Category: Professional Posters
Purpose: With the number of deaths due to opioid overdose increasing exponentially, there is urgency to expand naloxone access for at-risk patients and their communities. Regulatory, guideline, and evidence-based stakeholders all recommend co-prescribing naloxone to patients at increased risk for opioid overdose.1 A pharmacist’s role can be multifaceted in developing pathways to implement this broadly supported recommendation to improve the quality and safety of patient care. This pharmacist-led initiative to expand community access to naloxone in a rural healthcare network aimed to standardize naloxone co-prescribing for at-risk patients and streamline corresponding clinical workflow for providers, all within the electronic medical record.
Methods: This was a wide-reaching quality and safety improvement project conducted within the 5,000 square mile rural healthcare network. The scope of this automated naloxone co-prescribing program was initially targeted at ambulatory care centers, but has also been adapted for acute care facilities to use on discharge. The Quality Improvement (QI) project team consisted of Clinical Pharmacy Specialists (CPS), the Medical Director of Quality and Clinical Effectiveness, and the Information Technology/electronic medical record (EMR) build team. The QI team secured buy-in from key stakeholders including the interdisciplinary pain committee, and clinical and executive leadership.
A network-wide standardized naloxone co-prescribing guideline was developed based upon national best practice recommendations and evidence based guidelines. The guideline was then integrated into the EMR as an order set as well as a best practice advisory (BPA). The BPA automatically fires on a patient-specific basis when moderate to high risk opioid misuse criteria are met. The automated BPA and order panel link providerss to the naloxone prescribing guideline, medication orders for naloxone in each available formulation, a progress note template, the Opioid Risk Tool (ORT) for risk stratification,2 a urine drug screen, associated pertinent laboratory values, and billing codes. Finally, automatically printed patient education facilitates the provider-patient discussion regarding the risk of opioid overdose and appropriate use of naloxone.
Results: Network-wide usage of this interprofessional safety and quality improvement program was implemented on February 2017. Co-prescribing of naloxone was measured by the number of patients prescribed naloxone since the BPA and order set went live. Use of the ORT was measured by the number of patients evaluated for future opioid misuse since the ORT went live in the EMR.
At baseline, prior to EMR implementation, 36 naloxone prescriptions had been ordered. There were no documented risk assessments using the ORT, as it did not yet exist in the EMR. At 24 months after BPA and order set integration, there were 768 co-prescriptions for naloxone. Of the 768 prescriptions for naloxone, 646 were for intranasal, 2 for intramuscular, and 120 acted as place holders in patients’ medication histories showing they were referred to receive a free naloxone kit through a state-wide program for underserved and uninsured patients. Within 24 months after the ORT was integrated, 6614 patients were assessed for risk of opioid misuse, of which 1029 were determined to be at moderate or high risk and qualified for a naloxone co-prescription per network guidelines.
Conclusion: This automated naloxone co-prescribing program, consisting of an automated EMR integrated platform, has substantially improved the network-wide co-prescribing and accessibility of naloxone for at-risk patients. An effective clinical workflow was key to establishing a rapid and sustained increase in naloxone prescriptions across a large geographic region. Pharmacists are well positioned to take a lead role in quality improvement and safety initiatives focusing on opioid safety and harm reduction.