EXECUTIVE SUMMARY
In response to the opioid epidemic, some pioneering health systems are making progress by consolidating disparate efforts under one umbrella and using data and leadership to drive improvement in several areas.
- The Hospital of the University of Pennsylvania in Philadelphia has leveraged IT interventions successfully to assist physicians in easily accessing patient prescribing histories in state prescription drug monitoring programs, changing the defaults for opioid prescriptions, and strategically reminding physicians about best practices.
- Brigham and Women’s Hospital in Boston established the Comprehensive Opioid Response and Education program to drive its improvement efforts in this area. Leaders are championing a multidisciplinary, nonstigmatizing approach to treatment.
It has been nearly a year since The Joint Commission (TJC) unveiled new pain management standards as part of an effort to combat the opioid epidemic. While all accredited hospitals are held accountable for their implementation and adherence to the standards, some health systems have responded by centralizing their opioid-related initiatives under a single, purposeful umbrella to produce more powerful results.
Recently, TJC highlighted the comprehensive steps taken by the Hospital of the University of Pennsylvania (HUP) in Philadelphia and Brigham and Women’s Hospital in Boston to establish effective opioid stewardship programs and stem the tide of opioid overdose deaths in the regions they serve.
Both organizations report significant progress in caring for patients who present with opioid use disorders (OUD), changing the prescribing habits of their clinicians, and leveraging information technology (IT) to maximize their efforts. Further, to disseminate some of the best practices they have cultivated, leaders from the two hospitals outlined their initiatives and shared what they have learned along the way in a TJC-sponsored webinar on Oct. 10.
Philadelphia has one of the highest per-capita death rates due to opioid overdoses in the country, so HUP had been working on several fronts to address the problem by the beginning of 2018, explained Jeanmarie Perrone, MD, director of the division of medical toxicology and a professor of emergency medicine at the University of Pennsylvania and an emergency physician at HUP.
“When The Joint Commission released their initiative in January 2018 recommending that hospitals have a standard leadership committee to address safe opioid prescribing, we used that to formalize some of our initiatives into a cohesive group,” Perrone noted. “There were several different smaller efforts going on, but at this point we went to the decision-makers: the chief medical officer, the chief nursing officer, all of the C-suite executives, and the quality leaders.”
At this stage, HUP had collected relevant data it could use to formulate its opioid-related efforts. These data included the total number of pills prescribed, the average amount of those prescriptions for acute pain, and the top opioid-prescribing departments. There were some surprises, Perrone reported. “Departments like dermatology had a surprisingly high prescribing rate, so there were a lot of fairly easy things to address when we had the data across the health system,” she said.
When meeting with colleagues to discuss the issue, Perrone identified people with whom the issue resonated. Often, these were clinicians or administrators who knew a family member with an OUD. Such individuals — people with first-hand experience with the epidemic — tended to be particularly motivated to support HUP’s efforts in this area, she observed.
Perrone and colleagues divided their efforts into several groups, beginning with an executive committee that would provide oversight for the entire organization. “Included in that was a regulatory body that consisted of our health system lawyers, which were helpful when we ran into state guidelines we were trying to implement into our electronic medical record [EMR],” she said.
Also, there was an IT group, which proved important to implementing certain recommendations, such as changing the default number of pills. “You need to have a rapid and smooth gateway to your IT support so that these changes can be made relatively quickly,” Perrone advised.
Other distinct committees focused on patients with OUD, clinician education, acute pain management, and management of patients with chronic pain who were in opioid therapy already.
Among other goals, the initiative aimed to bring HUP into compliance with requirements set forth in guidelines from a range of organizations such as TJC, some insurers, as well as state mandates from both Pennsylvania and New Jersey. The opioid initiative also established a mandatory education program that all levels of clinicians could take, including faculty, house staff, advance practice personnel, nurses, and pharmacists.
“The program came with CME credit so that it met the state requirements for relicensure. In Pennsylvania, as in many states, there is a requirement to have some dedicated opioid prescribing safety CME,” Perrone said.
Using IT interventions, opioid program staff changed the defaults for several opioid medications and optimized choice architecture to prioritize nonopioid analgesics over opioids in revamped pain order sets for specific procedures. “It was also very helpful to have IT [expert] help to enumerate the number of patient visits we had for OUD, the number of patients who were being admitted with OUD as one of their problems ... and then to create some pathways to improve the treatment of those patients in and out of the hospital,” Perrone explained.
