Touchstone Gold: Safer Opioid Prescribing: Having the Right Tools at the Right Time

August 07, 2019
By: NHRMC
opioid prescribing 600w

A 2016 study showed that our community was the number one city in the United States for opioid prescription abuse. This report detailed that over 11.6% of the Wilmington population was abusing opioids, and 53.8% of the opioid prescriptions written were being abused.  

Data published by The Centers for Disease Control and Prevention (CDC) from 2015 shows that New Hanover and the surrounding counties prescribe the highest amount of opioids per capita in our state. In 2017, the state of North Carolina created an Opioid Action Plan in response to the increasing number of opioid deaths. 

The Project

Six months before Governor Roy Cooper signed the Strengthen Opioid Misuse & Prevention (STOP) Act, NHRMC developed its own Opioid Task Force to help providers comply and develop tools for safer opioid prescribing.  The first task was setting an internal prescribing guideline. This guideline was intended to balance safe and effective pain-management. It provided guidance on using non-opioid medications and limiting quantities of opioids to 3-5 day supplies for acute pain and 7 day supplies for post-operative pain. This guideline also suggests the consideration of a 5 or 7-day opioid taper and prescribing naloxone for patients at risk of opioid overdose.  

Issues Identified at NHRMC:

  • NHRMC did not have easily accessible or trackable information that could allow stakeholders to monitor any improvements.
  • Providers didn’t have tools that easily allowed them to adhere to the STOP Act and NHRMC opioid prescribing guidelines.
  • Providers were not alerted of patient-specific risks of opioid-related harm.

The project aimed to improve the safety of patients who are prescribed opioids. Specific objectives were to 1)  create a monthly opioid “dashboard” report to measure impact and revise strategies, 2) develop and implement tools to help providers adhere to opioid prescribing limits, and to 3) develop and implement automatic alerts, which would inform the provider if a patient was at risk of an opioid-related event.

Using Lean principles, the task force formed a subcommittee with representation from a host of departments, including information services. The task force also created an education team which built 5- to 10-minute presentations for different audiences. Over a three-week period, the team presented to over 30 audiences educating providers and nurses on the new culture.

The task force created a dashboard that included: raw number of opioid pills, raw number of opioid pills per patient encounter, number of prescriptions for naloxone, and percent of patients receiving adjuvant medications.

The task force then developed a way to provide easy prescribing for short-acting oral opioids.   We developed three new buttons with pre-built directions that included a 3-day prescription, a 5-day taper, or a 7-day taper for post-surgical patients.

Our baseline data showed that our providers were rarely prescribing naloxone. Alerts were built in to notify prescribers when a patient is at risk so they would know to review the NC Controlled Substance Database and prescribe naloxone if deemed appropriate.  

The Impact

Providers in the NHRMC network had prescribed an estimated 4,213,524 opioid pills during FY17, with 87 opioid pills per patient encounter.  We felt confident that a decrease in the amount of attainable medications would indirectly lead to a reduction in opioid-related emergency room visits and death related to opioid overdose. 

When the NHRMC guidelines were first enacted and the opioid dashboard was shared with stakeholders, there was an immediate decrease from a baseline monthly average of 351,127 opioid pills per month to 322,579 (8.1% reduction).  The number of opioid pills per patient encounter also decreased from 87 to 79 (9.2% reduction).  When the easy buttons went live at the end of October 2017, the next months also saw a sustained reduction in both measures dropping to the lowest amount of each opioid pills prescribed and opioid pills per patient encounter in February 2018, 257,325 and 76 respectively.  This represents a reduction in monthly opioid pills prescribed by 26% and a 12.4% reduction in the monthly opioids per patient encounter. In that four-month period, there was also a net reduction of 275,296 in overall opioid pills prescribed. 

Lower rates for the number of opioids pills prescribed monthly continued in the remaining months of FY18 resulting in a YTD reduction of 18.9% and 783,312 less opioid pills in the community.  The institution of the mega BPA in late June of 2018 further decreased the number of opioid pills per patient and at the end of FY18, the number of opioid pills per patient encounter was reduced by 15.5%.    

The task force also drove a significant increase in naloxone prescribing and percentage of patients prescribed adjuvant medications. Naloxone prescriptions increased from a baseline of 168 to 580 (245.2%).  At baseline, a mere 3.7% of patients were receiving adjuvant medications for pain. Immediately after the NHRMC guidelines were enacted, there was an 8-fold increase in the use of adjuvant medications.  Along with the reduction in opioid pills prescribed and increase in the prescribing of adjuvant medications and naloxone, the community saw a decrease in adverse events associated with opioid overdose.  There were 60% fewer opioid related emergency department visits in January to July 2018 compared to the same time frame in the previous year. 

By increasing the use of adjuvant medications and naloxone prescribing, we met our goal of safer prescribing of opioids, but the efforts continue. In FY19 NHRMC has seen further reductions in the numbers of opioid pills prescribed and opioid pills prescribed per patient encounter, -24.3% and –20.4%, respectively. 

Opioid stewardship continues at NHRMC through the implementation of new initiatives. NHRMC is committed to leading our community to outstanding health and reducing the impact of the opioid epidemic on our region.  

Many professional organizations have recognized our efforts and have asked NHRMC to share our successes, which we are happy to do. Members of our team continue to collaborate with and mentor others as we all fight this opioid epidemic. 

Table 1. Opioid Task Force (OTF) Year 1 Results

Metrics

FY17

FY18

Change

Raw number of opioid pills

4,213,524

3,376,798

-19.9 %

Raw number of opioid pills per patient encounter

87.1

73.6

-15.5 %

Number of naloxone prescriptions

168

580

345.2 %

Percentage of patients receiving adjuvant medications

3.7

29.9

703 %

 

Team Members:

  • John Altman, Clinical Informaticist
  • Kevin Cannon, Hospitalist and Chair of the Opioid Task Force
  • Lisa Edgerton, Pharmacist
  • Todd Hinshaw, Applications Coordinator IS Clinical Services
  • Mackie King, Pharmacist
  • Neda Pourdeyhimi, Pharmacist
  • Michelle Rager, Pharmacist
  • Eddie Seijo, Network Director of Pharmacy Services
  • Laurie Whalin, VP of Clinical Services
  • Andy Whitley, IT Developer
  • Vladimir Vasquez, Senior Application Analyst

Note: The NHRMC system has earned seven 2019 Touchstone Awards from Atrium Health. Each of the initiatives will be profiled in blogs in advance of Atrium Sharing Day on August 7. 

Categories: Touchstone Awards