Changes in Opioid Practices: Why?? Based on : Interdisciplinary Medication Safety Initiative to Improve Narcotic Use Practices in a Post Anesthesia Care Unit (PACU) Eric JP Romeril; B.Sc.Pharm ACPR Clinical Pharmacist; Perioperative Services, Hamilton Health Sciences Melanie MacInnis; BSc(Pharm), PharmD Clinical Pharmacy Coordinator and Chief of Pharmacy Practice, IWK Health Centre
Why are we here? Clinical Pharmacist in Perioperative Services Established Role Breadth of Practice Evidence Based Practice Direct Patient Care Medication Use Experts Policies/Procedures Education of Staff
Outline Problem What were we doing? Baseline practice review Why should we change? Cases What could we do about it? Working Group What happened & so what? Study What happens next? Act
What do pharmacists see differently? 1) Purchasing 2) Logistics 3) Dispensing Technologies 4) Ad hoc product manufacture Drug products are tools, use the right tool for the right job!
Problem Internal diversion and waste documentation problems Quality improvement needed Understand how opioids are handled Adhere to CNO medication standards (& waste) Solution needs to come from users (aka Nurses) 6% Medication of medication errors in PACU cause serious harm to patients 1 1 - Hicks, R. W., et al (2007). Medication errors in the PACU. Journal of perianesthesia nursing, 22(6), 413 419
Baseline Practice Review What were we doing? Chart review May 1 14, 2011 narcotic use
Working group Brain Storming with frontline staff Meds most often ordered Morphine 2-4mg PRN (or q5min PRN) Medication use process (flow diagram) Predrawn syringes left unattended in K basin Using partner s narcotic while on break Un-wasted drug left on med station Pocketed medications
PACU is unique Very high frequency of administration Morphine 2-4mg q5-20 min prn HYDROmorphone 0.2-0.4mg q5-20 min prn Narcotic medications comprise 80% of all administered medications during observation Phase 1 recovery patients can be quite unstable and have unpredictable medication needs High risk for colleagues with substance use problems
Working Group What could we do about it? Concepts from nurse consultation
Process diagram
Risky Business Multi-dose out of 1 syringe prepared from 1 vial 10mg/10ml morphine, 2mg/10ml HYDROmorphone Accepting/using predrawn dose from someone else Not OK per established standards Leaving narcotics unattended Product awaiting witness to waste Partially used predrawn narcotic, labeled, sitting in K-basin Temptation Freeing up limited work surface, using pockets Using AcuDose in med room isolated user from patients
Cases Why should we change? Examples of high risk practices
Case #1 Sally is a new PACU nurse and has learned the practice of predrawing her narcotic from colleagues. While handling a patient on her own.. What happens when she goes on break and family there? If that patient were to come to harm? Does she have Policy protecting this decision?
Case #2 Jenny is an experienced PACU nurse and has been working with the same group for 22 years. They are a blast, and many of them are friends outside of work. Another nurse Beth quits suddenly, and she later discovers it is due to recurrent bouts of substance misuse. Could we say we did all we could to help her resist? What if it she was only taking waste vials? How would you feel if she was using meds you forgot to waste? What if she got hurt? Could you get in trouble?
Medication Administration Maybe a little addition to how we think about giving meds Assessment Planning Implementation Evaluation.. And DISPOSAL!!. at least when handling narcotics.
Diversion If someone is determined to divert they will find a way We should focus on minimizing opportunity and temptation Automated dispensing & inventory technologies Good job with fidelity of custody until dispensing System gaps remain: 1. Preparation and storage after dispensing, before administration 2. Product waiting to be wasted (documentation) 3. Product discarded in a non secure receptacle
Working Group What could we do about it? Concepts from nurse consultation
Potential solutions Access to AcuDose Additional AcuDose machine, Move AcuDose closer to work areas Narcotics left unattended or unlabeled Make/buy premade narcotic solutions Unit dose prefilled syringe or vials Large prefilled syringe (10ml, made in pharmacy) Narcotic Mini-bag ( 1 per patient, then discard) Secure bedside medication storage
Solution chosen Make/buy unit dose prefilled syringes (PFS) Morphine (1mg, 2mg,3mg) @ 1mg/ml HYDROmorphone (0.2mg, 0.4mg) @ 0.2mg/ml Secure bedside medication storage Jointly developed data collection plan
Study What happened? And so what? Design and findings of observational trial
Methodology Prospective, controlled, blinded (data entry & analysis) comparative study using nonrandomized allocation 2 sites Juravinski Hospital (JH) = practice change site Hamilton General Hospital (HGH) = control Nurses (RN) trained and working at study site, caring for patients in post anesthesia phase 1
Data collection Trained(6h) & Standardized(2h) nursing student observers Timeline - Before (week 1&2), Process change at JH (week 3), After-evaluation (week 4&5) Developed a standardized case report form for direct observation, using convenience sampling Percent of Total Opportunities for Error (%TOE) Nursing Practice Deviations Patient demographic and descriptive data
