Background: An estimated 68,000 Americans died of opioid-related overdoses between March 2017-2018. In Monroe County NY heroin/fentanyl deaths are up 200% from 2015- 2017. Guidelines recommending naloxone co-prescription for high-risk patients on opioid pain medications have been issued. The inpatient setting provides unique opportunities for identifying patients at risk for opioid adverse events (OAE) and implementing the guidelines.
Purpose: We developed an interdisciplinary quality improvement pilot project to increase access to naloxone in the community by identifying patients at risk of an OAE upon hospital discharge, and targeting education and naloxone prescription.
Description: Our institution is an 846-bed academic, tertiary care center in upstate NY with an average daily census of 215 patients on the hospital medicine service. We created an interdisciplinary unit-based team of advanced practice providers, nurses, pharmacists and physicians to collaborate on identifying patients at risk for an OAE. Patients identified included those with a history of substance abuse, co-administration of opioids and benzodiazepines, prescription of ≥ 50 morphine milligram equivalents (MME)/day or previous history of an overdose. Educational sessions were provided to nursing staff over two weeks on opioid use disorder, the opioid epidemic, signs of an overdose and naloxone administration. Patient education handouts were created and providers attended an educational conference. This program was piloted on one hospital medicine unit with a daily census of 24 patients. Screening for high-risk patients occurred at any point during the hospitalization, with a focus during daily interdisciplinary rounds. Prescriptions were filled and delivered to the bedside by outpatient pharmacy. At the time of discharge, nursing provided education and training on naloxone administration for patients and their support persons. In the first 3 months following implementation twenty-three patients have received naloxone and education at discharge compared to no prescriptions given during the preceding two months. Patients were mostly male (52%), mean age 51 ± 14 years, median hospital length of stay was 8 days, and 65% were on chronic opioids prior to admission. Often patients were identified as high-risk by more than one categorization; high MME (13), opioid/benzodiazepine use (4), high risk for opioid misuse based on history (5), or overdose (1). All received naloxone nasal spray and only 7 (30%) patients had a co-pay. Future plans include expanding the intervention to all hospital medicine units and automating the identification of high-risk patients in the computerized physician order entry system.
Conclusions: This pilot unit-based quality improvement intervention successfully identified at-risk patients, educated hospital staff and utilized appropriate resources, which increased the number of naloxone prescriptions at discharge.