9/8/2014. I have no conflicts of interest to disclose. Conflict of Interest Disclosure. Carrie Brunson: Except
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1 ENSURING OPIOID SAFETY: DO OUR NURSES POSSESS THE KNOWLEDGE Click to add subtitle TO RESCUE PATIENTS? Carrie Brunson MSN, APRN-BC, ACNS-BC Clinical Nurse Specialist Acute Pain Service September 2014 ASPMN National Conference Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 1 Conflict of Interest Disclosure I have no conflicts of interest to disclose Carrie Brunson: Except Any views or opinions in this presentation are solely those of the author/presenter and do not necessarily represent the views or opinions of the American Society for Pain Management Nursing. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 2 Non-Profit, Faith Based ADC ,000 ED Visits Per Yr 18,345 Inpatient Admits Yr Approx 8,000 inpatient Surgeries per Yr Largest Hospital in 8 Hospital System Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 3 1
2 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 4 Discuss recent regulatory body recommendations for improving patient safety related to opioid therapy Describe how results of random nurse interviews were used to support funding for opioid safety education Describe how engaging the heart, utilizing a pre-test/post test format and sharing data with nursing staff helped transform the culture of pain management at our organization Carrie Brunson contact information kpaincns@live.com Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 5 How times have changed Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 6 2
3 "She could light up a room just walking though the door," her father said. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 7 Opioid Timeline 1950s Opioid use discouraged, Cancer feared, elective surgeries deferred, chronic pain tolerated 1960s Methadone treatment introduced, St. Christopher Hospice s 1970s 90s CR opioids marketed Morphine ~1992, Oxy s JCAHO, chronic VA-5th pain, positive vital trials sign, of opioids other for pain non-cancer quality pain initiatives IASP 1973, APS 1977, Pain Medicine, Aggressive tx cancer pain & acute pain, Interdisciplinary care of chronic pain Observations cancer pts not inevitable addicted or tolerant, interdisciplinary care of 1990s Controlled/Extended release opioids marketed, morphine 1992, oxycontin 1995 Era of *****TJC possibilities: & VA Health pain Systems can be PAIN vanquished! IS THE 5 TH VITAL SIGN, Pain Quality Initiatives Started, Opioid therapy for all pain increases-no CEILING ON OPIOIDS Pain Technologies Evolve 2014 Medicine as business with decline in Interdisciplinary Pain Management and extensive increase in opioid sales and marketing. Accidental Opioid Overdose deaths have quadrupled since 2006, Exceed deaths from MVC, United States Consumes 90% of the world s supply of opioids Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 8 While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 9 3
4 On September 13 th, 2013 in Colorado we suffered a tragedy because we were not prepared in advance for the destruction that would come Fatalities -- 8 killed [Boulder (4), El Paso (2), Clear Creek (1), Larimer (1)] Missing -- 1 (Presumed dead in Larimer County) Homes destroyed -- 1,882 Homes damaged -- 16,101 Businesses destroyed Businesses damaged Number of people evacuated -- 5,958 Number of people evacuated by air -- 2,256 Number of pets evacuated by air -- 1,047 Animals in pet shelters as of 9/24/2013 Shelters -- 4 Counties impacted by flood 17 Miles of road damaged Square miles affected -- 1,533 Cost to repair bridges, roads -- $475 million Retrieved from denverchannel.com/news/local-news/colorado-flooding-by-thenumbers-a-look-at-the-destruction-caused-by-the-september-2013-floods July 20, 2014 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 10 Retrieved from July 17, 2014 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 11 Retrieved from July 17, 2014 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 12 4
5 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 13 Retrieved from July 17 th, 2014 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 14 Evaluation Strategy for Risk Assessment & Monitoring Frequency Retrieved from SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter pdf Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 15 5
6 Focus on Error Prevention- Not RCA after an Event Anesthesia Patient Safety Foundation (APSF) 2006 Dangers of Postoperative Opioids Opioid-Induced postoperative respiratory depression is a preventable cause of morbidity and mortality Postoperative Opioids need system wide overhaul Anesthesia Patient Safety Foundation (2012) the conclusions and recommendations of APSE are that intermittent spot checks of oxygenation (pulse oximetry) are not adequate for reliability recognizing clinically significant evolving drug-induced respiratory depression in the post-operative period. Institute for Safe Medication Practices (ISMP) One reason why it (periodic spot checks by caregivers and pulse oximetry) is not effective is that a periodic check and pulse oximetry would only catch an error, not prevent the error & 2. Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 16 We Need a Clearly Defined Rescue Operation Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 17 Achieving Balance While Maintaining Safety How do we achieve balance between keeping patient s safe and meeting the pain satisfaction expectations? Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 18 6
