Decreasing Opioid Use at Englewood Health: A Quality Improvement Project

Abstract

The opioid crisis represents one of the largest public health problems in the United States. Over the period 1999-2018, over 450,000 people have died from misused opioids, including prescription pain relievers and heroin users. In 2018, over 50% of opioid related deaths were prescribed by physicians. We aim to identify problems with in patient opioid prescribing patterns, and implement mechanisms to improve them. METHODS:Pre-intervention retrospective data was collected from 100 charts during July and August 2019 on 5 hospital floors, including surgical and medical patients. Reports were run in our electronic medical record to identify patients who had received any opiates during their hospital stay. Patients on the oncology floor, or on comfort care were excluded. For each chart, various parameters including demographics, length of stay, types and frequency of opiates used, number of doses administered and the discharge instructions. After gathering data and defining the problems, ongoing data collection was done from September 2, 2019-March 15, 2020 with interventions during this time to include: educational sessions, change in opioid prescribing order sets and automatic discharge instructions for patients receiving opioids. Data collection was halted early to facilitate response to the pandemic.RESULTS: Intravenous (IV) hydromorphone was the most frequently used opiate, with patients receiving this for an average of 2.8 days. Only 4% of patients that were discharged on opiates received opiate discharge instructions. Of all patients discharged with opiates, 24% did not receive/require opiates 48 hours prior to discharge. To address these findings, the first intervention was to change the expiry date on intravenous opiates from 5 days to 1, which resulted in a statistical significant trend toward the goal of 1 day. Secondly, opiate discharge instructions were automatically populated for patients discharged on opiates resulting in a statistically significant improvement to 100%. Interventions to decrease discharge prescriptions to patients who did not require any 48 hours prior to discharge, resulted in a shift in data points, corresponding with a possibly statistical improvement. However, this improvement was not sustainable, as education alone, rather than forced functions, is not a long-lasting intervention. CONCLUSIONS:We should aim to decrease our opioid use in hospitals in an effort to stem the tide in this epidemic. Forced functions are needed to ensure best practices are adhered to, and changing order sets will lead to significant improvements. CLINICAL IMPLICATIONS:The Society of Hospital Medicine indicates that: IV opiates administered for more than 24 h after an initial IV dose in patients not NPO is inappropriate and can increase the risk of dependence and opioid related morbidity and mortality.