Purpose: To promote patient safety by providing clear guidelines and tools for educating patients, physicians, and advanced practice providers while successfully managing out-patient’s chronic “non-cancer” pain.
Description: A pain management registry was created for an ambulatory care family practice physician group that consists of 8 physicians and two advanced practice providers. The physicians, staff, and nurse leader registered approximately 400 patients within the first year, and successfully executed a multifaceted program that resulted in a 31% reduction of opioid prescriptions. The goal was for patients to visit the clinic on a specialized pain clinic day that was designed to focus on opioid assessment and education. In addition, the patient and provider completed a mandatory pain agreement, drug screen, functional assessment score, calculation of MME’s (morphine milligram equivalent), and scheduling of a return office visit to see the physician every 3 months; the prescriptions are given at these appointments only (including naloxone prescription when indicated). A positive correlation identified with this trial has been that the patients do not call the office for narcotic refill requests, which in turn increases patient compliance and staff perception of increased safety.
The creation of this registry allows ambulatory care nurses to be more proactive and efficient in how patients are managed while enhancing education, collaboration among health care teams, active engagement in clinical workflow development, and support of the development of safe treatment options. Clinical team members quickly check patients’ needs against evidence-based clinical guidelines, including incorporation of the state PMP (prescription monitoring program), to assess for any potential diversion of opioids; preparation includes development of a urine drug screen protocol, and coordination with the psychology department to have LCSWs (licensed clinical social worker) onsite to counsel appropriate patients.
The registry includes the name and MRN (medical record number) of the patient, name and dose of the prescription, last prescription fill date, date of last urine drug screen, status of naloxone prescription, PMP information, chosen pharmacy, date of last office visit, status of pain agreement, functional assessment scores, MME, and diagnosis. PCPs (primary care providers) were provided with education regarding the opioid weaning process as well as education regarding critical conversations with patients related to the risks of opioids and education regarding the use of the functional assessment tool, calculation of MMEs, and documentation requirements.
Evaluation/outcomes: First-year outcomes have shown patient/physician collaboration, which resulted in a 31% reduction in the amount of chronic opioid prescriptions. This includes identified diversions and physician/patient collaboration to wean. Embracing the evidence-based guidelines, the health care team is able to meet the needs of this specialized patient population, which promote positive outcomes, and enhance patient and staff safety.
1. Kral, Lee A., (2006). Opioid Tapering Safely Discontinuing Opioid Analgesics. Retrieved from http://paincommunity.org/blog/...
Purpose: The objective was to assess the current nurse-led safety monitoring program, propose process improvements, and implement necessary changes.
Description: In 2017, a nurse-led safety monitoring program was established within the rheumatology clinic at a large academic medical center to closely monitor patients prescribed chronic opioids. The monitoring program highlighted the role of the nurse as a vigilant guardian and was aligned with institutional and national recommendations for monitoring of patients receiving chronic opioid prescriptions.
The development of the safety monitoring program improved the documentation of recommended screenings and assessments. In early 2019, documentation of the screenings and assessments decreased. Additionally, gaps in the current monitoring program were identified.
A workgroup was formed, comprised of two RNs, an LPN and a clinical nurse specialist. A baseline assessment was completed of the current safety monitoring program to identify areas for improvement. The identified areas for improvement were prioritized and a specific measurable goal for each identified need was determined. Benchmarking assisted with formulating proposals for process improvement.
The workgroup collaborated with multidisciplinary members within the division to garner support for workflows that extended beyond nursing. After approval of process improvements, a comprehensive education session was conducted with the nursing team to review the safety monitoring program. The monitoring program was also reviewed at a division meeting to ensure all team members were aware of and on board with changes.
Evaluation/outcome: Improvements to the established safety monitoring program included identification and implementation of a multidisciplinary escalation process to use when safety concerns arise. Additionally, a standard multidisciplinary process was established for patients requiring a urine screen prior to prescription pick-up.
Metrics showed improved results for documentation of all recommended education, screenings, and assessments. The annual RN education visit and the controlled substance agreement were completed for an additional 34% and 17%, respectively, of the total patients on chronic opioids. Annual urine drug screen completion rates increased an additional 50%. The state prescription monitoring program was reviewed 55% more frequently. A multidisciplinary opioid plan of care was established for an additional 35% of the total patients on chronic opioids.
A comprehensive, nurse-led safety monitoring program for patients prescribed chronic opioids assists with adherence to institutional and national safety recommendations. Continuous improvement of such a program supports continued success.
1. Costello, M. (2015). Prescription opioid analgesics: Promoting patient safety with better patient education. American Journal of Nursing, 115(11), 50-56.
2. Dowell, D., Haegerich, R., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. Retrieved from https://www.cdc.gov/mmwr/
Purpose: The purpose of this project was to develop and assess a simulation toolkit for teaching key ambulatory care nursing competencies to pre-licensure nursing students.
Background: As health care needs in the community grow in complexity, there is an increased need for nurses to deliver high quality care in ambulatory care settings. Yet, nursing students are not adequately trained for this specialty role. As part of an academic-practice partnership (APP) between a major university school of nursing and a regional health care organization, an ambulatory care (AC) simulation toolkit was designed to enhance clinical reasoning and skills unique to ambulatory care settings.
Methods: The APP curriculum team developed simulations addressing: 1) annual wellness visits (AWV), 2) EHR inbox management, 3) telephone triage, 4) chronic illness self-management, and 5) psychological first aid. Clinical content experts reviewed all simulations, which were then revised accordingly. Simulations were implemented with BSN students in Autumn 2020 via video conferencing due to COVID-19. Students completed online evaluations on which they rated their attainment of the learning objectives and responded to items from the simulation evaluation tool-modified (SET-M). On the SET-M, respondents rate the effectiveness of prebriefing, the scenario, and debriefing. All items were rated “strongly agree,” “somewhat agree,” or “do not agree.” The study procedures were approved by an institutional review board.
Results: A total of 79 students completed the AWV, EHR inbox management, and telephone triage simulations to date, of which 44-53% completing the evaluations. Over 90% of the students responded “strongly agree” or “somewhat agree” on their ability to meet the 5 learning objectives for each of the simulations. “Strongly agree” was endorsed by ≥75% of students on all except 3 objectives: understanding top-of-scope RN practice in the AWV simulation (68%), and ability to document care in the EHR inbox (57%) and telephone triage (69%) simulations. On the SET-M, students responded “strongly agree” to the items in each domain. Pre-briefing (2 items): AWV, 68-76%; EHR inbox, 77-80%; telephone triage, 83-95%. Scenario (11 items): AWV, 38-76%; EHR inbox, 51-83%; telephone triage, 60-91%. Debriefing: AWV, 84-92%; EHR inbox, 88-91%; telephone triage, 95-100%.
Conclusions and implications: Results indicate that overall, the AC simulation toolkit was designed in such a way that the learning objectives were met, except for three objectives addressing top-of-scope RN practice and documentation. Future work will focus on strengthening the simulations to meet these objectives. The SET-M responses supported the effectiveness of the prebriefing for the EHR inbox and telephone triage simulations, and debriefing of all 3 simulations. The prebriefing of the AWV will be revised, and the scenarios of all 3 simulations will be revised according to the specific SET-M items that were rated poorly, which differed between the scenarios. Future research will explore the translation of the competencies addressed in these simulations to in-person clinical settings. The AC simulation toolkit demonstrates promise in filling a crucial gap in addressing the nation’s health by providing practical RN training that is specific to ambulatory care.