Future prevention of Gosport events: evidence and assurance

Alice Oborne, Consultant pharmacist and MSO, Guy’s and St Thomas’ NHS Foundation TrustSurinder Ahuja, MSO I Lead Governance and Formulary, The Rotherham NHS Foundation Trust Jane Starr, Medication Safety Officer, East Sussex Healthcare NHS TrustKevin Gibb10 April 2019 Guy’s Robens Suite

www.ukclinicalpharmacy.org

Aim and Objectives

A forum to discuss evidence and assurance available in response to the Gosport report

Learning objectives

1. To be able to describe the main Gosport Report findings

2. To understand opportunities for assurance of opioid and sedative drug use in an acute Trust

3. To understand opportunities for assurance of opioid and sedative drug use in community settings

4. To be able to plan data collection to provide evidence of safety in attendees own organisation

Outline

1. Outline Gosport Report findings

2. Current status in acute and community settings

3. Group work on how organisations can identify

inappropriate practice, prevent recurrence and

provide evidence to assure organisations

4. Summary and close

Gosport report summary

• Report covers patient care 1988-2000

•At least 450 patients thought to have died after receiving inappropriate high doses of opioids

• Failure of systems and culture- lack of protection against poor care

• Themes included:- Concerns not treated seriously

- Lessons consistently not learned or implemented

- Lack of quality of investigations• Intimidation of staff and “whistle blowers”

-felt unable to 'speak up‘• Isolated practice- lack of connections

Changes in healthcare since 2000

• Culture of speaking up, supported by national reports

• More pharmacists, closer to the patient

• Better multidisciplinary team working

• Closer scrutiny, both in-house and external regulation

• Electronic systems

• National Alerts and guidance e.g. NICE

• More local guidance

• Better shared decision-making with patients

• Change pharmacy services

• Professional standards (GPhC)

Culture and speaking up

• 2013 Francis Report- Identified warning signs

• 2013 A Promise to Learn- Commitment to Act

• 2014 Trusted to Care review- Care of older frail patients was compromised

• 2014 Duty of Candour

-Openness

-Transparency

-Candour

Current practice and policy to provide assurance

Practice

• Regular clinical pharmacist review (prioritised)

– Access to senior staff with expertise in pain /palliative care

• ‘Deteriorating patient’ teams

• Palliative care teams in primary and secondary care

Policies

– Dispensing of opioids

– Storage of high dose opioids

Opportunities for drug use monitoring

• Quarterly CD audits in clinical areas, with pharmacy staff

• Monitor prescribing

– Prescriptions / 100 patients- over time

– Doses above 120mg morphine oral equivalents per day

– Co-prescribing of reversal agents

• Monitor supply

• Monitor administration

– Reversal agent use

• IHI ‘global trigger tool’

– use of reversal drugs

Local example – electronic pain scoring

Local example - safe practice with patches

Smarter use of technology

• Pharmacy supply data

• Electronic prescribing and medicines administration data

– new initiations per 100 occupied bed days

– Doses equivalent to morphine above 120mg/day orally

• Audit of electronic drug cabinet e.g. weak opioid stock levels

Controlled Drug Accountable Officers and Local Intelligence Networks

• Controlled drugs accountable officers (CDAOs) responsible for all aspects of controlled drugs management within organisation

• CDAOs roles, responsibilities, requirement to appoint CDAO, governed by Controlled Drugs (Supervision of Management and Use) Regulations 2013

• Local Intelligence Networks (LINs)

• Benchmarking

• Share concerns

Good practice in guidance/policies

• PRN always has max dose and max frequency

• Start low go slow

• Add indication

• Use pain scoring

• Have available reference eqivalcnes

Dose equivalence guidance

• BNF

• Prescribing in palliative care (NICE/BNF)

• London Cancer Alliance: Switching drugs and routes guidance

• Local guidance-all

•

• http://gti/clinical/directorates/oncology_haematology/teams/palliative/guidelines.aspx - AO to add from this site

Monitoring mortality – SHMI, HSMR

– Hospital standardised mortality ratio (HSMR)

– Summary Hospital-level Mortality Indicator (SHMI)

Monitoring mortality - SJR

• Structured judgement review

Palliative care vs Acute pain

Palliative care

• Often need to titrate dose up to manage pain

Acute pain

• Usually need to titrate dose down as clinical condition improves

Guidance for palliative care

• Screen shots and key quotes –all

• “Just in case” bags – JS Add image

Add excerpts form each of our local

guidance e.g. how much to give for anticipatory Rx

Prescribing discharge

medications for last days of life care

Guidance for acute pain

• Screen shots and key quotes –all

• All - Add image

Add excerpts from each of our local

guidances e.g. how much to give for

acute pain

Safe use of strong opioid medication in

pain management

Groupwork 5-8 in each group

• plan how your organisation can identify inappropriate practice, prevent recurrence and provide evidence to assure the organisation

Case 1 Acute hospital before electronic prescribing and medicines administration

• Oxycodone prescribed as required, patient was still in pain, subcutaneous dose was administered.

• Patient deteriorated and collapsed.

• Noticed patient had had several doses only two hours apart

• What difference would e prescribing systems make?

Case 2 Community bedded units with paper-based prescribing

• Opioid naïve 73 year old patient admitted with hip fracture

• Post op -Started on Morphine 10mg PRN every 2 hours

• Day 3- Analgesia increased- Oxycodone 15mg BD plus 10mg PRN 2 hourly,

• Day 5- Switch to Fentanyl patch 25mcg applied every three days

• Physios report patient as drowsy…

Case 3 Transition of care or hospices

Feedback from groups

Summary and future actions

• Stock take of current safety steps in your trust• Review previous alerts

– Reducing dosing errors with opioids medicines– Risk of distress and death from inappropriate doses of naloxone

in patients on long- term opioid/opiates treatment– Reducing risk of overdose with midazolam injections in adults

• Audit – incident data, pharmacy contributions, pharmacy issues, electronic data how often?– Controlled drugs – safe use and management– Improving patient safety: Pharmacy audit of patients prescribed

opioids >120 mg morphine equivalent and/or pregabalin >600 mg per day

Review access to local guidance

Resources 1

Faculty of Pain Medicine of Royal College of Anaesthetists with Public Health England UK wide guidance Opioids Aware resource for patients and healthcare professionals to support opioid prescribing for pain

• Good for acute pain and end of life but little evidence for long term pain

• Small proportion of people may obtain good pain rtelief with opioids in the long term if dose can be kept low and esp if use is intermittent (difficult to identify these people at initiation)

• Risk of harm increases above morphine equivalent120mg daily

• If still pain severe despite opioids, opioids are not working and should be stopped even if no treatment is available

• Chronic pain is very complex, if patients have refractory, disability symptoms particularly on high dose opioids, detailed assessment of emotional influences on pain is essential.

Resources 2

Royal College of Anaesthetists briefing to health professionals on

management of opioid medications: There is an urgent need to:

1. Screen and assess people on opioids

2. Make clinical decisions about opioid reduction and optimal pain

management

3. Identify the best clinical approach and location

4. Ensure resources

5. Employ a corporate approach to manage non-compliance

Linked to interdisciplinary pain management

https://www.rcoa.ac.uk/system/files/FPM-Opioid-letter-2018.pdf

Resources 3

• West Suffolk CCG opioid tapering guidelines https://www.westsuffolkccg.nhs.uk/wp-content/uploads/2018/04/2828-NHSWSCCG-Opioid-Tapering-Resource-Pack.pdf

International example proposed - Canada

• Opioid patch exchange scheme to be launched in Canada in primary care