Opioid Management Training June 2013

Joint Commission Sentinel Event  Sentinel Event - A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.  Sentinel Event Alert published when appropriate as suggested by trend data

Safe Use of Opioids In Hospitals  Opioid analgesics may be associated with adverse effects  Most serious effect – respiratory depression, generally preceded by sedation.  Other common adverse effects: Dizziness, n/v, sedation, hallucinations, falls, hypotension and aspiration pneumonia.

Opioid Use  Morphine  Codeine  Hydromorphone (Dilaudid)  Oxycodone  Fentanyl  Methadone  Meperidine (Demerol)  Hydrocodone (Lortab)

Goal of the Alert  Provide a number of actions that can be taken to avoid the unintended consequences of opioid use among hospital inpatients.

Causes for adverse events  Lack of knowledge about potency differences among opioids  Improper prescribing and administering of multiple opioids or different modalities  Inadequate monitoring of patients on opioids

What the data shows…  Opioid-related adverse drug events: 47% Wrong dose medication errors 29% Improper monitoring of patient 11% Other factors: excessive dosing, medication interactions and adverse drug reactions

Joint Commission Recommendations  Screen patients for respiratory depression risk factors  Conduct full skin assessment prior to administering new opioids to rule out patch or implantable device  Use an individualized multimodal treatment plan to manage pain  Take extra precautions with patients who are new to opioids

Joint Commission Recommendations cont.  Consult a pharmacist or pain management expert when converting from one opioid to another or changing route  Avoid rapid dose escalation of opioid analgesia

Evidence-based Actions  Create and implement policies and procedures for clinical monitoring of patients receiving opioid therapy by serial assessments of: Quality and adequacy of respirations Depth of sedation Assess ○ Oxygen Saturation ○ Ventilation

Evidence-based Actions  Create second level review by pharmacist of pain management plans  Create and implement policies/procedures for tracking and analyzing opioid related incidents.

Evidence-based Actions  Educate: Effect of opioid therapy on sedation and respiratory depression Continuum of consciousness Difference between ventilation and oxygenation Clinical and technological monitoring  Educate and provide written instructions to patients who are on opioids

Evidence-based Actions  Provide standardized tools to screen patients for risk factors associated with over sedation and respiratory depression.

Patient Story  Near sentinel event  Told from the view point of the patient’s husband

Opioid Management Guidelines  New Patient Care Policy  The safe use of opioids relies on an accurate pain assessment and then applying appropriate pain management techniques.

Action:  Provide standardized tools to screen patients for risk factors associated with over sedation and respiratory depression.  Sedation Precautions

Sedation Risk Assessment Green Sheet Completed on Admission Prompt you for signage Nurse’s signature required

Action: Sedation Precautions  Patients are screened for sedation risk using the Sedation Risk Assessment (Form # ) on admission and post procedure based on but not limited to the following risk factors:  a.Sleep apnea or sleep disorder diagnosis;  b.Morbid obesity with high risk of sleep apnea;  c.Snoring;  d.Older age; >60;  e.No recent opioid use (e.g. Oxycontin, Percocet, Vicodin, Lortab, Codeine, Fentanyl, Dilaudid, Duragesic Patch, Morphine, Demerol, etc.);  f.Post-surgery, particularly if upper abdominal or thoracic surgery;  g.Increased opioid dose requirement or opioid habituation;  h.Longer length of time receiving general anesthesia during surgery;  i.Receiving other sedating drugs, such as benzodiazepines, antihistamines, diphenhydramine, sedatives, or other central nervous system depressants;  j.Preexisting pulmonary or cardiac disease or dysfunction or major organ failure (e.g. Renal Failure, COPD, CHF, etc.)  k.Thoracic or other surgical incisions that may impair breathing;  l.Smoker

Sedation Precautions  One “YES” answer to any of the above criteria places the patient in Sedation Precautions.  Identify the patient as a sedation risk patient by placing the green Sedation Precaution signage on door.  Educate patient and family members concerning sedation precautions.  Sedation Precautions is communicated during hand off communication.

Sedation Precautions  Nursing scans the Sedation Risk Assessment to pharmacy, then places in the patient’s medical record.  Pharmacy conducts a second level review of pain management plans that include high-risk opioids, such as methadone, fentanyl, IV Dilaudid, Demerol, and PCA pumps.

