TEAM Northland DHB Safe use of opioids Alan Davis Clinical Lead Karen O Keeffe Improvement Advisor Helen Dunn Pharmacy Manager Chanchal Ajoda Anesthetist Pain Team Sarah Preston Specialist Nurse Pain Team Bryce Kivell Medication Safety Pharmacist Sharon Kerwin ACNM Surgical Ward John Lengyel General Surgeon Sharon Scott Pharmacist Mania PHO
Available data BPAC Prescribing GTT Incident Chart review unplanned ICU Coding data ( Y450 )
GTT 135 patient reviewed Harm Category Breakdown Count of Harm Cat Where Sub Cat When Med Ortho Surg Dargaville Other Not Recorded Abnor Bleed During Admission 1 1 Med Glyc During Admission 1 1 Med Hypoten During Admission 1 1 Med N+V During Admission 2 3 3 1 9 Grand Total Not Recorded 2 2 PI During Admission 1 1 PI 1 or 2 During Admission 3 1 1 5 Not Recorded 1 1 Not Recorded During Admission 4 1 4 9 Not Recorded 3 3 Fall / Inj During Admission 1 1 2 Patient Care Other During Admission 1 1 Med Other During Admission 1 4 1 1 1 8 Not Recorded 1 1 2 SSI Prior to Admission 1 1 During Admission 1 1 Med Diarrhoea During Admission 1 1 Med Delirium During Admission 1 1 PI 3 or 4 During Admission 1 1 Resp Inf During Admission 1 1 2 CAUTI During Admission 1 1 1 3 DVT/VTE During Admission 1 1 Med Allergy During Admission 3 3 Med Bleed Prior to Admission 1 1 Surgery Other During Admission 1 1 Events Related to Surgery / Other Procedures During Admission 1 2 3 Not Recorded 1 1 Grand Total 16 17 16 1 4 12 66
Review of 87 charts with Y450 code opioids causing adverse effects Pareto Chart Opioid Harm 70 93.2% 100.0% 90.0% 60 83.6% 80.0% Pareto Chart Opioid Harm 50 40 30 20 21 52.1% 28.8% 17 16 74.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10 7 7 5 10.0% 0 Constipation Other Resp depre Unknown Delirium Hypotention5 Categories 0.0%
Time between resp depression 50 45 Time between Events 40 35 30 25 20 15 10 5 6.75 0 Date/Time/Period/Number
Incident data reviewed Incidents July 2013 - June 2014 50 40 30 20 10 21 34% 10 74% 62% 51% 7 7 6 84% 90% 4 4 97% 2 100% 100% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 0% CD count issues Wrong dose Other Wrong time Precribe issues Not given Care coord pharmacy issue Number
Materials / Smart technogy Avail of IS Process/Methods Transistons of care After hours Monitoring Decisison support Various look a like work practices Communication Health literacy Problem Statement Opioid related harm Oversedation Resp depression Hypotension Constipation Dependance Knowlege Older persons Human Factors Variation in Co morbidty At risk Clinical staff Patients and Ishikawa Fishbone Diagram Cause Effect Analysis
What we ve learned so far Respiratory depression much greater than we expected. Constipation a real issue readmissions, patient experience. Significant variation in pain management practices. Lots of opportunity for improving processes. Challenges to finding good measures Coding Y450 looks promising
Driver diagram intial draft Goal: Primary Drivers Secondary Drivers Standardised protocols / decision support algorythms. Changes Ideas Pain management order set To reduce opioid related adverse events. Reliable pain management processes Reduce variation of practice High risk patient protocols Pre-printed laxitive orders Sp02 monitoring for at risk patients. Outcome Measures: Regional blocks Pain management plan Oxycodone education 1. Reduce constipation related to opioids (GTT) 2. Reduced use of oxycodene on discharge 3. Reduced opioid hypotension. 4. Reduced community opioid use. 5. Coordination of care Patient centered care Transition process Communication with primary care. - Education - Alternative pain regimes - Health literacy - medications Time limited opioid perscription Limit oxycode prescriptions Medicaition reconcilliation Pre-op educaiton Patient handouts Safety Culture Safe medication systems Learning systems Human factors Release improvement staff to attend Learning session Involve in spread strategies
Issues to consider Time frame for this project is 18 months How we can demonstrate improvement Outcome, process Good idea to scope project Evidence change ideas Team