If you are accessing this Implementation Toolkit it may be because a patient, maybe even your patient, was harmed, or possibly died from opioid-related respiratory depression, at your workplace. Perhaps your facility has not had a serious safety event related to opioid administration, but you are a chief medical officer (CMO), chief quality officer (CQO), chief of staff (CoS) or a member of your hospital’s safety committee and have noticed there are frequent activations of your hospital’s rapid response team due to opioid-related sedation or respiratory depression. Many of these events may have resulted in respiratory failure and unplanned transfers to your intensive care unit (ICU). Alternatively, you may be a member of your hospital’s pharmacy and therapeutics committee and you have noted that there continues to be a persistent, and what seems to you to be too frequent, use of unplanned opioid reversal agents in your facility. Perhaps you are part of the frontline staff, a nurse or hospitalist who has noticed many “near misses” due to prescribing too high a dose of hydromorphone, or an incorrect patient-controlled analgesia (PCA) setting. These errors were caught, but if perhaps the nurse or pharmacist had been less experienced, there would have been patient harm.
If any of these situations describes why you are referencing this Implementation Toolkit, then you are in good company. The patient safety movement is well into its second decade.1 Decreasing opioid-related adverse events in all settings is an important and growing body of work that will result in fewer patients harmed.2 Specifically in the hospital setting, opioids are the most commonly prescribed class of medications, and the second most common class of medications to cause adverse patient events.3 Described by some as the “dead in bed” syndrome, respiratory arrest and death related to opioids has an incidence that is hard to measure but is real as evidenced by frequent case reports.4 One review identified 700 patient deaths directly attributed to PCA between 2005 and 2009.5 Lesser events, such as respiratory failure, unplanned mechanical ventilation, reversal agent administration and unplanned transfers to the ICU, should all be considered near misses and are common. Approximately one in 200 hospitalized post-operative surgical patients experiences post-operative respiratory depression.6 Other adverse reactions related to opioids, such as constipation or nausea, are even more common. In spite of all these facts, most hospitals have either incomplete or outdated policies or procedures when it comes to safe opioid prescribing and administration. In addition to being common, and at times devastating to patients and caregivers alike, adverse events related to opioids are costly. In a 2011 study, yearly costs in the United States associated with opioid-related post-operative respiratory failure were estimated at $2 billion.7
Though the evidence is incomplete, many systems have shown a decrease in patient-related harm with the implementation of rigorous quality improvement (QI) programs to improve opioid prescribing and administration. The Joint Commission recommends specific steps every hospital should take to reduce opioid-related respiratory depression. They include implementing effective processes, safe technology, education and training, and effective tools.2 This Implementation Toolkit will review how your hospital can meet The Joint Commission recommendations and move toward reducing adverse events related to opioid prescribing and administration.
This work is challenging. Complicating factors include patient expectations. In part, patient expectations are driven by government-mandated surveys. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a government-mandated survey of the patient’s experience in the hospital. The results are publicly reported and are tied to hospital reimbursement. Eight dimensions are reported, all of which must meet a threshold level for hospitals to be eligible to recuperate a Medicare reimbursement withhold. One of the dimensions is Pain Management. The HCAHPS survey question reads: “During your hospital stay, how often was your pain well-controlled?” The outcome reported is “always,” 4 on a 4-point Likert Scale. It is unknown if hospitals that score well on this answer have more opioid-related respiratory depression. Additionally, in 2001 The Joint Commission brought to light evidence that pain was undertreated in the hospital setting, and recommended measurement and more aggressive treatment of pain for inpatients.8,9 Since that alert, use of opioids as well as related adverse events has increased.10
The purpose of this Implementation Toolkit, Reducing Adverse Drug Events related to Opioids, or RADEO, is to provide step-by step instructions for your hospital to implement a successful QI program to make opioid prescribing safer, with fewer adverse events, and much less likely to result in dangerous sedation, respiratory depression and death. Its scope is for hospitalized patients. The Toolkit provides the essential building blocks for developing a QI initiative to improve inpatient safe opioid prescribing and administration including forming a quality improvement project team in your hospital, gaining institutional support and securing buy-in of frontline staff to ensure successful implementation. The Guide will also provide strategies for facilitating policy formation, evaluating current processes, tracking progress against implementation goals and identifying best practices. Although the scope of this Toolkit is inpatient patient safety as it relates to opioid prescribing and administration, the Toolkit also discusses transitions of care for patients in the outpatient setting on opioid therapy.
Like many patient safety issues, there is not always clear evidence. The Implementation Toolkit will present evidence and best practice where it exists. Each hospital’s QI team will be required to learn from best practices around the country and the medical literature as presented in this Guide. Also important will be the experience, culture and environment in your own institution. Implementation will look different site to site, especially where the evidence is not clear-cut. Your QI team will provide the structure and support to combine evidence, best practices and local experimentation to learn what works, or does not, in your hospital to achieve the goal of less patient harm related to opioid administration.
This is exciting work. Dig in, have fun and work together to make a real positive difference in the safety environment in your hospital and the well-being of each individual patient!
This project was supported by a grant from Covidien, LP.
The authors had full responsibility in designing and compiling the Toolkit. Covidien had no involvement in, or influence over, the development of the content included in this Toolkit