Frontline Pharmacist
F rontline Pharmacist
Implementation of a pain medication stewardship program
P
ain medication stewardship is important to pharmacy practice because of its impact on quality patient care and medication safety. The Joint Commission recently published a Sentinel Event Alert on opioid safety suggesting that hospitals create and implement policies and procedures for a secondlevel review of pain management plans with high-risk opioids by pain specialists or pharmacists.1 A pain medication stewardship pharmacist would fulfill this role and enhance patient safety. In this article, we describe our experience with the development of such a program, which was created to bridge the gaps between pain management services provided by multiple disciplines within our institution, an academic medical center with more than 600 staffed beds. Program development. In November 2009, an interdisciplinary pain steering committee was created to identify barriers to improving patient satisfaction with pain management. The committee comprised representatives from various departments,
including anesthesia, physical medicine and rehabilitation, surgical services, inpatient pain management consultation team, palliative medicine, pharmacy, and
nursing. One of the major health care gaps identified was that while our institution had five consultation services for dif-
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).
2070
Am J Health-Syst Pharm—Vol 70 Dec 1, 2013
ferent types of pain management, there was no accountability for any one service to address the needs of the patient population as a whole. The committee championed recommendations to restructure the pain management services under the coordination of a medical director and through collaboration with other departments, including nursing and pharmacy. Recommendations specific to pharmacy included monitoring analgesic medications for safe use and providing evidenced-based prescribing guidelines through the enhancement of order sets and clinical services. The director of clinical pharmacy services and the pharmacist specializing in pain management were members of the pain steering committee and took the lead on addressing the medication safety and prescribing recommendations. To this end, an evaluation of clinical pharmacy practice at our institution was conducted, assessing the impact of current medication safety policies and guidelines on analgesic prescribing, the level of staff education and competency, staffing resources, and tangible outcomes. The evaluation revealed the following: 1. Medication safety initiatives that have been implemented (smart pumps for patient-controlled analgesia, standard order sets for pain management, and bedside bar-coding) do not guarantee that the drug and dosage prescribed are appropriate for the patient. Continued on page 2074
Frontline Pharmacist Continued from page 2070
2. Pharmacists are required to monitor opioid dosages according to medication safety policies and guidelines but do not have the expertise to design comprehensive pain management plans. 3. Demand for pharmacist services on weekends and holidays remains higher than the resources allocated. 4. Pharmacist involvement during transitions of care (i.e., admission and discharge medication reconciliation) has the most potential for positive patient outcomes. A proposal for the pharmacy pain medication stewardship program received approval from the hospital’s Medical Executive Committee prior to implementation in 2010. Physicians were notified of the program through an announcement in the hospital’s newsletter. The pain medication stewardship pharmacist engaged nurses by presenting the program at a nursing practice council meeting. Several presentations were provided to pharmacists and clinical team leaders to explain the purpose of the program and the role of the pain medication stewardship pharmacist. Pharmacists’ credentials and responsibilities. Selection criteria for pain medication stewardship pharmacists are based on years of experience in clinical practice, postgraduate residency or fellowship training in pain management or palliative care, and demonstration of strong leadership skills. Pharmacists involved in the pain medication stewardship program are responsible for providing medication reconciliation on patient admission using the information available through the Minnesota Prescription Monitoring Program (PMP).2 They also collaborate on perioperative pain management plans for complex cases, implement medication safety programs to address opioid-induced oversedation, attend service rounds with decentralized pharmacists to evaluate pain management problems, and provide expertise for
2074
