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December 18, 2018

ED Pharmacists Keep Opioid-Naive Patients Naive

ED pharmacists Zachary Brent, Pharm.D., BCPS, and Julie Bennett, Pharm.D., MBA, BCPS, discuss opioid metrics.

IN THE EMERGENCY DEPARTMENT (ED) of Baptist Memorial Hospital in Memphis, Tenn., an innovative opioid stewardship program is showing real promise in keeping opioid prescriptions to a minimum while making sure patients are comfortable and pain-free. The program’s primary goal is to keep opioid-naive patients naive.

Opioids in the ED

“Opioids are an increasing problem in the ED, not because pharmacists are seeing so many more overdoses — those are often treated by EMTs — but because the ED is often where a patient is first exposed to opioids,” explained Julie Bennett, Pharm.D., M.B.A., BCPS, a pharmacist who works in Baptist Memorial Hospital’s bustling ED. “We realized that if we could find a way to eliminate that first exposure, then we could make a significant impact on the opioid crisis.”

With the full support of Baptist Memorial’s ED physicians and leadership, Dr. Bennett and Zachary Brent, Pharm.D., BCPS, also an ED pharmacist at Baptist Memorial, set out to create an opioid stewardship program that offers opioid alternatives to patients.

The two pharmacists, both members of ASHP, began the project in January 2017 by collecting data on opioid usage in Baptist Memorial’s ED. They chose milligrams of morphine equivalents per 100 emergency department patient visits as the primary metric. The data showed that in January 2017 the ED staff was giving 120 mg morphine equivalents per 100 ED patient visits. “This was sobering,” said Dr. Brent. “We were giving a dose of opioids to one out of every four patients in the ED.”

Opioid Alternatives

To reduce opioid dispensing, the hospital’s pharmacy team created an opioid stewardship program based on a program implemented at the Swedish Medical Center in Englewood, Colo. First, the Baptist Memorial pharmacy team identified five conditions that are typically treated with opioids: chronic abdominal pain, headache/migraine, renal colic, extremity fractures/joint dislocations, and musculoskeletal pain. The team then provided physicians with non-opioid alternative treatment options for each condition.

Dr. Bennett orders medications from an automated dispensing system.

“Treatment options are broken down into first-, second- and third-line options,” said Dr. Brent. “For example, first-line treatment for headache/migraine might include a liter of saline plus oxygen, ketorolac, ketamine, or lidocaine injections. A physician might choose one, two, or even three of these options.”

He noted that many of the first-line options are common OTC pain medications, but in IV form. “All of the treatment options are built into our computer physician order entry system so our physicians can easily access and order these alternative pain medications,” said Dr. Brent. “Most of the alternative options are also stocked in our automated dispensing cabinets in the ED to allow for quick retrieval by nurses.”

If an opioid is needed, then the pharmacy team will try to use the lowest effective dose. “If patients come in on opioids, that’s fine, but it doesn’t necessarily mean that we are going to give them opioids while they are in our ED,” said Dr. Brent. “The alternative medications we use tend to work quicker and more effectively to alleviate patients’ pain.”

For example, Dr. Bennett recalled a recent situation where a patient who used morphine and oxycodone at home for a certain condition wanted a prescription from the ED pharmacist to alleviate pain caused by her shoulder bursitis. “She already had topical lidocaine patches and creams and every other alternative I could think of at home,” said Dr. Bennett, who ultimately recommended a nonsteroidal anti-inflammatory drug called ketorolac. The patient remembered that she received ketorolac for a dental procedure and that it had really helped with the pain.

Communication and Education

Soon after rolling out the new opioid stewardship program, the pharmacists experienced a bit of pushback from physicians who were used to ordering opioids and from patients who expected to get them. The pharmacy team used a combination of communication and education to demonstrate why opioid alternatives can often be a better option.

ED physician Katrina Hutton, D.O., and Dr. Bennett talk about opioid alternatives for a patient being discharged.

On the patient side, the pharmacy team assisted nurses with answering patients’ questions about the alternative medications and made sure that patients’ pain needs were always being met. “There were many times when I was called to a room to explain to a patient how the alternative medication works and why it is better than an opioid,” explained Dr. Brent. “Sometimes the patient was satisfied with the explanation, and other times they weren’t.” He believes the conversations with patients helped them understand that the providers in the ED were trying to do what was best for them, instead of just defaulting to using opioids.

Although the physicians were excited about the change and enthusiastic about providing more appropriate care for their patients, “it was still difficult for them to curb their opioid use, since it was a habit for them to order opioids,” said Dr. Brent. “Once our providers knew they had support [from hospital leadership], and we provided them with the order sets and educated the nurses about opioid alternatives, they were all in.”

