QUERI – Quality Enhancement Research Initiative

Effective Hospital Practices to Prevent Immediate and Delayed Opioid Adverse Events While Improving Pain and Functional Outcomes

Iowa City Veterans Healthcare System, Iowa City, IA

Overview:

Pain is highly prevalent among Veterans, especially among hospitalized Veterans who often have complex, chronic comorbidities. Recent VA initiatives have resulted in decreased numbers of Veterans on long-term therapy, high-dose therapy, and co-prescribed opioids and benzodiazepines. However, pain treatment during hospitalization is complicated by the context of epidemic opioid use. Successful efforts to expand multimodal pain treatment options and implement Whole Health concepts, and guidance such as the recent Society of Hospital Medicine (SHM) consensus statement on safer opioid prescribing to hospitalized patients, create opportunities to adapt these approaches across the care continuum, including hospitalization. QUERI-VISN Initiative is an ideal mechanism to support the development of an implementation plan to improve pain treatment, reduce reliance on opioids, and diagnose and treat opioid use disorder in the hospital. 

This start-up project will bring together interdisciplinary teams to implement a bundle of interventions to achieve these improvements. During the pilot period, investigators will test strategies to implement:

• Best medical practices for physician, physician assistant, and ARNP (Advanced Registered Nurse Practitioner) assessment of medical inpatients with chronic pain;
• Recently articulated national guidance for inpatient opioid prescribing; and
• Hospital appropriate measures to assess both pain and function to guide inpatient pain treatment.

The four implementation strategies that will be used to realize these improvements are provider education, inter-professional team interactions, electronic health record order sets, and audit and feedback. At the end of the pilot period, there will be a comprehensive team-based approach to implementing these effective practices, that will then be spread to the hospitals in VISN 23 and nationally. This addresses the priorities of:

• Improving access to non-opioid pain treatment modalities by de-emphasizing opioids in the hospital, and
• Reducing the development of long-term opioid use – a potential waypoint in the development of opioid use disorder. 

Aims

Specific implementation objectives of this project are to: 

• Develop and implement an educational program for hospital-based medical providers about best practices for assessing and treating acute and chronic pain, including guidance for safe opioid use in the hospital.
• Develop and implement an inpatient pain order set to support delivery of non-pharmacologic pain treatment menu. 
• Implement pharmacist-directed opioid stewardship to promote safe and effective use of schedule II medications during medical hospitalization.

Expected Impacts

This project will develop an inpatient multi-modal pain treatment implementation toolkit, as well as guidance for diagnosis and initial treatment of opioid use disorder tailored for inpatient clinicians. This toolkit and guidance will help other facilities and VISNs implement this pain treatment and opioid use disorder treatment linkage intervention.

Principal Investigator: Hilary Mosher, MD (hilary.mosher@va.gov)

Operations Partners: VISN23 Leadership Team and the Iowa City VA Health Care System Medicine Service Line