Using improvement methodology to solve one piece of America’s opioid epidemic. Dr. Sean Stokes and team used the practice of scoping to focus on one population and one procedure to achieve manageable, measurable improvement.
The Problem: It’s a Crisis
The opioid epidemic has become one of the nation’s most pressing health care concerns — officially declared a national emergency just yesterday (August 10). The mortality rate is chilling: the CDC reports every day more than 90 Americans die from opioid overdose. The national economic burden for misuse alone averages $78.5 billion annually. And it’s a problem that hits home: Utah is ranked #10 in the nation for opioid drug overdose deaths.
The Solution: Start Small
The opioid problem is immense but we can begin to tackle this challenge by targeting one small piece at a time, a concept in improvement work called “scoping.” Projects can be scoped and bounded in a number of ways to achieve measurable, manageable improvement. That’s exactly what surgery resident Sean Stokes learned when his team began addressing opioids. A key element in the epidemic is prescribing patterns which are well within the control of providers.
Most clinical guidelines are dedicated to chronic pain management, and yet research suggests first time use after a procedure may put patients at increased risk for later chronic abuse. This is where Stokes’s team focused. As part of the Department of Surgery’s value improvement training, led by Dr. Brigitte Smith, Stokes and faculty team lead Benjamin Brooke, resident team lead Lily Gutnik, and fellow residents Austin Cannon, Adam Dzuiba, Luke Martin, and Mark Taylor decided to look at prescribing patterns for common outpatient general surgery procedures, such as laparoscopic cholecystectomy. The team mapped the patient’s value stream through our system, from clinic to the Post Anesthesia Care Unit (PACU). While they identified four areas where a possible intervention could work, they decided to limit the scope of their work to the operating room and the number of pain medications prescribed.
Project Overview: Reducing Overuse of Opioid Prescriptions in Outpatient General Surgery
Presented at the annual University of Utah Health Department of Surgery Value Symposium on July 12, 2017
Stokes and team hypothesized that outpatient general surgery prescription practices vary widely and standardization would reduce narcotic over-prescription without effects on patient satisfaction. To examine prescription patterns, they looked to University of Utah’s data visualization program, Value-Driven Outcomes, and a specific program adapted from the Operating Room Cost Accountability (ORCA) utility nicknamed “PORCA,” that revealed wide variation in pills prescribed by surgeon: ranging from 18 to nearly 50 tablets per procedure. On average, most patients were getting 30 tablets compared to the 15 tablet evidence-based recommendation.
Problem defined. Baseline analyzed. What’s next?
The overall improvement goal is to reduce the number of opioids prescribed without negatively impacting patient pain control. Based on their findings, the team plans to work with decision support and the Epic team to develop an order set in the EMR to provide evidence-based guidance the moment a prescription order is written. In addition to the order set, the team is developing provider education with plans to conduct pre- and post order set implementation patient satisfaction surveys.
What Did you Learn?
When asked the most important lesson learned working on the project, Stokes reflected on the interdisciplinary team that made it possible, citing Jeff Young, David Ray, Antoine Clawson, Robert Glasgow and all the residents of the team. Scope is important, but the team makes it all happen.
We learned of Dr. Stokes’ improvement work at the first annual Department of Surgery Value Symposium this past July 12. His project was one of three selected and two to actually be profiled on Accelerate. We applaud these efforts to share and spread best practices in delivering high value health care within our community and beyond.