One of the first steps the opioid program organizers took toward reducing the use of opioids for pain was to encourage multimodal analgesia, Perrone said. This included adding new options, such as gabapentin, some anticonvulsants, and local anesthetics. Ketamine also was added for specific perioperative procedures.
“Then, we put together an education module that met CME requirements ... and brought everyone up to speed on the idea that we were trying to manage pain more judiciously, but without the umbrella of aiming for a zero-pain floor,” Perrone reported.
A major accomplishment, achieved with the help of IT expertise, was finding a way to integrate the state’s prescription drug monitoring program (PDMP) into HUP’s EMR so that providers could access a patient’s entire controlled substance prescribing history with the click of a button. Previously, providers had to exit the EMR, log into the state PDMP website, and then enter a patient’s information to bring up the prescribing information.
“Now, directly from the EMR, we are able to smoothly get this one-button integration ... and it has greatly increased our compliance with PDMP access,” Perrone explained.
Patients who were hospitalized with OUD received considerable attention in the initiative. Perrone and colleagues believed the health system’s care of these patients was falling short. “We had a very high rate of patients who would leave against medical advice in the middle of their treatment,” she said. “Patients who were admitted for endocarditis or cellulitis or any of the complications of OUD were really being poorly cared for in terms of having their opioid withdrawal managed on the inpatient side.”
To rectify the problem, buprenorphine was added to the formulary for new starts; this meant patients could get either buprenorphine or methadone to treat their withdrawal while they were in the hospital, Perrone noted. Mechanisms also were put in place to bridge these patients to outpatient treatment after they were discharged. “One of the more effective ways to do this was to reach out to the medical students, pharmacists, and residents who were real advocates for this patient population and also came face to face with the patients who wanted to leave in the middle of their care [only to return] even more sick a few days or a few weeks later,” Perrone said.
The hospital set up outpatient practices to take these patients after hospitalization. These practices were staffed by the same clinicians who were advocating for them.
“They would get full waver training [to prescribe buprenorphine] and then began to see these patients a half morning per week in their clinics,” Perrone said. “That has grown substantially so that now there are seven or eight practices in the health system accepting patients after discharge.”
In the ED, a default was implemented in the EMR to remind clinicians to prescribe naloxone, the opioid antidote, to patients discharged following an overdose as well as to patients seeking treatment. In fact, one project that proved highly successful involved keeping a stock of naloxone in the ED that could be dispensed for free.
“We would then go back and bill the patient’s Medicaid if the patient was on Medicaid so then the patient got [naloxone] directly from us but with a very low cost to us,” Perrone said.
Since the program’s inception, HUP has decreased its overall prescribing of opioids by 10%. Further, HUP has taken steps to disseminate the various interventions through the creation of a stewardship website that houses all the initiative’s protocols, education modules, and guidelines. Still, dissemination remains one of the bigger challenges. “We have worked hard on trying to communicate, but we realize that health system emails fall short when providers are trying to access this information ... so our website has served a good purpose,” Perrone said.
Scott Weiner, MD, MPH, FAAEM, FACEP, is an assistant professor of emergency medicine at Harvard Medical School and an attending physician at Brigham and Women’s Hospital (BWH) in Boston. He also directs the BWH’s Comprehensive Opioid Response and Education (B-CORE) program, a hospital-wide initiative aimed at reducing opioid-related morbidity and mortality. He noted the alarm was sounded in Massachusetts in 2014 when officials projected that more than 1,000 lives would be lost to opioid overdoses.
“That is when our work really started,” he said. “Just like in the rest of the country, by the time we hit 2016, that number had already doubled. Even in 2014, the actual number of lives lost was actually much higher than we had even anticipated.”
Weiner noted that the B-CORE program shares many of the same concepts and features of HUP’s program and that B-CORE has achieved success in changing provider practices regarding opioids and implementing new approaches in the care of patients who present with OUD.
Based on his experience with BWH’s initiative, Weiner advised colleagues interested in establishing their own programs to begin by identifying a champion who is nondepartmental, a person who serves in a hospital role as a surrogate for hospital leadership. “It gives credibility and also the clout that is necessary,” he said. “It is also important to provide some funding. Of course, it is hard under tight budgets, but it is a significant amount of work. Getting some funding to support a director is, in my experience, crucial.”
