Riverside Health System, Newport News, VA
Improving the safety and effectiveness of postoperative pain management
In August 2017, our organization joined a CMS HIIN focused on improving the safety and effectiveness of postoperative pain management. Five acute care facilities within the organization are participating in this performance improvement program, which is focused on elective total joints and colectomy. Nationally, approximately 30 hospitals are in the cohort, allowing an opportunity to learn from others.
In order to establish a baseline, an interdisciplinary team answered a questionnaire that encompassed all aspects of operative pain management. The performance improvement initiative includes eight months of data collection to measure compliance on a bundle of best practices aimed to improve the safety and effectiveness of operative pain management practices within the organization.
Key Elements of Success
The optimal care bundle for the program consists of 7 elements:
- Measurement of patient baseline opioid utilization and categorization as opioid naïve, opioid tolerant or opioid dependent. This information is then used to customize the pain plan for the procedure and hospital stay
- Sleep apnea assessment pre-operatively
- Use of multi-modal pain management throughout the surgical admission
- Use of a standardized methodology to assess pain at least every shift
- Use of a standardized methodology to assess sedation at least every shift
- Patient involvement in establishment of paint management goals and a pain plan
- Discharge education bundle that includes reason for use, anticipated duration and intensity of use, risk of opioid use, safe disposal, safe storage, and under which circumstances to contact a provider or 911.
Results of chart audits are shared with key stakeholders to develop improvement efforts.
Impact on Patient Outcomes
Measurable results include consistent use of multimodal pain management (95 percent), high compliance with apnea screening prior to procedure (80 percent), qshift assessment of pain score (100 percent), involvement of patient in pain management goal setting (90 percent). Chart audits helped to identify an opportunity to improve discharge education materials to meet all bundle elements, which is in the process of implementation. Additional outcome measure of use of naloxone for patient group audited are still pending.
Role of the Pharmacy and Pharmacists
The overall project is being led by the Chief Pharmacy Officer. Pharmacy leadership from each facility is actively involved in the process. A PGY1 pharmacy practice resident selected the project as her focus, and is working with the health-system navigator on the content (print and presentation) for Joint University, with a focus on establishing realistic pain goals, the role of multimodal pain management and non-pharmaceutical pain management, and patient education on the risk of option therapy.
The lessons learned during this initiative included :
- Importance of having a strong baseline of consistent use of multimodal pain management due to previous work on robust operative order sets that drive the practice
- Need to ensure the engagement of providers in the process
- Collaboration with IT on the build required to meet the core bundle elements.
A key challenge was the lack of validated tools to effectively determine a patient’s opioid status at admission and translate that into decision support to drive appropriate opioid dosing that is both safe and effective. Additionally, engaging champions for the initiative — anesthesia, a general surgeon, and the CMIO — was vital.
Budget & Resource Allocation
Currently, this program is in a pilot phase. At this point there is no specific budget for the program. The goal is to apply the concepts from total joint and colectomy patients to a broader surgical population.
Once the eight-month pilot is completed and performance improvement implemented, we plan to expand the process to other surgical procedures.