Satisfied Patients, Satisfied Providers

As a result of implementing the opioid stewardship program in the ED at Baptist Memorial, opioid use decreased by 73 percent. Where previously one out of four patients received a dose of an opioid in the ED, the number has now dropped to 1 out of 10. Patient satisfaction with how they felt their pain was being addressed increased by around 30 percent.

Dr. Brent believes the entire team of ED pharmacists, physicians, and nurses at Baptist Memorial has done a great job of communicating to the patient why they are being given an opioid alternative. “We are all focused on taking care of patients effectively and efficiently,” said Dr. Brent. “Through the opioid alternative program, pharmacists are providing physicians and nurses with the support to do that. ED pharmacists are in the perfect position to partner with our providers to give them the tools needed to take care of patients appropriately.”

 

By Ann Latner

 

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December 17, 2018

ASHP Continues to Lead on Pharmacy Workforce Well-Being & Resilience

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

I am pleased to share with you that over the last year ASHP has continued to increase our efforts to support the well-being and resiliency of the pharmacy workforce. ASHP is an original sponsor of the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience and is honored to support the pharmacy profession on this important patient care and workforce issue. As the NAM Action Collaborative on Clinician Well-Being and Resilience approaches the two-year mark, I would like to share some updates with you on our efforts to help address this important issue facing pharmacists, pharmacy residents, student pharmacists, and pharmacy technicians.

These past 15 months, through the NAM Action Collaborative and ASHP’s own organizational efforts, we have raised the visibility of clinician burnout, depression, stress, and suicide. Over that time, ASHP has developed resources, educational programming at our national meetings, and community connections for members to learn more about the issue. Former U.S. Surgeon General Vivek Murthy kicked off our 2018 ASHP Summer Meetings by challenging attendees to include well-being as the core of what we do as healthcare workers.

Summer Meetings attendees also heard about some of the science behind resilience and were introduced to interventions for building individual and team resilience through two interactive presentations by Dr. Bryan Sexton, Director of the Duke Patient Safety Center. Conversations on the topic continued in the ASHP House of Delegates, where delegates approved an ASHP policy on Clinician Well-Being and Resilience. We are very pleased to have an official professional policy for members to reference as they begin and continue discussions at their institutions. Efforts by the ASHP House of Delegates also helped form a joint ASHP Council and Commission session on the pharmacists’ role in suicide prevention during the 2018 ASHP Policy Week.

We know that burnout is associated with compromised patient safety and a loss of productivity in the healthcare workforce. As such, we continue to help advance pharmacy-specific research on resilience and well-being. ASHP recently partnered with the Pharmacy Technician Certification Board (PTCB) and Duke University Health to study the prevalence of burnout in pharmacy technicians and identify resources to support this important and growing segment of ASHP’s membership. While both NAM and ASHP are improving baseline understanding of challenges to clinician well-being, we are reminded that this is a local issue that requires local solutions to address it. ASHP members continue to share their strategies on how to foster the creation of resilience in clinical learning and managing preceptor burnout. If you traveled to Anaheim for the recent Midyear Clinical Meeting, there were multiple educational sessions on workforce well-being. Many of these sessions were recorded and will be available on ASHP eLearning in early 2019.

NAM recently kicked off a consensus study to examine systems approaches to improve patient care by supporting clinician well-being. ASHP nominated M. Lynn Crismon, Dean, University of Texas, College of Pharmacy, to serve on this committee, which will issue a report with recommendations for system changes to streamline processes and manage complexity, minimize the burden of documentation requirements, and enhance workflow and teamwork to support the well-being of all clinicians and trainees. In the meantime, the NAM clinician well-being knowledge hub continues to grow with solution strategies for leaders, organizations, and individuals, including ASHP contributions to a discussion paper on implementing optimal team-based care to reduce clinician burnout. ASHP state affiliates are also an important part of the conversation, and ASHP has created a state affiliate toolkit on well-being and resilience to assist them in their state-level efforts.

Our continued work in advancing workforce well-being and resilience is ultimately growing a foundation for long-term culture change. We have enhanced our SSHP Recognition Program for the 2018–2019 academic year to encourage our students to address the issue. We know that many of you are working on well-being and resilience within your organizations, and we would appreciate hearing from you. We encourage you to share your stories through our community on ASHP Connect. Or, maybe you know of an individual or an organization that is demonstrating positive progress on resilience and supporting a healthy and engaged workforce. If so, we encourage you to fill out this brief survey so that we can create case studies others can learn from.

I hope you share our enthusiasm about this very important work to support the resilience and well-being of the entire pharmacy workforce and about the impact this work will have on improving patient care.

Thanks so much for being an ASHP member and for everything you do for your patients and pharmacy teams. I look forward to sharing more with you in the future as ASHP’s efforts continue in this important area. Have a safe holiday season.

Sincerely,

Paul

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