Ashika Maharaj/Gill Robb

Improvement Science Professional Development Program

Tackling Opioid-related Harm

Global Trigger Tool (GTT)

• Systematic methodology for quantifying patient harm using a targeted chart review process

• Adverse Drug Event Trigger Tool (ADE TT) subset of GTT

• Developed by IHI 2003

• ‘Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalisation or that results in death’

• Reference: White Paper: IHI Global Trigger Tool for Measuring Adverse Events 2009

Definition of Harm

Harm Category

Revelations from 2011 ADE data:• 30% of medication-harm related to Opioids• 23% of this was Constipation• Risk highest on surgical wards

Forum to discuss findings (mid 2012)

Retrospective detailed analysis of a surgical ward requested

Background

Pareto Chart of Harm 2011

New Data Collection Tool

Baseline Data

N = 131Opioids = 114Harms = 49

N = 131Opioids = 114Harms = 49

Results: Focusing on Constipation

131Records Reviewed

114Patients

prescribedopioids

14%Nausea &Vomiting

8%Other

12%Oversedated

49Opioid-related

Harm

32/ 49 (65%)Constipation

25/ 32 (78%) on

Regular opioids

16/25 (64%) not monitored regularly

22 /25 (88%) Charted laxatives

14/22 (63%)‘Delayed Charting

12/22 (55%)Delayed

administration

Opioids implicated in Harm

Project ATackling high rate of opioid-related constipation

Project BTackling opioid-related oversedation

Projects identified

Aim (Project A)

To reduce Opioid related constipation on Ward 10 (combined surgical ward) from

30% to 15% by 1 July 2013

13

Driver Diagram

Change Concepts & Ideas for PDSAsIdea for Testing in a

PDSATheory and prediction about what will happen

when you test this idea

Regular Bowel charts for all patients on opioids

Regular bowel monitoring will identify problems early allowing for effective intervention earlier

PRN Laxatives charted in conjunction with opioids

routinely

If bowel charts are working well then nurses will be alerted to administer laxatives early

Regular Laxatives charted in conjunction with opioids

routinely

Laxatives to be administered in conjunction with opioids daily

Patient LeafletsLeaflet informing patients of constipation as an

adverse effect of opioids and to let nurses know if bowels have not moved as per normal.

Name ofMeasure

Is this an Outcome, Process or Balancing

Measure?

% Patient Harm from constipation

Outcome

% Laxatives Charted concurrently with opioids

Process

% Laxatives Administered on time

Process

% Bowels Monitored Regularly Process

% Patients who developed diarrhoea Balancing

% Patients who refused Balancing

Measures

1.Team established

2.Phase 1: Bowel monitoring (implemented)

3.Phase 2: Charting and administration

4.Phase 3: Patient Experience

5.Retrospective analysis

Next steps (Project A)

89 year old patient was admitted due to R) femur fracture following a fall. His bowels did not open for seven days whilst on the ward secondary to regular oxycodone, fentanyl, and morphine. He required several interventions including laxatives and fleet enema.

Examples

Examples

35 year old was admitted to orthopaedics after developing lower back pain in medical ward. Cause was not identified, however, patients bowel had not moved for five days. She was on regular morphine for pain. It was only after she complained that laxatives and enemas were offered and her bowels opened.

Examples

Other DHB(worst case scenario): Patient passed away suddenly and unexpectedly shortly after admission to the Surgical Unit. The cause of death was ascertained by the coroner to be due to bowel ischaemia (from constipation) and that morphine could not be excluded as a contributing factor. Patient had also been on clozapine.

By Gill Robb

NO CRAP!

40% of patients on opioids experience harm in the form of constipation, nausea and vomiting or over sedation

Constipation is the most common harm

When is constipation harm??

When the bowels have not opened for 3 days, requiring an intervention and / or increased length of stay

This has an impact on the patient experience of care

and the hospital’s bottom line! $$

63% of patients charted laxatives have delayed charting TO GET THE MAX CHART THE LAX!

55% of patients charted laxatives have delayed administration

NO DELAYS PROMPTNESS PAYS