Ashika Maharaj/Gill Robb Improvement Science Professional Development Program Tackling Opioid-related Harm

Global Trigger Tool (GTT) Systematic methodology for quantifying patient harm using a targeted chart review process Adverse Drug Event Trigger Tool (ADE TT) subset of GTT Developed by IHI 2003

‘Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalisation or that results in death’ Reference: White Paper: IHI Global Trigger Tool for Measuring Adverse Events 2009 Definition of Harm

Harm Category

 Revelations from 2011 ADE data: 30% of medication-harm related to Opioids 23% of this was Constipation Risk highest on surgical wards  Forum to discuss findings (mid 2012)  Retrospective detailed analysis of a surgical ward requested Background

Pareto Chart of Harm 2011

New Data Collection Tool

Baseline Data N = 131 Opioids = 114 Harms = 49 N = 131 Opioids = 114 Harms = 49

Results: Focusing on Constipation

Opioids implicated in Harm

Project A Tackling high rate of opioid-related constipation Project B Tackling opioid-related oversedation Projects identified

Aim (Project A) To reduce Opioid related constipation on Ward 10 (combined surgical ward) from 30% to 15% by 1 July 2013

13 Driver Diagram

Change Concepts & Ideas for PDSAs Idea for Testing in a PDSA Theory and prediction about what will happen when you test this idea Regular Bowel charts for all patients on opioids Regular bowel monitoring will identify problems early allowing for effective intervention earlier PRN Laxatives charted in conjunction with opioids routinely If bowel charts are working well then nurses will be alerted to administer laxatives early Regular Laxatives charted in conjunction with opioids routinely Laxatives to be administered in conjunction with opioids daily Patient Leaflets Leaflet informing patients of constipation as an adverse effect of opioids and to let nurses know if bowels have not moved as per normal.

Name of Measure Is this an Outcome, Process or Balancing Measure? % Patient Harm from constipation Outcome % Laxatives Charted concurrently with opioids Process % Laxatives Administered on time Process % Bowels Monitored RegularlyProcess % Patients who developed diarrhoeaBalancing % Patients who refusedBalancing Measures

1.Team established 2.Phase 1: Bowel monitoring (implemented) 3.Phase 2: Charting and administration 4.Phase 3: Patient Experience 5.Retrospective analysis Next steps (Project A)

89 year old patient was admitted due to R) femur fracture following a fall. His bowels did not open for seven days whilst on the ward secondary to regular oxycodone, fentanyl, and morphine. He required several interventions including laxatives and fleet enema. Examples

35 year old was admitted to orthopaedics after developing lower back pain in medical ward. Cause was not identified, however, patients bowel had not moved for five days. She was on regular morphine for pain. It was only after she complained that laxatives and enemas were offered and her bowels opened.

Examples Other DHB(worst case scenario): Patient passed away suddenly and unexpectedly shortly after admission to the Surgical Unit. The cause of death was ascertained by the coroner to be due to bowel ischaemia (from constipation) and that morphine could not be excluded as a contributing factor. Patient had also been on clozapine.

By Gill Robb