7 Stakeholder Gap Analysis Nursing Leadership & Bedside Pharmacy Anesthesia Respiratory Risk Quality Educators APN Pain Management Internal Medicine Critical Care Surgical Services Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 19 Organization Performed Gap Analysis to Prioritize Safety Actions Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 20 Random Survey from all Nursing Units to Determine Level of Knowledge What did our nurses already know? What were they struggling with? Did they know how to use the equipment (End Tidal C02 Monitor) and leverage the technology available? What method of learning did they prefer? Did they possess the knowledge to anticipate opioid induced progressive respiratory depression AND did they have the knowledge to rescue the patients? Include Pre and Post Test to Measure Knowledge and planned a 6month to one year follow up to measure retention of knowledge Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 21 7
8 52% Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 22 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 23 We shared the standard of practice American Society Pain Management Nursing Position Statement All nurses caring for patients receiving opioid therapy should be educated about individual risk factors for opioidinduced unintended advancing sedation and respiratory depression Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 24 8
9 Curriculum Content Extensive Literature Review of Practice Recommendations Shared their own practice data Discussed opioid deaths in and out of hospital Patient Risk Factors Iatrogenic (Hospital) Risk Factors Treatment Risk Factors Differentiation of Oxygenation and Ventilation & Measurement of Each Normal Values & Symptoms of Hypoxia Sedation Assessment Rescue Actions Policy Review Documentation Expectations Non-Opioid therapies to manage pain WE MADE IT FUN!! Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 25 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 26 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 27 9
10 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 28 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 29 Although pulse oximetry will monitor oxygenation during PCA, it may have reduced sensitivity, as a monitor of hypoventilation, when supplemental oxygen is administered. When supplemental oxygen is indicated, monitoring of ventilation may warrant the use of technology designed to assess breathing or estimate arterial carbon dioxide concentrations. Continuous monitoring is most important for the highest risk patients, but depending on clinical judgment, should be applied to other patients Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
11 Pasero, 2009 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 32 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
12 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 34 SEDATION PRECEDES RESPIRATORY DEPRESSION Sisters of Charity of Leavenworth Health System, Inc. All rights reserved Evaluations from Staff Were Overwhelmingly Positive Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
13 Our Current Methods are Broken Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 37 When medications get into the wrong hands, bad things can happen.. Reviewed literature from ISMP, TJC, FDA and many other organizations and created Opioid Safety Discharge Instructions Reviewed more than once with each APS Consult Patient Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 38 Retrieved from PrescriptionPainkillerOD.pdf July 21, 2014 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
14 Opioid Safety For Every Patient inpatient and upon Discharge Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 40 Where Do We Go From Here? A Call to Action for Pain Nurses Demonstrate energy, excitement and passion for pain management nursing Maintain competency-demonstrates a commitment to lifelong learning for self and others Develop, implement and evaluate policies, procedures and guidelines to improve the quality of pain management nursing practice APN: Designs appropriate pain management education Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 41 Call To Action Tactics for Pain Nurses Become informed about the opioid death rate in your state Increase your knowledge about opioid overdose prevention Become active in groups and agencies which seek to improve both inpatient and public safety Develop curriculum to train your nursing and ancillary staff Implement tools and patient education materials while hospitalized and upon discharge Take a pro-active versus reactive approach Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
15 Resources Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 43 Retrieved from July 17, 2014 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 44 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
16 Colorado Policy for Prescribing and Dispensing Opioids (Draft ) Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 46 Autonomy Mastery Purpose: Our Yearning to connect to something larger than ourselves ENGAGE THE HEART Studer, 2003 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 47 Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
17 Exempla St. Joseph Pain Resource Nurses and Pain University Nurses are Making an Impact at Our Organization Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 49 Carrie Brunson contact information The footprints we leave as nurses will save lives because A teacher effects eternity, they never know where their influence ends Sisters of Charity of Leavenworth Health System, Inc. All rights reserved. 50 QUESTIONS??? Sisters of Charity of Leavenworth Health System, Inc. All rights reserved
9/8/2014. I have no conflicts of interest to disclose. I have no conflicts of interest to disclose
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