Project CLEAN Community Leaders Eliminating the Abuse of Narcotics Columbus Community Hospital National Rural Health Day November 16, 2017
Project CLEAN - Rural health...CCH Overall ED/UC Satisfaction – Patient Experience Rating, Rating of Care, and Likelihood to Recommend Restrictive Prescribing and Patient Perception
Project CLEANCommunity Leaders Eliminating the Abuse of Narcotics
Columbus Community HospitalNational Rural Health Day November 16, 2017
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- 75-85% of those who have become addicted to heroin started on prescription opioids
Current Environment
Current National Environment• National – United States in December 2014
• 80% -99% Consumption US makes up 4.6% of the world's population, but consumes 80% of its opioids (99% of the world's hydrocodone)
• 259 Million Health care providers wrote 259 million prescriptions for opioid pain relievers -“enough for every American adult in the US to have a bottle”
• 300% IncreasePrescription opioid sales in the United States have increased by 300% since 1999, with no overall change in the amount of pain reported
• 2 Million Almost 2 million Americans (age 12 +) either abused or were dependent on opioid pain relievers – self reported
• 16,234 (2013) to 28,000 (2014)Died from an overdose of opioids in the US. Each day, over 46 people die from an overdose of prescription painkillers.
14,000+ from Prescription Opioids8,300 > Heroin12,000 > Antidepressants13,000 > Cocaine
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The United States makes up only 4.6 % of the world's population, but consumes 80% of its opioids - and 99% of the world's hydrocodone, the opioid that is in Vicodin® (ABC News, April 20, 2011). Deaths: this is�- 8,300 more than heroin 12,000 than antidepressants 13,000 more than cocaine https://www.cdc.gov/vitalsigns/opioid-prescribing/index.htmlhttp://abcnews.go.com/US/prescription-painkillers-record-number-americans-pain-medication/story?id=13421828 https://www.cdc.gov/media/releases/2011/p1101_flu_pain_killer_overdose.html
Current National Environment
1980 - 5.6% to 2003 -12.4%
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US =#11 Quality (Low) and Cost (Highest) In order to combat its low ranking, the US Healthcare system is making efforts to shift from a volume to value based model. Value is the relationship between quality and cost In addition, vast opioid prescribing and consumption is extremely expense, further lowering the value equation. In the United States, personal healthcare spending on prescription drugs has increased from 5.6% in 1980 to 12.4% in 2003 and continues to rise Thus, prescribing excessive opioids is not aiding the US in providing value added healthcare CCH was proven to be a high value organization through ACA Impact on Wisconsin Hospital Providers in Regards to Value paper. Therefore, proof of high value status is beyond the scope of this analysis. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror Was a report in 2017 that mirrored this same issue - http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017
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According to the commonwealth fund, Wisconsin is within the top quartile for quality Top quality quartile states (2015 ranking) - Wisconsin is ranked #11 out of 51, Minnesota Vermont #1 Minnesota #2 Hawaii #3 Rhode Island #4 Massachusetts #5 Iowa #6 Colorado #6 New Hampshire #8 Connecticut #8 Washington #10 http://datacenter.commonwealthfund.org/#ind=1/sc=1 https://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html http://www.commonwealthfund.org/interactives/2017/mar/state-scorecard/
Rating of Care Likelihood to RecommendSatisfaction
CCH Mean PercentageCCH in WI Percentile BenchmarkCCH in National Percentile Benchmark
CCH Overall ED/UC Satisfaction – Patient Experience Rating, Rating of Care, and Likelihood to Recommend
Restrictive Prescribing and Patient Perception
2015 Formulated Restrictive Prescribing Practices
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Many believed that the combination of these efforts would have resulted in CCH ED/UC receiving low Patient Satisfaction Scores, specifically regarding the Patient Experiences measured through Care Rating and Likelihood to recommend and the Patient’s Perception of “how well your pain was controlled CCH’s ED/UC has been at or above the 90th percentile for over a year Recently received the 2016 Guardian of Excellence Award for patient experience
Local EnvironmentColumbia Dane Dodge
Population – 2013 (January – June) 56,753 503,072 88,807
Prescriptions 559,000 823,000 480,000
Prescription Percentage Narcotics 56% 55% 55%
Number of Narcotic Prescriptions 313,040 452,650 264,000
Narcotic Prescriptions To Population Per Person 5.52 0.90 2.97
Columbia Dane Dodge
Population – 2013 (January – June) 56,753 503,072 88,807
Prescriptions 559,000 823,000 480,000
Prescription Percentage Narcotics 56% 55% 55%
Number of Narcotic Prescriptions 313,040 452,650 264,000
Narcotic Prescriptions To Population Per Person 5.52 0.90 2.97
Columbia Dane Dodge
Population – 2013 (January – June) 56,753 503,072 88,807
Prescriptions 559,000 823,000 480,000
Prescription Percentage Narcotics 56% 55% 55%
Number of Narcotic Prescriptions 313,040 452,650 264,000
Narcotic Prescriptions To Population Per Person 5.52 0.90 2.97