formulary management of analgesic medications. Opioid medication reconciliation using the state PMP is the cornerstone of the service because it creates a medication review structure that can be easily identified in the electronic health record (EHR) and is well received by physicians and pharmacy staff. The medication review process is conducted daily each morning, with the pain medication stewardship pharmacist obtaining a computer-generated report of all active orders for oral long-acting opioids, fentanyl formulations, and methadone. Each new patient admission is reviewed to verify that the current opioid orders in the hospital are appropriate and that the dosages prescribed are the same as what the patient was receiving before hospital admission. This process is very helpful for opioid-tolerant patients who often are in pain because their regimen is not restarted at the dosage taken before admission. The process also benefits patients who are admitted directly to a surgical service who otherwise would have been missed, because their medication reconciliation would not have been completed until their transition to postoperative care. A standard form for medication regimen review is used to document physician requests for medication consultations in the EHR. The same form is used to document information obtained through the state PMP along with recommendations to resolve any dosage discrepancies. To expedite orders for opioids, the pharmacist contacts the physician via text paging to discuss the recommendations and offer to write opioid orders, if approved. The pharmacist is also responsible for recommending pain management regimens for patients with complex profiles (e.g., patients receiving highdose i.v. opioids or multiple pain medications). Pharmacists and physicians can request a consultation for moreextensive monitoring and follow-up of patients. The pain medication stewardship pharmacist interviews the patient regarding medication use and health history and writes a note in the EHR
Am J Health-Syst Pharm—Vol 70 Dec 1, 2013
that details the patient’s current illness, functional status, medical history, and pain medication history (including information obtained through the state’s PMP) as well as the pharmacist’s assessment and recommendations. He or she then contacts the inpatient pharmacist or physician who requested the consultation to discuss the recommendations. The pain medication stewardship pharmacist modifies orders for opioids and other analgesics if the recommendations are approved by the physician and continues to follow the patient’s progress on a daily basis until a discharge plan for pain medication is established in the EHR. The pharmacist may request consultations for other inpatient services and departments, including the pain team, psychiatry, and palliative care, when the medication issues are outside the scope of pharmacy practice (e.g., discontinuing pain medication due to chemical dependency). In addition, the pain stewardship pharmacist attends rounds for complex patients to teach other pharmacists pain management pearls. The postgraduate year 1 and 2 residents on the pain medication stewardship rotation acquire experience on providing complex pain consultations during their time with the pharmacist. Mitigating opioid-related adverse events through surveillance and prevention strategies is another responsibility of the pain medication stewardship pharmacist. The pharmacist is responsible for reviewing respiratory depression cases requiring naloxone reversal that are reported in the hospital’s adverse-event database. Adverse events are coded using the National Coordinating Council for Medication Error Reporting and Prevention criteria.3 Data are documented for events that result in prolonged hospitalization, resuscitation to sustain life, or the transfer to intensive care. The pain medication stewardship pharmacist collaborates with physicians, nurses, and pharmacy directors to improve medication safety through the use of standard order sets, policy and procedures for opioid administration, smart-pump
Frontline Pharmacist
technology, capnography, and the provision of staff education. Preliminary findings. From June 2010 to June 2011, the pharmacist reviewed opioid orders for 2499 patients. These patients were identified through pharmacy-generated reports and represented 16% of all admissions to the hospital for that period of time. Of the patients screened, 1099 (44%) required an intervention related to pain medication reconciliation. The most frequent intervention was EHR documentation of the most recent history of opioid medication use to clarify inpatient dosages (86%, n = 945). Pain medication stewardship consultations were requested by physicians or pharmacists for 154 patients (16%) for various reasons, including history of substance abuse, presence of psychiatric comorbidity, discrepancy between inpatient and outpatient opioid use, drug-seeking behavior, and drug diversion during hospital admission. Four adverse events occurred during this time period and resulted in prolonged hospitalization. In 2011, many changes occurred in our hospital, including the implementation of an epidural smart pump, new software for pharmacy and EHRs, and medication bar-coding, increasing the potential for errors due to the steep learning curve within a short period of time. The pain medication stewardship pharmacist monitored high-risk opioid practices (i.e., i.v. patient-controlled analgesia and methadone i.v. continuous infusion) and worked collaboratively with physicians and nurses to develop order sets to minimize prescribing errors. Monitoring opioid infusion pump medications became a permanent responsibility of the pain medication stewardship pharmacist to help prevent errors, especially with drug shortages that affect the performance of the devices. Challenges. The pain medication stewardship program uses an interprofessional approach but not in the traditional framework of the clinical rounding service that is common in academic medical centers. Pain medication use is so widespread throughout our academic