Operational Markers 2 weeks pre 2 weeks post Units of morphine 95 amps 231 syringes Mg of morphine 950 615 Units of hydromorphone 60 vials 142 syringes Mg of hydromorphone 120 51.2 Feb 5-18 2012 March 18-30 2012 Source = Acudose reports
Expected vs Actual Dose administered 2 weeks chart review 2011 Morphine 1mg 5 6 2 weeks Acudose review 2012 Morphine 2mg 115 85 78 Morphine 3mg 47 168 153 Hydromorphone 0.2mg Hydromorphone 0.4mg 11 31 28 15 126 114 2012 Adjusted for returns Higher proportion of waste transactions on the 3mg (13 waste to 9 return) relative to the 2mg (2 waste to 5 return)
Chart audits Taking multiple syringes Documented med administration did not match the syringes taken Unit of use Waste Syringes not returned in the Acudose cabinet under the patient they were originally signed out from Showed preference for higher volume syringe; conflicting with initial chart review data
Results Nurse Survey (final) Direct Observation All respondents (100%) wanted to continue with narcotic PFSs 39% believed higher dose PFS were needed. Eliminated narcotic waste documentation problems Trend towards reduction of patient s average pain score. Fully reported elsewhere System Usability Scale (worst=0, best 100) This is a standardized 10 question survey that is used to quantitatively contrast system usability. Workload 7 hours of pharmacy assistant time per week 0.2 FTE for one site 0.8-1 FTE for all HHS Administered Before ( SUS Score =78.1) and after (75) Production not cost effective, given doses used per week. No significant difference could be shown Produce less variety
So What? Chart Review Lessons learned retrospective chart review uncovered irregularities integrity of signature chain was interrupted. Based on the review of this data; PFS manufacture stopped Morphine amp size changed Clear lock boxes removed Modified duty nurses Longer observation before evaluation Recognize unique care environments like PACU Provide only one drug as prefilled syringe (morphine) User driven problem solving Use complaints to generate answers
Current State Acudose added, neither in med room Morphine vials - 2mg/1ml Rarely need to waste unit of use (confirmed) HYDROmorphone 2mg/1ml vials back to the old way Starting similar work @ Hamilton General using learning and staff feedback different team & patients
Thank you to our Study Collaborators Leslie Gauthier R.N. M.Sc. Director of Perioperative Services Leslie Gillies R.N. M.Ed. Chief of Nursing Practice Marianne Kampf R.N. PACU Education Clinician James Paul M.D. Director of Research and Acute Pain Service, Department of Anesthesia Also to HHS PACU staff champions Silvia Katsaros, Cathy Mezzalira, Danielle Lloyd, Michelle Marcoux, Amanda Staples, Claudia Bozek, Debra Re, Chris Body
Questions? romeril@hhsc.ca, eric.jp.romeril@gmail.com melanie.macinnis@iwk.nshealth.ca Our Deepest thanks to the following people, without whom this would not have been possible: Anne Marie El-Kahlout and Michelle Stevenson for tireless efforts producing and managing the stock of pre-filled syringes during the study. Silvia Katsaros, Cathy Mezzalira, Amanda Staples, Danielle Lloyd, Michelle Marcoux, Claudia Gogishvilli, and Christine Body for their help with students, operationalizing the study and coping with day-to-day issues. Lehanna Thebane and Emmy Cheng for help with statistical elements. Toni Tidy for administrative support and advocacy. And our nursing students: Chinyere Ariaga, Nayeema Mahzabeen, Dilruba Chowddhury, Waheeda Salimi, Danielle Fabbro, Ruben Ozuna, Stephen Darfour, Chris Zeng, Osahon Osawe
STUDY Primary objective observe and analyze the impact that the process change may have on medication errors and nursing practice deviations Primary Outcomes: Medication errors (%TOE) Nursing practice deviations (%TOE) Secondary outcomes Prevalence of narcotic administration Nurse demographics and beliefs* Patient demographics and clinical scores* System Usability Scale* Methodology Blinded, prospective, controlled 5 week before-and-after study Two sites (PACUs) observed Juravinski intervention Hamilton General control Blinded data entry and analysis Observers, nurses and patients were assigned ID#s Selection of Nurses-patient pair Nurse = RN, HHS employee, and trained site PACU nurse Patients = from operating room, non overflow ** Excluded from week 3 Patients = Orthopedics, PCA, nerve or spinal block
STUDY - Timeline
STUDY Years since Years being being last fulltime student registered as a (n=9) nurse (n=9) Years have worked at HHSC (n=9) Years have worked at critical care (n=9) Years have worked as perianesthesi a nurse (n=8) Mean (SD) 16.89 (14.00) 20.78 (14.20) 17 (13.24) 16.67 (13.33) 12.88 (10.11) Median (Min, Max) 16 (1, 40) 26 (1, 40) 23 (1, 37) 21 (1, 35) 13 (1, 23) < = 5 years 3 (33.33%) 2 (22.22%) 3 (33.33%) 4 (44.44%) 4 (50.00%) 6-20 years 2 (22.22%) 2 (22.22%) 1 (11.11%) 0 (0.00%) 0 (0.00%) > 20 years 4 (44.44%) 5 (55.56%) 5 (55.56%) 5 (55.56%) 4 (50.00%)
STUDY Non significant changes ( before v. after) Practice environment beliefs Medication system System Usability Scale ( standardized, 10 q s)