Reducing opioid-related harm and building quality improvement capability in New Zealand: a national formative collaborativeKristiansen J, Kumar P, Lee A, Loe E, Petagna C – Health Quality & Safety Commission New Zealand

www.hqsc.govt.nz

Who are we?The Health Quality & Safety Commission New Zealand (the Commission) is an independent crown entity funded by the government. It is mandated to lead and coordinate work nationally across the health and disability sector to improve the quality and safety of care and to advise government. We work towards achieving the New Zealand Triple Aim for quality improvement:• improved quality, safety and experience of care• improved health and equity for all populations• better value for public health system resources.

The problemOpioids are essential medicines for treating pain but are the most common class of medicines that cause harm to inpatients.1 Harms range from life-threatening over-sedation and respiratory depression to less severe, such as constipation.2 There is no universally accepted ‘bundle’ of evidence-based interventions to reduce harm from opioids.

The collaborative The Commission partnered with 20 district health board* (DHB) hospitals from across New Zealand in an 18 month-long national ‘formative’ collaborative.

AimTo reduce the harm related to opioid use nationally by 25 percent in all participating areas of DHB hospitals by April 2016.

Goals1. Develop care bundles for opioid safety.2. Increase the capability of participating teams

in improvement science.3. Create a reusable clinical network across

New Zealand for further medicationsafety work

ResultsHarm reductionMost change ideas were tested in surgical areas. Constipation was the most common harm area chosen by DHBs. Some teams focused on discharge processes related to opioid prescribing to improve the transition of care.Twenty teams were eligible for the collaborative: 17 actively participated; five were excluded from the analysis because a baseline was not established.Of the remaining teams:• 7/12 hospitals (58 percent) showed greater

than 25 percent relative reduction in opioid-related harm, with 6/12 (50 percent)exhibiting a special cause in SPC chart

• two hospitals showed a 0–25 percent relativereduction (one with special cause)

• three hospitals showed a relative increase inharm (no special cause).

SustainabilityTeams are currently focused on embedding their improvement to date, and using the care bundles created by the collaborative, with ongoing support from the Commission.

Lessons learned1. Co-design, partnership and relationships –

key elements for success at a national level.

2. ‘Formative’ nature – teams were askedto develop interventions while learningimprovement science; many struggledwith the notion of ‘building the plane,while flying it’.

3. Modified-Delphi technique – a popular andeffective mechanism for consensus-making.

4. Team work – successful teams had an inter-professional structure with strong projectsponsor support.

5. Measurement – teams needed explicitdirection regarding baseline data requirements.

6. Aggregation – challenges were encounteredwith data aggregation because differentoperational definitions were used acrossthe teams.

7. Methodology – teams needed help withthe practical use of PDSA in their clinicalsettings, especially small- versus large-scaletesting.

8. Bundle creation – not easy!

9. Shared learning – national learning sessionswere effective for bringing the teams togetherto share and learn from each other.

Care bundlesInterventions for each care bundle were identified by DHB teams then reviewed by national and international expert panels using a modified-Delphi technique. Inclusion of interventions in the care bundles was based on published evidence, local quality improvement data and expert opinion.Four care bundles were developed, including three care bundles for individual harm areas (opioid-induced constipation, opioid-induced ventilatory impairment and uncontrolled pain) and a composite care bundle (covering all of the harms as well as opioid-induced nausea and vomiting), supported by a comprehensive ‘how- to-guide’ to support further opioid safety work.

Capability buildingLongitudinal surveys showed an increase in team quality improvement capability.

A national network of inter-professional teams focused on opioid safety has been established.

Example of an SPC chart – Lakes DHB focused on staff education and the use of dietary measures to reduce opioid-induced constipation.

Example of a patient information resource from

Waitemata DHB who focused on patient empowerment to

help reduce uncontrolled pain for those prescribed opioids.

Measurement Each participating team identified their measures, developed a data collection plan and manually collected data on a weekly basis in their pilot areas for their identified outcome, process and balancing measures. Data was analysed using three methods: two-sample test of proportions, statistical process control (SPC) charts and relative percentage change from baseline. DHB monthly reports were shared with the Commission and national dashboards were created.

Design The Commission used the Institute for Healthcare Improvement’s (IHI) collaborative model underpinned by the Model for Improvement to develop care bundles to reduce opioid-related harm. National and regional learning sessions and site visits supported teams in the use of quality improvement tools and methods. Teams developed SMART aim statements, theory of change using driver diagrams, and data collection tools. They then tested their change ideas using plan–do–study–act (PDSA) cycles to address an opioid-related harm area of their choice.Consumers were involved at all levels.

Learning session attendees’ knowledge of improvement science methodologies

SPC chart of % of patients on opioids with constipation – Lakes DHB

Up to $158m

33% opiods 10% anticoagulents

is the estimated annual cost of preventable ADEs in New Zealand.3-5

ADE collaborativeThe medicines that were most commonly implicated for causing an ADE were:6

3. Briant R, Ali W, Lay-Yee R, Davis P. Representative case series from public hospital admissions 199: drug and related therapeutic adverse events.NZ Med J 2004; 117 (1188).

4. Brown P, McArthur C, Newby L et al. Cost of medical injury in New Zealand: a retrospective cohort study. J Health Serv Res Policy 2002; 7: 29–34.5. Kunac DL, Kennedy J, Austin N et al. Incidence, preventability and impact of adverse drug events (ADEs) and potential ADEs in hospitalized

children in New Zealand. Pediatr Drugs 2009; 11(2): 153–16.

