question= 24

8a) A pain management specialist is available for consultation, ei-ther onsite or external, which provides mentoring as well as

specific consults.

8b) A pain medication steward-ship program is in place (e.g.

processes for identification and implementation of best practices, daily monitoring of adherence to best practices, plan for interven-tion of deviation from best prac-tices, processes for monitorin

8c) Standardized pain assess-ment scales are used throughout

the facility.

05

101520253035

Yes

No

# 16. 8.d .There is a process in place to discuss and agree upon specific pain goals and strategies with the patient prior to a surgical procedure.

Number who responded to question= 32Number who skipped the question= 24

56.3%

43.8%

Yes

No

# 17. The facility has practice guidelines in place for appropriate use of tactics to reduce opioid use, which include:

8e) Non-narcotic medications (e.g., NSAIDs, acetaminophen,

regional infusions of local anesthetics, steroids,

gabapentinoids, etc.) are rou-tinely used as a tactic to re-

duce opioid administration on the patient care units.

8f) Non-narcotic medications (e.g., NSAIDs, acetaminophen,

regional infusions of local anesthetics, etc.) are routinely

used as a tactic to reduce opioid administration in the

operating room.

8g) Non-pharmacologic ther-apy (e.g., healing touch,

massage, music, guided im-agery, aromatherapy, etc) is offered and maximized when possible, as tactics to reduce

opioid administration.

0

5

10

15

20

25

30

35

511

17

2619

13Yes

No

Number who responded to question= 32Number who skipped the question= 24

IV. Critical Thinking and Knowledge Strategies

# Sub-section Questions Total Number of Questions

1 4

# 18. The facility provides interdisciplinary education on opioid therapy, which includes:

9a) Initial training for new hires and existing staff, including proto-cols and guidelines.

9b) Post test incorporat-ing a case-study ap-

proach to demonstrate proficiency; covers top-ics such as dose stack-ing, dose equivalency, interpretation of vital signs and monitoring

equipment.

9c) Plan for targeting gaps in knowledge.

9d) Ongoing opioid education is provided when new relevant in-formation is available.

0

5

10

15

20

25

30

35

6

2016

10

25

10 1520 Yes

No

Number who responded to question= 32Number who skipped the question= 24

V. Patient Education

# Sub-section Questions Total Number of Questions

1 7

# 19. When initiating opioid therapy, patients/caregivers receive verbal and written information on purpose, action, side effects, and monitoring, including:

Number who responded to question= 31Number who skipped the question= 25

# 20. Is your organization a member of the California Hospital Engagement Network?

60.0%

40.0%Yes

No

Number who responded to question= 25Number who skipped the question= 31

Contact Information Provided

Number who responded to question= 12

Number who skipped the question= 44

Discussion and Questions

Next Steps

Survey Topic

Survey Date Distribution

Completed Survey Due

Date

30 min Sharing Call Scheduled

Hypoglycemic Agent Adverse Drug Event GAP Analysis

August 19th

August 30th

September 11th