Opioid Related Deaths – 2015 Per 100,000 Population 10.5 11.2 16.7
Opioid Related Hospitalizations – 2014 84.5 57.8 49.4
Prescription Opioid Related Hospitalizations – 2014 66.9 34.8 34.8
Ambulance Run -– Naloxone Administered – 2015 101.7 87.1 103.8
Neonatal Abstinence Syndrome – 2015 20.1 6.6 12.1
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https://www.dhs.wisconsin.gov/publications/p4/p45718-14.pdf https://www.dhs.wisconsin.gov/publications/p01690.pdf https://www.dhs.wisconsin.gov/wish/opioid/index.htm Columbia = Rural Dane = Urban Dodge = Urban
It is Real• National, state, regional and local! • Rural and urban• Problem in all of our communities• It is an Epidemic
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An epidemic is “a widespread occurrence of an infectious disease in a community at a particular time or a sudden, widespread occurrence of a particular undesirable phenomenon”. The United States has declared 16-18 epidemics since the 18th century (Understanding the Epidemic, 2016). The opioid issue has been tracked and rising since 1999-2000, the CDC announced the rising opioid issue as an epidemic in 2015 establishing great awareness and urgency to addressing the issue. More does not equal/does not relate to improved quality of healthcare
Project CLEAN• Program started in 2012 as a result of dissecting Emergency
Department Data
• Modeled after Antibiotic Stewardship Program • Focus on education
• 3 Fold:• Emergency Department Collaboration and Safeguards• Educating High School Students
and Communities• Physician Partnership and
Best Practice Recommendations
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6 Physicians from a variety of practices: Internal Medicine Emergency Medicine Family Practice General Surgery Hospital Administration – myself, CEO, VP of Patient Care And 2 Pharmacy Managers Acute condition Limited resources as CAH – do not start if cant sustain (AODA) Prevent accidental dependency from forming – head off the problem And prevent excess / left over in the community
• Patients who visit any of the collaborating Emergency Departments more than 10 times (in total) in one year • File is reviewed• If deemed “inappropriate” usage, a letter is sent to the patient
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Emergency Physician Letter
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DO NOT PRINT THIS SLIDE IN HANDOUTS
Education • Present at local high schools• Presenters: ED Physician, ED Manager and Law Enforcement
• Abuse and addiction of opiates • Dangers and risks of sharing opiates • Taking medications as prescribed or recommended
• Take less if able • Prescription does not mean safe• Psychological impact of opioids on the body and the brain• What to do with remaining opiates • Non-opiates avenues for pain
management
Education • “Craig’s Story” shows the danger, impact and effects that our
choices can have on ourselves and othershttps://www.youtube.com/watch?v=lmV3R8EqcKE
• Charge them to stay CLEAN
• Community Education• Ongoing• Geared toward adults and loved ones
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http://www.youtube.com/watch?feature=player_embedded&v=6SeqZs4tURI Video about 40 minutes
Physician Partnerships• Blind Matrix of 11 Prescribing Practices
• Identification of best practices and opportunities for improvement
• Education of Physicians and Delegates on PDMP• Prescription drug monitoring database• One on one pharmacy outreach regarding database utilization and
setup for physician and/or delegates • Tapering Schedule• Brochures and website creation for Project CLEAN• Future goals
• Standard pain agreement template for acute conditions
• Continue to increase awareness incommunities
Prescription Drug Monitoring Portal - PDMPs
• 49 States • Wisconsin’s PDMP
• Improve patient safety, reduce opioid abuse, and diversion of prescription drugs• All providers and pharmacists are required to submit information regarding
prescription drugs (Stages II-V) dispensed to patients in WI• April 2017, Providers are required to check the PDMP prior to prescribing
• 4 Exceptions
• CCH engaged in 1-on-1 training with providers and delegates
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Wisconsin has a Prescription Drug Monitoring Portal (PDMP) that was developed alongside the HOPE legislation. This portal is a tool designed to improve patient safety, reduce opioid abuse, and reduce diversion of prescription drugs. All providers and pharmacists are required to submit information regarding prescription drugs (Stages II-V; Stage I is illegal in the US) dispensed to patients in Wisconsin. In addition, providers are encouraged to check the PDMP before issue controlled substances to determine if the patient has already been prescribed an opioid, how much was prescribe and if any patterns are evident in regards to opioid prescriptions as a result of “doctor hopping”. “Forty-nine states have either an operational prescription drug monitoring program or have enacted legislation to establish a PDMP and are in the process of creating one”(In Wisconsin Department, 2016). From 2012 to 2013, both New York (75%) and Tennessee (36%) saw a reduction in patients “who were seeing multiple providers to obtain the same drugs,…[putting them] at a higher risk of overdose [and dependency]”. CCH’s Pharmacy