Case
A 67-year-old opioid-naive male with a history of obstructive sleep apnea and chronic kidney disease became unresponsive 2 days after hip replacement. Physical exam revealed a respiratory rate of 6 breaths/minute and oxygen saturation of 82%. He had received 6 doses of 6-mg IV morphine within the past 7 hours. How can I improve opioid safety at my hospital?
Dr. Keri T. Holmes-Maybank
Background
Opioids are the most commonly prescribed class of medication in the hospital and the second–most common class causing adverse drug events (ADEs), the most serious being respiratory depression and death.1
Opioid ADEs and side effects can cause prolonged length of stay and patient suffering. These vary from potentially life-threatening events such as serotonin syndrome and adrenal insufficiency to more manageable problems still requiring intervention such as constipation, urinary retention, cognitive impairment, nausea, and vomiting. Treatment of side effects can lead to complications, including side effects from antiemetics and urinary tract infections from catheters.
A 4-year review found 700 deaths in the United States attributed to patient-controlled analgesia (PCA) use.2 Another study revealed that one out of every 200 patients has postoperative respiratory depression attributable to opioids.3
It is estimated that 2 million patients a year become chronic opioid users. Inpatient opioid prescribing contributes to this problem;4 for instance, 5.9% of patients after minor surgery and 6.5% after major surgery become chronic opioid users if discharged with an opioid.5 Calcaterra et al. found 25% of opioid-naive medical patients received an opioid at discharge from a medical service.6 Those patients had an odds ratio of 4.90 for becoming a chronic opioid user that year.6
Most hospitals have incomplete or outdated policies and procedures for safe opioid prescribing and administration.7 The Joint Commission on Accreditation of Healthcare Organizations has specific pain standards for pain assessment, pain management, and safe opioid prescribing for hospitals. Additions and revisions were developed to go into effect Jan. 1, 2018. (Table 1)8
Quality improvement
Quality improvement (QI) is an effective way to improve opioid safety. The Society of Hospital Medicine has developed a QI guide, “Reducing adverse drug events related to opioids” or “RADEO,” to increase safety and decrease serious ADEs attributable to opioids.7
The steps in the RADEO program are as follows:
1. Assemble your team
It is critical to identify and include stakeholders from multiple disciplines on your project team. This team will be essential to develop a practical project, identify barriers, create solutions, and gain buy-in from medical staff and administrative leadership.
Front-line staff will have invaluable insight and need to be team members. The majority of interventions are performed by nurses; therefore, nursing leadership and input is essential. Representatives from pharmacy, information technology, and the quality department will be extremely valuable team members to guide you through the correct approach to a successful QI project.
A project champion can keep a high profile for the project and build and lead the team.
Identify an “executive sponsor” such as your CEO, CMO, or CNO. This leader will focus the team on issues critical to your organization, such as accreditation from governmental agencies, and help you obtain dedicated time and resources. Aligning with hospital goals will make your project a priority.
Coordinate with existing opioid initiative teams in the hospital to integrate efforts. This will keep the work of different departments aligned and allow you to learn from pitfalls and barriers the other groups experienced.
Patients/families contribute a unique and valuable perspective. Consider including a member of your hospital’s patient and family advisory council on your team.