medical center that daily rounds with one or two services would not address the needs of many patients in the hospital. The pain medication stewardship pharmacist screens patients throughout the hospital for opioid therapy problems. If a problem is detected, this triggers a pain management review to ensure that changes are made to the medication regimen in a timely manner. The biggest limitation to this approach is that not all patients experiencing pain are taking long-acting oral opioids, fentanyl formulations, methadone, or high-dose regimens that will trigger a review. These specific groups of agents were selected for monitoring due to the risk of translation problems with the dosage form, strength, and unintentional interchange of product (e.g., Oxycontin 15 mg instead of short-acting oxycodone 15 mg). This is why it is important that decentralized pharmacists contact the pain medication stewardship pharmacist for patients who are reporting pain that is not relieved with the current regimen, which may include other opioids or analgesic medications. Our pharmacy department requires pharmacists to screen opioid orders to improve medication safety. During the first year of the program, pharmacists requested 71 consultations for complex patients; this number did not include the drug therapy questions answered on a daily basis. In March 2011, our hospital changed the EHR system and pharmacy computer system. All of the data collected from the start of the program in June 2010 had to be formatted into an Excel (Microsoft Corp.) spreadsheet so that the data would be available for retrieval after the switch to the new systems. The change in the EHR system also affected the pain medication stewardship note template, as there was no specific header available for the template until July 2011. Therefore, the pharmacist consultations and opioid reconciliation notes were not always recognized by staff. Service availability is another limitation. The pain medication stewardship program is available only on weekdays. Consultation requests during evening
and night shifts are addressed the following day, except for weekends. Before the weekend, a proactive plan for patients who have complex opioid regimens is documented in the EHR so that pharmacists have a guide on how to convert the opioid dosage and make adjustments. Pharmacy practice residents started training on the pain medication stewardship rotation in September 2010 and provide assistance with coverage of the service. There continues to be discussion on how other pharmacists may provide coverage for the pain medication stewardship pharmacist in the future. Conclusion. A pain medication stewardship program was developed at an academic medical center to help ensure the safe use of opioids and improve patient care through conducting admission medication reconciliation, monitoring and managing opioid-related adverse events, and providing pain management consultations for complex patient cases. 1. Joint Commission. Safe use of opioids in hospitals. www.jointcommission.org/ assets/1/18/SEA_49_opioids_8_2_12_ final.pdf (accessed 2013 Aug 20). 2. Minnesota Prescription Monitoring Program. Program homepage. http://pmp. pharmacy.state.mn.us (accessed 2013 Aug 27). 3. Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm. 1991; 48:2111-6.
Virginia L. Ghafoor, Pharm.D., Pharmacy Specialist—Pain Management University of Minnesota Medical Center 420 Delaware Street SE Suite C-265A, MMC 611 Minneapolis, MN 55455 [email protected] Pamela Phelps, Pharm.D., FASHP, Director, Clinical Hospital Pharmacy Services Fairview Health Services Minneapolis, MN John Pastor, Pharm.D., FASHP, Director of Pharmacy Services University of Minnesota Medical Center
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp120751
Am J Health-Syst Pharm—Vol 70 Dec 1, 2013
2075
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
F rontline Pharmacist
Implementation of a pain medication stewardship program
P
ain medication stewardship is important to pharmacy practice because of its impact on quality patient care and medication safety. The Joint Commission recently published a Sentinel Event Alert on opioid safety suggesting that hospitals create and implement policies and procedures for a secondlevel review of pain management plans with high-risk opioids by pain specialists or pharmacists.1 A pain medication stewardship pharmacist would fulfill this role and enhance patient safety. In this article, we describe our experience with the development of such a program, which was created to bridge the gaps between pain management services provided by multiple disciplines within our institution, an academic medical center with more than 600 staffed beds. Program development. In November 2009, an interdisciplinary pain steering committee was created to identify barriers to improving patient satisfaction with pain management. The committee comprised representatives from various departments,
including anesthesia, physical medicine and rehabilitation, surgical services, inpatient pain management consultation team, palliative medicine, pharmacy, and
nursing. One of the major health care gaps identified was that while our institution had five consultation services for dif-
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).