Manager provided one-on-one training with each physician to (1) establish the physician within the PDMP; (2) show how to use the PDMP; (3) establish a delegate, such as his/her chief nurse, for the physician if desired; and (4) train the delegate on how to use the PDMP. However, neither the legal nor prescribing recommendations have had enough impact to stop the growing opioid epidemic. Knowing the issue, the root causes and challenges and what has been done is vital to knowing where one can head. CCH looked for a model to adapt or use as a guide but before an appropriate model can be found, CCH must know its limitations. Exceptions to the requirement to review are: - Patients receiving hospice care - Prescriptions intended to last the patient 3 days or less that are not subject to refill, - Drugs that are administered directly to the patient, - Emergency situations that prevent the practitioner from reviewing PDMP records, and technological failures.
Blind Matrix• Purpose
• To gain understanding on prescribing practices• Barriers encountered• Identification of best practices and opportunities for
improvement
• Results• Non-judgmental environment• Open dialogue• Collaboration among practices
Blind Matrix Best Practices• Chronic vs Acute Pain• 28 Day Cycle – Refills• EHR Default = 30 Tablets • Drug Testing – Presence vs Quantity • Standard Pain Agreements • Realistic Level of Pain
• No Pain, Moderate Pain, Tolerable Pain, Bearable Pain…what is the expectation of the patient’s pain?
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Not specific to patients pain expectation Habit vs need
Therapeutic Tapering• In pilot phase• Patient terms
• Behind the scenes - convert dosage to pill count• Goal is to:
• Show patients pain is a part of the healing process • Pain relief vs pain free• Goal of a “zero” pain level is dangerous
• Setting expectations with the patient• Number of pills prescribed and taken will decrease• If pain is not managed effectively with the
taper schedule, call their physician• Prescribing habit vs need• Meet CDC guidelines of 3 – 14 days,
if appropriate
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Number of pills prescribed and thus, taken, will decrease Prescribing habit: x pills per x days = standard pill count for pain rather than based per person. For example: I give 40 pills for pain. Need to be specific for that patient, their need vs another's
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This is the template Only 8 cells to fill in (tan)– two are drop down Rest automatically populates
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EFFECT SLIDE _ DO NOT PRINT
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Drop Down List By inserting how many hours a patient should go between taking pain medication, such as take one every 4 hours…the pill count per day calculates Select a tapering percentage – the CDC recommends 20% per day for those not addicted to pain medication – this can be done for most patients without adverse withdrawal type of effects Then select the date in which the patient should start – I selected todays date
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In this example I am prescribing: Hydrocodone 2.5 mg with Acetaminophen 325 mg (selected from my drop down list) per tablet to be taken every 4 hours (so it calculates 6 per day), I am also going to tell the patient that he can take 2 Ibuprofen (which I selected from my drop down list) as needed every 6 hours I selected the recommend opioid tapering of 20% by the CDC and a downward tapper of 5% of Ibuprofen so that they patient can still have some pain relief support after the opioid has been completely tapered off I put in today’s date and the rest calculates If you can sleep, then your body can heal! Not dependent on or currently on or have history of dependency
20% 10%
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After talking with my patient, I know he may not be able to handle the 20% taper because he does not have a high pain threshold so I am going to change the taper to 10% to allow for a longer process – I have kept everything else the same You can see that in the original scenario the patient completed his opioid medication on July 31and in this case he will be completing the taper on August 5th
20% 10%40%
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In this case, my patient has a much higher threshold of pain and after discussing with him, he would like to taper much quicker, so I am going to change the taper to 40% to allow for a shorter process – I have kept everything else the same You can see that in the original scenario of a 20% recommended taper, he will completed the taper on July 31 (18 pills) Second scenario of a 10% taper, he will completed the taper on August 5 (33 pills – average 50/40) In this scenario of a 40% taper, he will be completing the taper on July 29 (11 pills)
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Now I have put all the settings back to the original scenario : 20% taper This tool also identifies to the prescriber when the maximum dosage per day for Acetaminophen and Ibuprofen have been exceeded, when the opioid uses a combination per tablet such as the one shown. It computes the dosage within the combined tablet as well as the one prescribed in addition for further relief.