6. Seddon ME, Jackson A, Cameron C et al. The Adverse Drug Event Collaborative: a joint venture to measure medication-related patient harm.NZMJ 25 January 2013, Vol 126: 9–20.

* DHBs are responsible for providing health and disability services to populations within 20 definedgeographical areas.

© Linda Gilbert: www.drawntogether.net

AcknowledgmentsThe Commission acknowledges the 20 DHBs and MercyAscot Hospital (Auckland) for participating in the safe use of opioids national collaborative, and the staff from IHI, especially Dr John Krueger for his advice and guidance.

– –

0 1 2 3 4 5 6 7 8 9 10

NO PAIN MILD PAIN MODERATE PAIN MODERATE PAIN SEVERE PAIN WORST PAIN POSSIBLE

Managing pain – what YOU can doBe informed Be empoweredBe prepared

1 speak up

5 ways you can help us help you• It is easier to manage pain early • Tell your nurse, doctor or pharmacist if you are in pain • It is OK to ask for pain relief

2 know your painTo help us manage your pain early tell your nurse, doctor or pharmacist: • WHERE your pain is

• WHEN is your pain worst • WHAT makes it better. WHAT makes it worse • HOW it feels (sharp, dull, stabbing, burning?) • HOW much pain you are in when RESTING and MOVING. Use the pain scale above to tell us. 3 protect yourselfPainkillers are effective but can also cause side effects.• Tell us if you use other painkillers at home • Let us know if you are allergic to any medicines

• Tell your nurse or doctor if you have: – No bowel motions (poo) in the last 24hours – Darker than usual bowel motions or things like coffee grounds in your vomit – Vomited or are feeling sick – Feeling more sleepy or drowsy than usual 4 get smart about medicines

We may not be able to take away all your pain but we can help you manage it. If you are on painkillers:

• ASK do I need them? • ASK how they work and how to take them • ASK about side effects and how to manage them It is OK to ask about your medicines and their side effects 5 prepare for home

Before leaving hospital ask your doctor, nurse or pharmacist: • HOW much pain can I expect ? • WHEN should it get better? • HOW long should I be on pain killers?

• WHAT can I do to reduce pain after leaving hospital? • ARE THERE any symptoms or SIDE EFFECTS I need to watch out for and what should I do? • WHO can help me if I have questions or worries?

May 2014Board endorsement for safe use of opioids collaborative

June–July 2014• Recruitment process for

national project team• Stakeholder engagement• Initial launch planning• Expert faculty membership

finalised

October–November 2014• Open for better care

campaign forum• Resources/tools/

educationprogrammedeveloped and approved

• Learning session zeroregional workshops

• DHB teams start prework

February 2015• Learning session one• DHB team engagement

collaborative methodology

May 2016• Collaborative

wrap-upworkshop

May–July 2016• Bundle development

process• DHBs’ identification

of bundle elementsduring workshop

• Delphi panel process• Engagement with

expert faculty

November 2015• Learning

session three• Ongoing DHB

engagement incollaborativemethodology

June 2015• Learning

session two• Ongoing DHB

engagement incollaborativemethodology

August–SeptemberResources/tools/education programme developed• Education programme

finalised and approved• DHB teams identified

and finalised• First meeting of

expert faculty

2015

2014 2016

Baseline phase

Prop

ortio

n

Improvement/Testing phase

Week ending harm

0.0

0.2

0.4

0.6

0.8

1.0

15/0

2/20

1522

/02/

2015

8/03

/201

529

/03/

2015

12/0

4/20

1519

/04/

2015

03/0

5/20

1510

/05/

2015

17/0

5/20

1524

/05/

2015

31/0

5/20

157/

06/2

015

14/0

6/20

1521

/06/

2015

28/0

6/20

155/

07/2

015

12/0

7/20

1519

/07/

2015

26/0

7/20

152/

08/2

015

9/08

/201

516

/08/

2015

23/0

8/20

1530

/08/

2015

6/09

/201

513

/09/

2015

20/0

9/20

1527

/09/

2015

4/10

/201

511

/10/

2015

18/1

0/20

1525

/10/

2015

8/11

/201

515

/11/

2015

22/1

1/20

1529

/11/

2015

6/12

/201

513

/12/

2015

20/1

2/20

153/

01/2

016

17/0

1/20

1631

/01/

2016

14/0

2/20

1621

/02/

2016

13/0

3/20

1627

/03/

2016

UCL = 1

P = 0.551

LCL = 0LCL = 0

P = 0.307

UCL = 0.768

Documentation – doses of ondansetron

Prunes/ kiwicrush PE run 1

Prunes/ kiwicrush PE run 1

HO rotation

Prunes/kiwicrush PE run 4 & HO rotation with prior education PGY1

education

Permanent implementation of prunes/Kiwicrush

Prunes/kiwicrush PE run 3 & Grand round

H/O joins team

Stickers large test

Nursing newsletter/education

0% 20% 40% 60% 80% 100%

Learning session 3 survey (n=59)

Learning session 2 survey (n=69)

Learning session 1 survey (n=56) Moderate, 36% High, 7%

High, 12%

High, 19%

Moderate, 56%

Moderate, 71%

© Linda Gilbert: www.drawntogether.net

The collaborative timeline. Source: Synergia. 2016. Evaluation report. Auckland: Synergia.

1 Seddon ME, Jackson A, Cameron C et al. The Adverse Drug Event Collaborative: a joint venture to measure medication-related patient harm. NZMJ 25 January 2013, Vol 126.

2 Institute for Safe Medication Practices (ISMP). ISMP’s List of High-Alert Medications. http://www.ismp.org/tools/highalertmedications.pdf (accessed Oct 2016).