Opioid overdose and misuse in the U.S. are at epidemic levels, with the largest source of prescription drug misuse coming from legitimate prescriptions. The issue is not just affecting adults.
According to a recent study in Pediatrics, there was a 33 percent increase in opioid misuse among youth exposed to opioid prescription medications prior to high school graduation. And one in 25 high schoolers report misusing opioids in the last year.
To help tackle the issue, Children's Hospital Colorado convened a team including representatives from dentistry, the emergency department, hospital medicine, nursing, patient safety and clinical effectiveness to discuss options to standardize opioid prescribing efforts at the hospital.
"We wanted to develop a clinical pathway to address the variability in providers' prescribing practice, but limited research and no benchmarks for the duration of opioid therapy for children posed a challenge," says Leigh Ann Bakel, M.D., MSc, assistant professor of pediatrics and pediatric hospital medicine at Children's Hospital Colorado.
Because there was no consensus in the literature, Bakel says team members created what they believe to be the first clinical pathway for prescribing opioids to pediatric patients, including prescribing recommendations for providers.
Once the pathway was complete, team members partnered with orthopedic surgery to deploy three interventions, which Bakel and her colleague, Sara Nickels, Ph.D. M.S.W., process improvement lead at Children's Hospital Colorado, outlined at the 2019 Quality and Safety in Children's Health Conference. The aim of the interventions is to increase compliance to prescribing recommendations:
- Clinical decision support. The team embedded recommendations within the order sets in the electronic medical record and included a link to clinical pathway within order set for providers.
- New state legislation. Enacted in Colorado last summer, legislation now limits the initial prescription of opioids to seven days, with exceptions for cancer patients and those with chronic pain or post-surgical pain. "While the law didn't apply to the pilot population we were working with; it required providers to review the state's controlled substance registry prior to providing a second prescription of opioids," says Nickels. To educate providers on the new law, the team partnered with the chief medical officer and internal communications team to spread awareness of this change.
- Opioid stewardship. Using a quality improvement grant, the team created an opioid stewardship program. Now, pharmacy and anesthesiology providers review discharge prescriptions written for longer than seven days. They then discuss with the prescriber the rationale for prescriptions that exceed the recommended duration.
The stewardship program also includes patient and caregiver education and talking points for nurses in the EMR to increase standardization of the education process. These teaching points correlate with a patient handout nurses can print from the EMR.
Results
After implementing the pathway and interventions and piloting these efforts with orthopedic surgery, the team hoped to increase the percentage of discharge prescriptions in compliance with the seven-day recommendation from 56 percent to 75 percent.
But the team saw better than expected results. The orthopedic surgery team hit almost 87 percent of prescriptions in compliance. The team now plans to introduce the pathway and interventions hospital-wide.