2070
Am J Health-Syst Pharm—Vol 70 Dec 1, 2013
ferent types of pain management, there was no accountability for any one service to address the needs of the patient population as a whole. The committee championed recommendations to restructure the pain management services under the coordination of a medical director and through collaboration with other departments, including nursing and pharmacy. Recommendations specific to pharmacy included monitoring analgesic medications for safe use and providing evidenced-based prescribing guidelines through the enhancement of order sets and clinical services. The director of clinical pharmacy services and the pharmacist specializing in pain management were members of the pain steering committee and took the lead on addressing the medication safety and prescribing recommendations. To this end, an evaluation of clinical pharmacy practice at our institution was conducted, assessing the impact of current medication safety policies and guidelines on analgesic prescribing, the level of staff education and competency, staffing resources, and tangible outcomes. The evaluation revealed the following: 1. Medication safety initiatives that have been implemented (smart pumps for patient-controlled analgesia, standard order sets for pain management, and bedside bar-coding) do not guarantee that the drug and dosage prescribed are appropriate for the patient. Continued on page 2074
Frontline Pharmacist Continued from page 2070
2. Pharmacists are required to monitor opioid dosages according to medication safety policies and guidelines but do not have the expertise to design comprehensive pain management plans. 3. Demand for pharmacist services on weekends and holidays remains higher than the resources allocated. 4. Pharmacist involvement during transitions of care (i.e., admission and discharge medication reconciliation) has the most potential for positive patient outcomes. A proposal for the pharmacy pain medication stewardship program received approval from the hospital’s Medical Executive Committee prior to implementation in 2010. Physicians were notified of the program through an announcement in the hospital’s newsletter. The pain medication stewardship pharmacist engaged nurses by presenting the program at a nursing practice council meeting. Several presentations were provided to pharmacists and clinical team leaders to explain the purpose of the program and the role of the pain medication stewardship pharmacist. Pharmacists’ credentials and responsibilities. Selection criteria for pain medication stewardship pharmacists are based on years of experience in clinical practice, postgraduate residency or fellowship training in pain management or palliative care, and demonstration of strong leadership skills. Pharmacists involved in the pain medication stewardship program are responsible for providing medication reconciliation on patient admission using the information available through the Minnesota Prescription Monitoring Program (PMP).2 They also collaborate on perioperative pain management plans for complex cases, implement medication safety programs to address opioid-induced oversedation, attend service rounds with decentralized pharmacists to evaluate pain management problems, and provide expertise for
2074
formulary management of analgesic medications. Opioid medication reconciliation using the state PMP is the cornerstone of the service because it creates a medication review structure that can be easily identified in the electronic health record (EHR) and is well received by physicians and pharmacy staff. The medication review process is conducted daily each morning, with the pain medication stewardship pharmacist obtaining a computer-generated report of all active orders for oral long-acting opioids, fentanyl formulations, and methadone. Each new patient admission is reviewed to verify that the current opioid orders in the hospital are appropriate and that the dosages prescribed are the same as what the patient was receiving before hospital admission. This process is very helpful for opioid-tolerant patients who often are in pain because their regimen is not restarted at the dosage taken before admission. The process also benefits patients who are admitted directly to a surgical service who otherwise would have been missed, because their medication reconciliation would not have been completed until their transition to postoperative care. A standard form for medication regimen review is used to document physician requests for medication consultations in the EHR. The same form is used to document information obtained through the state PMP along with recommendations to resolve any dosage discrepancies. To expedite orders for opioids, the pharmacist contacts the physician via text paging to discuss the recommendations and offer to write opioid orders, if approved. The pharmacist is also responsible for recommending pain management regimens for patients with complex profiles (e.g., patients receiving highdose i.v. opioids or multiple pain medications). Pharmacists and physicians can request a consultation for moreextensive monitoring and follow-up of patients. The pain medication stewardship pharmacist interviews the patient regarding medication use and health history and writes a note in the EHR
Am J Health-Syst Pharm—Vol 70 Dec 1, 2013
that details the patient’s current illness, functional status, medical history, and pain medication history (including information obtained through the state’s PMP) as well as the pharmacist’s assessment and recommendations. He or she then contacts the inpatient pharmacist or physician who requested the consultation to discuss the recommendations. The pain medication stewardship pharmacist modifies orders for opioids and other analgesics if the recommendations are approved by the physician and continues to follow the patient’s progress on a daily basis until a discharge plan for pain medication is established in the EHR. The pharmacist may request consultations for other inpatient services and departments, including the pain team, psychiatry, and palliative care, when the medication issues are outside the scope of pharmacy practice (e.g., discontinuing pain medication due to chemical dependency). In addition, the pain stewardship pharmacist attends rounds for complex patients to teach other pharmacists pain management pearls. The postgraduate year 1 and 2 residents on the pain medication stewardship rotation acquire experience on providing complex pain consultations during their time with the pharmacist. Mitigating opioid-related adverse events through surveillance and prevention strategies is another responsibility of the pain medication stewardship pharmacist. The pharmacist is responsible for reviewing respiratory depression cases requiring naloxone reversal that are reported in the hospital’s adverse-event database. Adverse events are coded using the National Coordinating Council for Medication Error Reporting and Prevention criteria.3 Data are documented for events that result in prolonged hospitalization, resuscitation to sustain life, or the transfer to intensive care. The pain medication stewardship pharmacist collaborates with physicians, nurses, and pharmacy directors to improve medication safety through the use of standard order sets, policy and procedures for opioid administration, smart-pump
