Dispensing a Naloxone Kit at Hospital Discharge: A Retrospective QI Project

Abstract

Purpose: The aim of this quality improvement (QI) project was to increase the coprescription of naloxone kits at patient discharge as a harm reduction strategy to combat the opioid epidemic. An interdisciplinary team identified hospitalized medical patients who were at high risk for an opioid overdose or opioid-related adverse event. Methods: Led by a physician champion, an interdisciplinary QI team composed of physicians (MDs and doctors of osteopathic medicine), advanced practice providers (NPs and physician assistants), RNs, care coordinators, social workers, and pharmacists developed and implemented a naloxone distribution program on one medical unit at an academic tertiary care center. The team developed and implemented criteria to identify high-risk patients, workflow for patient screening, staff and patient education programs, and processes for naloxone kit delivery to the patient's bedside. Data on naloxone kit distribution from the seven months prior to implementation (March 2018 to September 2018) and the seven months after implementation (October 2018 to April 2019) were evaluated and are reported descriptively. Results: Two patients preimplementation and 64 patients postimplementation received a naloxone kit at discharge. In the postimplementation group, common reasons for identifying a patient as at high risk for an overdose or adverse event were a prescription for a pain medication at a daily dosage greater than or equal to 50 morphine milligram equivalents (50% of patients), concomitant opioid and benzodiazepine use (19%), history of substance use disorder (11%), and medication-assisted treatment (9%). Most patients in the postimplementation group (86%) received a naloxone kit at a personal cost of $1 or less. Conclusion: This unit-based pilot project was successful in identifying patients at high risk for an opioid overdose or opioid-related adverse event and in providing naloxone kits and education at hospital discharge.

Role of the pharmacist in acute care interventions for opioid use disorder: A scoping review

“…An additional 405 articles were included in secondary screening, yielding three additional articles meeting inclusion criteria (Figure 1). In total, seven articles were included in this review (Table 1): Four articles described initiatives aimed at harm reduction for individuals with OUD, [18][19][20][21] and three articles described initiatives aimed at increasing MOUD initiation or improving MOUD management in the acute care setting. [22][23][24]…”

“…Four studies describing the implementation of naloxone dispensing programs in acute care settings, one at hospital discharge 18 and three in the ED, [19][20][21] were included. The key component to all of these was the dispensing of naloxone, as opposed to the provision of a prescription for naloxone upon discharge.…”

“…In the first retrospective study, an interdisciplinary team consisting of physicians, advanced practice providers, nurses, a unit-based care coordinator, a licensed social worker (LSW), and pharmacists implemented a quality improvement project to screen for patients with SUDs or at high risk of opioid-related adverse events, provided those identified with a naloxone kit upon discharge, and provided ongoing education for hospital staff and patients. 18 The overall workflow consisted of six steps: collaboration within an interdisciplinary group to champion and educate hospital staff, screening for highrisk patients during interdisciplinary care rounds, discussion with The second study also described a program implemented by a multidisciplinary team composed of pharmacists, physicians, nurses, and case management professionals. 19 A protocol for opioid overdose education and naloxone distribution consisting of five steps was developed: patient screening, order placement via the electronic health record (EHR), screening of a patient training video, dispensing of a naloxone kit, and provision of written discharge instructions.…”

“…In the first study, the role of the pharmacist appeared to be limited to attendance of interdisciplinary rounds and dispensing naloxone kits to identified patients. 18 Any credentialing or training for pharmacists involved in this program was not described. Further, it is unclear whether pharmacists participated in developing the screening criteria used for this program and the extent of their participation in interdisciplinary rounds and patient screening.…”

“…Finally, the role of the pharmacist in providing education to hospital staff was also not clear in this study. 18 The role of the pharmacist in the other three studies was both more involved and described in greater detail than the first. [19][20][21] As part of a multidisciplinary team, pharmacists assisted with developing protocols and training hospital staff in their implementation.…”