When is the Sedation Risk Assessment completed? 1. At shift change 2. At handoff 3. On admission 0%

What do you do with the Assessment sheet once complete? 1. Place on chart 2. Fax to pharmacy 3. Fax to pharmacy, place on chart 4. Throw it away 0%

Action:  Create policies/procedures for the ongoing clinical monitoring of Quality and adequacy of respirations Depth of sedation

Nursing Assessment  Dependent upon the type of opioid therapy used: Routine Opioid Therapy High Risk Opioid Therapy ○ PCA pump ○ Methadone ○ Fentanyl ○ IV Demerol ○ Dilaudid

Routine Opioid Therapy  Assess pain status and sedation level prior to each opioid mediation administration.  Pain scale  POSS scale

POSS Scale RatingAction S = Sleep, easy to arouseAcceptable: no action necessary 1 = Awake and alertAcceptable: no action necessary 2 = Slightly drowsy, easily arousedAcceptable: no action necessary 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable: notify physician to consider decreasing dose or changing medication 4 = Difficult to arouse (Somnolent), minimal or no response to verbal and physical stimulation Unacceptable: stop opioid, consider administering naloxone (Narcan), call MRT if indicated; stay with patient, stimulate, and support respirations as indicated by patient status, notify physician; ask patient to take deep breaths every 15 to 30 minutes and monitor respiratory status and sedation closely until sedation level is stable at less than 3 and resp status is satisfactory

 Document findings in the patient’s medical record.

For routine opioid therapy I assess Pain and POSS how often? 1. Every 2 hours for 24 hours 2. Every 15 minutes 3. With each pain medication administered 4. Every 4 hours 0%

What do I do if my patient is a 3 on the POSS scale prior to their next scheduled dose of Morphine? 1. Call an MRT 2. Hold Morphine and call physician 3. Give Narcan 4. Give Morphine 0%

High Risk Opioid Therapy  PCA pump  Methadone  Fentanyl  IV Demerol  Dilaudid

Which of the following is considered a high risk opioid? 1. IV Dilaudid 2. Morphine 3. Demerol 4. PCA Pumps 5. 1, 3, and 4 0%

Serial Assessments  Pain Pain Scale  Respirations (Quality and adequacy)  Depth of Sedation POSS Scale  Vital Signs (including O2 sat)

When?  On initiation of therapy  With dose changes or bolus  During an event or deterioration  At hand offs or shift change

How often?  On initiation of therapy: Baseline Q 15 x 1 hour Q hour x 4 hours Q 2 hours x 24 hours Q 4 hours Pain Respiratory Status Sedation Level VS with 02 sat

How often?  With dose change or bolus: Q hour x 4 hours Q 2 hours x 24 hours Q 4 hours Pain Respiratory Status Sedation Level VS with 02 sat

How often?  During an event or deterioration? Q 15 x 1 hour Q hour x 4 hours Q 2 hours x 24 hours Q 4 hours Pain Respiratory Status Sedation Level VS with 02 sat

The first 2 steps we watch them more, Its 4 for 1 and 1 for 4. Slow your pace, you can rest, The next 24 is in 2 hour sets. Until discharge, check every 4, Until they walk out our door.

I just started my patient on a PCA pump, what do I need to assess? 1. Pain 2. Respiratory (quality and adequacy) 3. POSS scale 4. Vital signs including 02 sat 5. All of the above 0%

The MD changed my patient from Morphine to IV Demerol, how often do I assess my patient? 1. Q1h x 4 then Q2h for Q4 hours 3. Q15 min x 4, Q1h x 4, Q2h x 24, then Q4 4. Q2h 0%

PCA Policy  Updated to reflect new assessment requirements.

Exceptions:  General Inpatient Hospice  Ventilated Patients

Action:  Educate and provide written instructions to patients who are on opioids

Action:  Create second level review by pharmacist of pain management plans

New PCA Orders Approval pending late June, early July Completed by Nursing Completed: On Admission by OPS or Inpatient unit OR When ordered by MD

BMI - Micromedex

Completed by MD

Naloxone Protocol

Fill in the blank: The first 2 steps we watch them more, Its 4 for 1 and ______. Slow your pace, now you can rest, The next 24 is in ________ sets. Until discharge, check every 4, Until they walk out our door for 4, 4 hour 2. 2 for 1, 2 hour 3. 1 for 4, 2 hour 0%

I just received my patient back from PACU with a new PCA pump, how often are my assessments? 1. Q15 min x4, Q1h x 4 then Q2h x Q15 min x 4, Q1h x 4, Q2h x 24, then Q4 3. Q1h x 4 then Q2h for Q2h 0%

It is time for my patient’s scheduled dose of Lortab, my patient has a POSS scale of 2, what is my next action? 1. Call the MD 2. Hold the medication 3. Administer the medication 4. Try a different treatment option 0%

My hospice patient has been started on IV Dilaudid, how often do I assess the POSS scale? 1. Q1h x 4 then Q2h for Q4 hours 3. GIP Hospice patients are excluded 4. With each dose 0%

These tools will help us keep our patients safer. 1. True 2. False