1. Improving Pain Control and Reducing Opioid Related Adverse Events
Adam Novak Manager, Patient Safety & Quality Michigan Health & Hospital Association Keystone Center
February 7, 2017

2. Discuss the impact of MHA Keystone Center Pain Management Activities
Objectives
Describe the MHA Keystone Center Pain Management activities and tools involved in reducing opioid-related adverse events
Discuss the impact of MHA Keystone Center Pain Management Activities

3. MHA Keystone Center: Our Mission
Vision
Healthcare that is safe, effective, efficient, patient-centric, timely and equitable.
Mission
To lead the nation in quality and patient safety through the diffusion of change using patient-centered, evidence-based interventions supported by cultural improvement.
Values
Excellence • Innovation • Compassion • Teamwork

4. Opioid Crisis - Background

5. Opioid Crisis – Additional Statistics
69% of people who misuse pain medication got them from a friend or relative
80% of heroin users began by misusing pain medication ordered by their doctors
Drug overdose is the leading cause of accidental death in the United States
More than car accidents

6. Opioid Crisis – In Our Backyard

7. MHA Keystone’s Timeline for Opioid Adverse Drug Events and Pain Management
MHA Keystone Surgery
IV Opioids Only
Surgical Population (Inpatient & Outpatient)
Exclusion: OB
29 hospitals submitting data
2015 – Sept. 2016
MHA Keystone Pain Management
IV Opioids Only
Inpatients, surgical outpatients
Exclusion: OB and ED
215 hospitals submitting data
Sept – Sept. 2019
Targeted Improvement
Opioids (All Routes)
Inpatients, surgical outpatients
Exclusion: OB and ED
300+ hospitals submitting data

8. Methods/Timeline of Activities – HEN 1.0 and HEN 2.0
CMS PfP Hospital Engagement Network (HEN)
Opioids called out as high-risk medication needing to be addressed
Coupled with MHA Keystone: Surgery efforts around Enhanced Recovery After Surgery (ERAS)
Advisory Committee
Obtained a physician champion for MHA Keystone
Convened an advisory committee comprised of an anesthesiologist, director of surgical services, independent nurse consultant, Michigan Surgical Quality Collaborative (MSQC) abstractor, pain nurse resource specialist, pharmacist, surgeon, and surgical nurses
Gap Analysis
Conducted gap analysis
Roll Out
Project launch meeting was held
Educational materials were distributed including the Michigan Opioid Safety Score (MOSS) tool, sample order sets, data dictionaries, and schedule of monthly content webinars and coaching calls
Expanded from surgical to inpatient and surgical inpatient and outpatient under HEN 2.0

9. Procedure Intervention 1: CUSP
The Comprehensive Unit-based Safety Project (CUSP) follows a six step iterative program to improve patient safety and the culture that drives safety attitudes and practices.
Intervention 2: Educational program including in-person and multi-media sessions
Monthly content webinars, monthly coaching calls (in collaboration with the Armstrong Institute for Patient Safety & Quality, Johns Hopkins University), and an annual conference (in person meeting) with national speakers.
Intervention 3: Implementation of a perioperative pain management toolkit
Gap Analysis tool, Michigan Opioid Safety Score (MOSS tool), patient and family education templates, pre-op checklist modification recommendations, and a multimodal analgesia tool (with specific recommendations for order sets).

10. Opioid Adverse Drug Event Prevention Gap Analysis

11. Pain Management Gap Analysis Results 2014

12. Michigan Opioid Safety Score (MOSS)
Goals
Incorporate patient/procedural risk factors
Incorporate respiratory rate
Incorporate sedation
Reinforce need for multimodal analgesia
Improve nursing documentation of patient assessment
Soto, Roy; Yaldou, Brandon. The Michigan Opioid Safety Score (MOSS): A Patient Safety and Nurse Empowerment Tool. Journal of Perianesthesia Nursing 2015, June, 30(3)

13. MOSS Continued…

14. MOSS Continued…

15. Results – 2014 (Surgical)
n = 24

16. MHA Keystone: Pain Management Collaborative
Launched in 2015
Improve appropriate pain management practices
Reduce opioid-related adverse events
Decrease the usage of opiates statewide
Enhance patient expectation management 

