Opioid Prescribing

1
(No Transcript)
2
Opioid Prescribing

• An audit of the prescribing of breakthrough
  opioid analgesia at RHCH
• Dr A Wilkinson, Dr K Conway, Dr H Staveacre, Dr S
  Harrington, Alexandra Tobin

3
Acknowledgements

• Dr S Harrington
• Dr H Staveacre
• Dr K Conway
• Dr H Bush
• Dr A Oswell
• Naomi Donachie
• Magdalen Thomson
• Fiona Geal
• Alexandra Tobin
• Malcom Irons
• Sonia Rushby

4
Why?

• Opioids are commonly prescribed in the Trust
• Prescribed mostly by junior doctors and
  administered by trained nursing staff
• Too low a dose leads to inadequate pain control
• Too high a dose may lead to toxicity
  potentially serious adverse effects

5

• Anecdotally as a HPCT we have observed several
  cases where the prescribing of breakthrough
  analgesia has been incorrect
• There are clear guidelines about how opioids
  should be prescribed
• The National Patient Safety Agency is now placing
  increasing onus on correct opioid prescribing and
  administration

6
National Inpatient Survey 2006

• Did you think the hospital staff did everything
  they could to help control your pain?
• Threshold for best 20 of NHS trusts 87
• Highest score (all trusts) 93
• RHCH score 81

7
Purpose

• To ensure all patients are prescribed correct
  rescue doses of opioid analgesia

8
Standard

• As published in the WEHT and RHCH palliative care
  handbook (The Green Book) and PCF2
• The breakthrough dose of opioids should be 1/6th
  of the total daily dose, prescribed for prn use,
  with no time limit between doses

9
Process
10
RAID Model for Service Improvement

• Review
• Agree
• Implement
• Demonstrate

11
Review Quantitative Data Collection

• Prospective data collection October 2006
  January 2007
• All RHCH inpatients prescribed long acting
  opioids
• Patients were identified using the controlled
  drugs book on each ward
• This prescription and their breakthrough
  analgesia prescription was then recorded from the
  JAC computer system

12

• Proforma
• Name
• Ward
• Long acting opioid prescription
• Breakthrough opioid prescription

13

• 1 week pilot daily data collection
• Weekly data collection thereafter
• Data entered onto spreadsheet
• Correct breakthrough doses then calculated and
  compared with the actual prescription

14
Review Qualitative Data Collection

• Individual, small and large group meetings with
  doctors, nurses and pharmacists
• Follow up letter to all consultants, SAS doctors,
  senior nurses and clinical nurse specialists

15
Results

• 70 patients
• 87 prescriptions for breakthrough analgesia
• 76 (87) prescriptions incorrect
• 11 (13) prescriptions correct

16
Results

• Of the 87 prescriptions
• 52 correct dose
• 13 correct timings
• 35 incorrect dose and timings
• Dose Timings

17
Results

• Of the 87 prescriptions
• 31 too low - range 0.08 to 0.6 times correct
  dose
• 15 too high - range 1.5 to 3 times correct dose

18
Parenteral Opioids

• 21 prescriptions for parenteral morphine
• 65 incorrect
• 7 too low
• 6 too high
• Oral morphine dose Breakthrough prescribed Ideal
• 100mg bd 5mg IV 15mg SC
• 90 mg bd 5-10mg IM 15mg SC
• 60 mg bd 10-20mg IM 10mg SC
• 20 mg bd 5-10mg IM 5mg SC
• 100mcg/hr fentanyl 5-10mg IV 30mg SC

19
Alternative Opioids

• 9 prescriptions for fentanyl patches
• 78 incorrect
• All too low
• Fentanyl dose Breakthrough prescribed Ideal
• 50 mcg/hr 5mg oramorph 30mg
• 50 mcg/hr 10-20mg oramorph 30mg
• 75 mcg/hr 30mg codeine phosphate 45mg
• 75 mcg/hr 20mg oramorph 45mg
• 75 mcg/hr 1020mg oramorph 45mg
• 100 mcg/hr 20mg oramorph 60mg
• 100 mcg/hr 30mg oramorph 60mg

20
Results Concluded

• Large numbers of prescribing errors
• Of particular concern are prescriptions for
  parenteral opioids and fentanyl

21
Recurrent Themes

• Fear of overdosing
• Fear of causing side effects
• Lack of confidence in prescribing
• Lack of confidence in administering high doses
• Frustration from nursing staff that analgesia is
  not prescribed frequently enough
• Many juniors will ask middle grades about
  appropriate doses
• Many middle grades do not feel confident
  prescribing opioids
• These conversations often quickly led to issues
  surrounding CPR and death when we were only
  discussing opioids
• Many keen for improved education
• Nursing staff suggested creating a quick
  reference wall chart for each CD cupboard
• Computer system gives incorrect options and is
  difficult to override

22
RAID - Agree

• Agreement reached using
• Data collection exercise
• Informal meetings
• Formal audit meetings
• Meetings with key stake holders
• Focus on
• Education and support
• Computer prescribing system
• On the job aide memoirs

23
RAID Implementation

• Mandatory protected teaching for nursing staff in
  conjunction with the acute pain team and pharmacy
• Protected teaching for F1, F2, ST1, ST2 and ST3
  doctors as part of regular teaching programme
• Higher profile of Pain teaching in 3rd and 5th
  year medical student attachments

24

• Change JAC prescribing options in conjunction
  with pharmacy department
• Trust guidelines on intranet (via the Drug and
  Therapeutics Committee)
• Quick reference wall chart for all CD cupboards
• Quick reference chart to be included in new
  doctor induction pack
• Ongoing liaison with pharmacy and the acute pain
  team

25
RAID - Demonstrate

• Re-audit December 2007 - March 2008
• Team of F1 and F2 doctors raring to go (to Paris)

26
Lessons Learnt

• Value of service improvement expertise mentored
  by Alexandra Tobin through the Wessex
  Professional Programme
• Value of qualitative information reflected
  recently in Help the Hospices report for World
  Palliative Care Day, October 2007

27

• Easiest area for implementing agreed
  interventions has been with doctors - ?
  why
• Digital patient stories value, how not to do it
• The smallest project grows. And grows.

28
(No Transcript)