Further, the initial goal should be to break down silos, Weiner offered. “What I am sure is happening at all hospitals is that there are excellent projects happening in different departments, but we like to think here of opioid-related issues similarly to how we treat cancer, which is interdisciplinary,” he said.
Noting that high-level support is important, Weiner advised colleagues to enlist the involvement of executive leadership. “For us, it was important to have the chief medical officer and the chief nursing officer [involved]. We also have a separate chief quality officer role, which has been very fundamental to the project,” he said. “We engaged with the chairs of anesthesiology, because they manage the pain clinic, and psychiatry, because they treat addiction in our health system.”
The director of strategy also jumped in to help with the effort, as did the director of addiction psychiatry, Weiner observed. “Take advantage of the momentum ... to solve this problem,” he added.
Similar to HUP’s effort, BWH divided their opioid program into several different groups that work under the direction of an executive committee. For example, there is a prescribing taskforce that has worked on guidelines, an addictions taskforce that works on care for patients with OUD, and another group that handles education.
When developing guidelines and metrics for the program, BWH began with the laws and the guidelines that already existed. From all these sources, the hospital created its own document, including a guideline for the treatment of acute pain and chronic pain. Program developers crafted broad, aspirational goals as well as specific metrics to measure. For example, the goal of the effort is to reduce the number of fatal and nonfatal overdoses.
“It is a very hard number to capture. Someone can be treated at the hospital across the street, and I might never see them in my hospital. Then, [he or she] overdoses on opioids, and the ambulance brings [him or her] to me,” Weiner noted. “We are looking at this by patients where we know their whole history ... and we can see exactly where they have been.”
For prescribing metrics, the hospital examines a urine toxicology screen at least once a year, prescribes naloxone for patients on high doses of morphine, and asks patients to visit at least every four months if they take opioids chronically, Weiner said.
“On the inpatient side, we look at adverse events, and then the addiction measures include how many times we are giving naloxone in the ED at discharge,” he explained. “The rest is really about increasing access to medication-assisted treatment and getting more wavered providers.”
Similar to HUP, BWH established a small bridge clinic that is staffed by a social worker, a recovery coach, and a clinician who can provide buprenorphine or naltrexone, Weiner noted. The result of this intervention is that some patients who otherwise likely would be admitted to the hospital for six weeks at a time with complications from injection drug use can be discharged.
“Since we opened [the bridge clinic] in April, we have already had nine patients that we have been able to successfully discharge home,” Weiner said. “They come back to the clinic for their buprenorphine, they have completed their IV antibiotics, and this has saved over 250 inpatient days for just those nine patients.”
Other results from the initiative include a significant drop in the number of opioid prescriptions. “In two years, we have gone from 9,000 prescriptions per month to 6,000 prescriptions per month,” Weiner reported.
“We have also decreased the number of patients who are receiving opioids, which we think is because we are using alternative modalities to address their pain that are nonaddictive.”
Meanwhile, the number of prescriptions for buprenorphine is rising, along with the number of patients receiving buprenorphine, and the number of BWH clinicians able to prescribe buprenorphine is on the rise, too. “In 2017, we were one of just seven states in the country that actually saw a slight decrease in the number of opioid-related deaths,” Weiner said. “We are hopeful that all of the interventions that are happening at the state level, federal level, and hospital level are actually moving the needle and saving lives.”
(Editor’s Note: Brigham and Women’s Hospital has established a website that houses many resources used in the B-CORE program. Interested providers are invited to review the materials and adapt them for their own use. The materials can be accessed at: https://bit.ly/2z42BR1.)
SOURCES
- Jeanmarie Perrone, MD, Director, Division of Medical Toxicology, Department of Emergency Medicine, University of Pennsylvania; Professor, Emergency Medicine, Hospital of the University of Pennsylvania. Email: [email protected].
- Scott Weiner, MD, MPH, FAAEM, FACEP, Assistant Professor, Emergency Medicine, Harvard Medical School; Attending Physician and Director, Comprehensive Opioid Response in Education Program (B-CORE), Brigham and Women’s Hospital, Boston. Email: [email protected].
It has been nearly a year since The Joint Commission unveiled new pain management standards as part of an effort to combat the opioid epidemic. While all accredited hospitals are held accountable for their implementation and adherence to the standards, some health systems have responded by centralizing their opioid-related initiatives under a single, purposeful umbrella to produce more powerful results.
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