17. Focused Interventions
1. All patients will be screened to determine if they are opioid naïve or opioid tolerant prior to receiving any opioids.
2. All patients needing pain control will have multimodal analgesia. Providers will follow the World Health Organization (WHO) analgesic pain ladder when prescribing.
3. All patients receiving opioids will be formally assessed via the Michigan Opioid Safety Score (MOSS) or Pasero Opioid-induced Sedation Scale (POSS) on a regular basis to prevent unintended sedation and respiratory depression.
4. Patients receiving opioids will not receive more than one concomitant sedative.
5. All patients receiving pain medications will be counseled on the medication they are receiving, any potential side effects and expectations of realistic pain management.
6. Policies and procedures will be established for patients who are no longer responding to treatment, directing that those patients receive increased monitoring, level of care, and appropriate pain consultation.
7. Patients requiring a PCA will be monitored via pulse oximetry and/or capnography.
75 hospitals are actively participating and have agreed to the following asks.
We continue to provide a educational resources and offerings, a toolkit of evidence based best practices and have also developed additional patient facing materials, including:

18. Pain Management Toolkit

19. Comparing 2014 to 2015 Gap Analyses

20. Expectation Management
Multiple contact points
Surgeon’s Office
Pre-Op Visit/Call or Joint Camp
Pre-Op (Day of)
Prior to discharge

21. This is a brochure for our surgery collaborative intended to educate patients on pain after surgery and assist with expectation management. 35% of Americans function at or below a basic level of literacy, so it was important for us to develop a tool between the 6th and 8th grade reading level. We worked with a team of experts including an anesthesiologist, a surgeon, a health literacy expert and our patient and family engagement advisory council – to ensure we are getting the information to patient they need.

22. Our goal was to help set expectation that patients will have pain following surgery. We broke the tool down into what you should do, why it is important to do these items.

23. We provided them with tools to help track their pain and side effects and shared with them the expectation was to keep their pain at or below a level of 4/10 (realistic).

24. We provide them with an opportunity to document their pain management plan as well as a location to track their pain medication they are taking.

25. Utilization of tools increased steadily over the one-year project and satisfaction of enrolled hospitals was high. Approximately 50,000 ‘Your Guide to Controlling and Managing Pain After Surgery” pamphlets were ordered and shipped across the country. The resources were also endorsed by the empowered patient coalition and engaged patients.

26. Results – 2015-2016 Inpatient and Surgical Patients
215 hospitals submitting this measure

27. Additional Programs/Tools

28. MHA Keystone Speak-up! Award
The MHA Keystone Center Speak-up! Award is designed to acknowledge the efforts of individuals or teams within Michigan hospitals who speak-up to prevent potential harm to patients or other staff members.
182 nominees
19 hospitals
55% of nominees who spoke up to prevent harm, prevented or mitigated an ADE

30. 10 Things Every Patient in Pain Should Know
10 day social media campaign
1 hour Twitter chat
1.5 million impressions
One of the recommendations put forth by the Governor’s Task Force was to develop a public awareness campaign – inform public on dangers of abuse, how to safeguard and properly dispose of medicines, publicize improper prescription practices and reduce stigma of addition. We launched this tool, which nationally with the empowered patient coalition and engaged patients and were able to make 1.5 million impressions during a twitter chat around this tool. We also did a 10 day social media campaign launching the tool.
Further, we worked with the Michigan Pharmacists Association and the Michigan Department of Environmental Quality to develop a tool to help educate people why they should dispose of their medications and how to do so appropriately and working to build an interactive map of Michigan which will house a comprehensive list of all take-back locations in Michigan.

31. Medication Disposal
Further, we worked with the Michigan Pharmacists Association and the Michigan Department of Environmental Quality to develop a tool to help educate people why they should dispose of their medications and how to do so appropriately and are working to build an interactive map of Michigan which will house a comprehensive list of all take-back locations in Michigan.

32. Endorsing and Supporting Organizations

33. The Future of Keystone and Opioids

34.
MHA Keystone Surgery
IV Opioids Only
Surgical Population (Inpatient & Outpatient)
Exclusion: OB
29 hospitals submitting data
2015 – Sept. 2016
MHA Keystone Pain Management
IV Opioids Only
Inpatients, surgical outpatients
Exclusion: OB and ED
215 hospitals submitting data
Sept – Sept. 2019
Targeted Improvement
Opioids (All Routes)
Inpatients, surgical outpatients
Exclusion: OB and ED
300+ hospitals submitting data
MHA Keystone Surgery
IV Opioids Only
Surgical Population (Inpatient & Outpatient)
Exclusion: OB
29 hospitals submitting data

35. Safe Care is what drives us. Collaboration is how we get there.
Leading Healthcare
Safe Care is what drives us.
Collaboration is how we get there.

36. Thank you!

37. Adam Novak, MA | Manager, Patient Safety & Quality
MHA Keystone Center
2112 University Park Drive | Okemos, MI (517)  | (517)  Fax