From the 2019 HVPAA National Conference
Dr. Betty Chiu (University of Toronto, Sinai Health Systems), Dr. Christine Soong (University of Toronto, Sinai Health Systems), Dr. Amir Imani (University of Toronto, Sinai Health Systems), Ms. Krystal Lawley (University of Toronto, Sinai Health Systems)
The opioid crisis has dramatically changed the culture surrounding opioid prescriptions across North America. In Canada, Health Quality Ontario (HQO), a third party organization focused on quality initiatives, has issued guidelines around opioid prescribing in the post-operative acute pain population. The guidelines suggest parameters to the maximum duration (7 days) and tapering regimen of opioids prescribed after surgery. Given the unintentional negative consequences of opioid over-prescription, Bridgepoint administrators were interested in understanding the causes of opioid over prescribing and ensuring that hospitalist physicians were adhering to guidelines surrounding opioid use in this population.
The objective of this project was to determine the amount of opioids prescribed at admission to patients on Orthopedic rehab floors at Bridgepoint, as well as evaluate current prescribing practices of hospitalist physicians during the length of stay and at discharge. Furthermore, the project aimed to understand the root causes of opioid prescribing and over-prescribing.
A chart review was conducted of 40 patients across 2 units in the hospital. Information surrounding opioid prescribing at admission, tapering and adjuvant therapy during their length of stay, and prescriptions at discharge were obtained. A root cause analysis was performed to understand the potential causes to prolonged and potentially unnecessary opioid prescribing both in hospital as well as at discharge. A process map was created to understand important junctions within a patients journey in the rehab hospital that could serve as elements for change.
As a review of the opioid prescriptions on the Orthopedic rehab floors at Bridgepoint, 90% of patients were opioid naïve, or not on any long term opioids prior to their stay in hospital. Furthermore, 92.5% of patients were prescribed either standing or ‘PRN’ opioids at admission. About 50% of patients had been tapered and their opioid stopped at the time of discharge. The root cause analysis identified physician, patient, interprofessional team, as well as systems and environmental causes contributing to opioid overuse. The process map identified areas of intervention at the level of the physician, patient, interdisciplinary team, as well as systems and processes.
There are many opportunities for the implementation of change ideas on the Orthopedic rehab floor that may help to ensure physicians are adhering to HQO guidelines, and that patients are prescribed opioids only for the shortest duration necessary after their surgery.
The project tackles improving population health and the quality of care. Indirectly, it also may affect the sustainability and per capital cost of health care. First, population health looks at the overall improvement of health care. By ensuring that the guidelines around safe opioid prescribing are adhered to at Bridgepoint, there is the opportunity to improve the health of the population as a whole. Furthermore, the quality of care, and the patient experience of care may be improved through more patient centred assessment of pain and individualized plans for pain management. Lastly, by practicing safe prescribing, we will limit the misuse and diversion of opioids in the community, which will ultimately reduce costs associated with morbidity and mortality of opioids.