Frontline Pharmacist
technology, capnography, and the provision of staff education. Preliminary findings. From June 2010 to June 2011, the pharmacist reviewed opioid orders for 2499 patients. These patients were identified through pharmacy-generated reports and represented 16% of all admissions to the hospital for that period of time. Of the patients screened, 1099 (44%) required an intervention related to pain medication reconciliation. The most frequent intervention was EHR documentation of the most recent history of opioid medication use to clarify inpatient dosages (86%, n = 945). Pain medication stewardship consultations were requested by physicians or pharmacists for 154 patients (16%) for various reasons, including history of substance abuse, presence of psychiatric comorbidity, discrepancy between inpatient and outpatient opioid use, drug-seeking behavior, and drug diversion during hospital admission. Four adverse events occurred during this time period and resulted in prolonged hospitalization. In 2011, many changes occurred in our hospital, including the implementation of an epidural smart pump, new software for pharmacy and EHRs, and medication bar-coding, increasing the potential for errors due to the steep learning curve within a short period of time. The pain medication stewardship pharmacist monitored high-risk opioid practices (i.e., i.v. patient-controlled analgesia and methadone i.v. continuous infusion) and worked collaboratively with physicians and nurses to develop order sets to minimize prescribing errors. Monitoring opioid infusion pump medications became a permanent responsibility of the pain medication stewardship pharmacist to help prevent errors, especially with drug shortages that affect the performance of the devices. Challenges. The pain medication stewardship program uses an interprofessional approach but not in the traditional framework of the clinical rounding service that is common in academic medical centers. Pain medication use is so widespread throughout our academic
medical center that daily rounds with one or two services would not address the needs of many patients in the hospital. The pain medication stewardship pharmacist screens patients throughout the hospital for opioid therapy problems. If a problem is detected, this triggers a pain management review to ensure that changes are made to the medication regimen in a timely manner. The biggest limitation to this approach is that not all patients experiencing pain are taking long-acting oral opioids, fentanyl formulations, methadone, or high-dose regimens that will trigger a review. These specific groups of agents were selected for monitoring due to the risk of translation problems with the dosage form, strength, and unintentional interchange of product (e.g., Oxycontin 15 mg instead of short-acting oxycodone 15 mg). This is why it is important that decentralized pharmacists contact the pain medication stewardship pharmacist for patients who are reporting pain that is not relieved with the current regimen, which may include other opioids or analgesic medications. Our pharmacy department requires pharmacists to screen opioid orders to improve medication safety. During the first year of the program, pharmacists requested 71 consultations for complex patients; this number did not include the drug therapy questions answered on a daily basis. In March 2011, our hospital changed the EHR system and pharmacy computer system. All of the data collected from the start of the program in June 2010 had to be formatted into an Excel (Microsoft Corp.) spreadsheet so that the data would be available for retrieval after the switch to the new systems. The change in the EHR system also affected the pain medication stewardship note template, as there was no specific header available for the template until July 2011. Therefore, the pharmacist consultations and opioid reconciliation notes were not always recognized by staff. Service availability is another limitation. The pain medication stewardship program is available only on weekdays. Consultation requests during evening
and night shifts are addressed the following day, except for weekends. Before the weekend, a proactive plan for patients who have complex opioid regimens is documented in the EHR so that pharmacists have a guide on how to convert the opioid dosage and make adjustments. Pharmacy practice residents started training on the pain medication stewardship rotation in September 2010 and provide assistance with coverage of the service. There continues to be discussion on how other pharmacists may provide coverage for the pain medication stewardship pharmacist in the future. Conclusion. A pain medication stewardship program was developed at an academic medical center to help ensure the safe use of opioids and improve patient care through conducting admission medication reconciliation, monitoring and managing opioid-related adverse events, and providing pain management consultations for complex patient cases. 1. Joint Commission. Safe use of opioids in hospitals. www.jointcommission.org/ assets/1/18/SEA_49_opioids_8_2_12_ final.pdf (accessed 2013 Aug 20). 2. Minnesota Prescription Monitoring Program. Program homepage. http://pmp. pharmacy.state.mn.us (accessed 2013 Aug 27). 3. Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm. 1991; 48:2111-6.
Virginia L. Ghafoor, Pharm.D., Pharmacy Specialist—Pain Management University of Minnesota Medical Center 420 Delaware Street SE Suite C-265A, MMC 611 Minneapolis, MN 55455 [email protected] Pamela Phelps, Pharm.D., FASHP, Director, Clinical Hospital Pharmacy Services Fairview Health Services Minneapolis, MN John Pastor, Pharm.D., FASHP, Director of Pharmacy Services University of Minnesota Medical Center
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp120751
Am J Health-Syst Pharm—Vol 70 Dec 1, 2013
2075
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
