Health systems should put resources in place to support clinicians in complex pain management. These resources can take multiple forms. For example, some health systems encourage prescribers to consult with pharmacists or present complex cases to an expert panel for guidance. Others proactively monitor patient data to identify high-risk cases that may require intervention.
Pharmacists: Kaweah Delta's secret to successful pain management
Kaweah Delta Medical Center in Visalia, California, uses a two-pronged approach that relies heavily on the expertise of pharmacists:
1) Pharmacist-led pain management consult service
Kaweah Delta's pharmacist-led pain management service consults on difficult pain cases on the medical and surgical floors. Providers can consult pharmacy through computerized physician order entry, or nurses can request that providers consult pharmacy. Three full-time pain management pharmacists review the patient's history based on patient acuity and urgency to control pain.
A pharmacist will then perform a thorough patient workup and visit the patient to conduct a pain assessment, complete a medication review, and look at an imaging summary, if available—a process that takes between 45 and 60 minutes. The pharmacist will then make recommendations, such as adjusting doses, incorporating multimodal regimens, suggesting non-opioid alternatives, and referring patients to other providers (e.g., anesthesiology, psychiatry). The pharmacists also check in with patients by phone 48 hours post-discharge.
The consult service is available seven days a week, 10 hours per day, and saved an estimated $1.8 million in 2017 by reducing drug-related complications and lengths of stay (LOS). Pharmacists also use these consults as an opportunity to teach medical residents and clinicians how to incorporate alternative pain management strategies and optimize multimodal medication regimens.
2) Opioid stewardship review program
The second way Kaweah Delta's pharmacists provide hands-on pain management support is through an opioid stewardship review program. Pharmacy and IT created an automated report to proactively flag patients who are at high risk of sedation or inadequately controlled pain. The report includes patients who meet more than three high-risk criteria, including: high-risk medications (e.g., methadone, opioid drips, and patient-controlled analgesia), Richmond Agitation-Sedation Scale score ≤ 0, chronic pain, or BMI > 35. This list is sent to the three pain management pharmacists for review.
Pharmacists review patient charts, develop recommendations, and communicate with providers to optimize medication regimens and prevent adverse drug events (ADEs). Suggested interventions include decreasing medication use frequency, adjusting doses, or using non-sedating analgesics.
Overall, the pharmacist-led opioid stewardship review has prevented more than $800,000 in avoidable costs over a four-year period—primarily from preventing ADEs and decreasing LOS.
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