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Now you can see if I change the additional pain relief to Ibuprofen at 200 mg it will remove the max dosage restriction and allow the patient to take one every 6 hour because the patient is not exceeding his max dosage per day of Acetaminophen or Ibuprofen.
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This also works with an opioid by itself as show using Codeine 15 mg. In addition, you can change the date as well - in this case I selected a patient who is being late this evening and will have taken her medication before discharge and therefore, should start her regiment tomorrow
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After talking with the patient, she is nervous about her pain so I could also prescribe a non-opioid, such as Acetaminophen or Ibuprofen or any from the drop down list…I this case I selected Acetaminophen at the 5% downward trend, taking 2 tablets it every 6 hours , also starting tomorrow.
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After talking with the patient, she is nervous about her pain so I could also prescribe a non-opioid, such as Acetaminophen or Ibuprofen or any from the drop down list…I this case I selected Acetaminophen at the 5% downward trend, taking 2 tablets it every 6 hours , also starting tomorrow.
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Delayed Taper
Physician Tool• Designed as a tool for physicians to use with their patients
1. Cheat Sheet on how to print the graph2. Graph can be given to patients as a reminder and tool 3. Shortcut on desktops4. Screenshot directions5. Smartphrases
• Prescription Free Text:please refer to medicationschedule provided by physician. Quantity *** equals *** days.• Bottle Label: Refer to Medication Schedule
• FYI Flag: This patient is on a therapeutic taper schedule in media tab. Can be found under document type, therapeutic taper"
• Impact patient satisfaction - Pain Management Score• Overall are fewer opioids prescribed• Number prescribed = number taken• Opioid proper disposal
• Completed Taper Schedule • Overall are fewer opioids prescribed• Number prescribed = number taken
• PDMP
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These determinates will be measured through Patient Satisfaction Surveys distributed by Press Ganey (third party vendor already utilized by CCH so not an additional step) Therapeutic Taper Survey and cross verification of patients prescribed a taper and those who submitted their completed Taper schedule Therapeutic Taper Survey and completed taper schedule will provide the team with information regarding the number of opioid tablets remaining (not consumed by the patient), the number of tablets properly disposed of, patient perception of an individualized pain management program, and patient’s perception of adequate pain management. All patients must complete the survey and taper schedule and return it to CCH either by their next appointment or through the prepaid and preaddressed envelope provider within each folder. The Project C.L.E.A.N lead will Cross reference the Epic report of patients on therapeutic tapers within the last week to those who have submitted a completed survey and taper schedule. (Note: all HIPPA compliance requirements will be meet in relation to mailing Personal Health Information – PHI). The project lead will then discuss the verification findings with the appropriate providers to aid in continuous quality improvement and enhance patient satisfaction, health and wellbeing. A secondary check will be available to CCH’s Chief Medical Officer (CMO) as of April 2017. The team will gather approval from all participating physicians within the pilot program to allow the CMO access to their prescribing history through the PDMP. This will be added as a verification source and be cross referenced among the other two lists. PDMP will open their public resource library in which organizations will be able to pull organizational blind data related to specific medications societal issues such as opioid abuse.
