1. Rural Hospital Taking Lead in CSR Abuse Educational Efforts & Outcomes Ann Vermilion, MBA, FACHE Admin. Director Medical Staff Services & Community Outreach Marion General Hospital October 29, 2015

2. Objectives 1.Demonstrate ways in which a rural hospital can reach outside of the healthcare system to impact controlled substance abuse in one’s community. 2.Identify hospital data standards to measure progress. 3.Define steps which can be made within the healthcare system to address community CS abuse.

3. MGH: Mission for Change STEP #1: Evaluate the CSR abuse: Knowledge is Power –MGH –Grant County –Indiana –USA STEP #2: Investigate “What can we do within our health system?” STEP #3: Implement Prescribing Guidelines STEP #4: Educate - MGH employees, physicians & Community

4. Rise in patient requests in ED & Physician Offices Patient’s disposition and aggressiveness Climate: threatening, volatile & disruptive = employee and physician dissatisfaction How are other hospital system's handling? STEP #1 CSR Abuse: Affects at MGH

5. STEP #1: A Local Epidemic Grant County Drug Court Stats

6. STEP #1 CSR Abuse: State & National

7. Where Do Abusers Get Their Drugs? 55% From friend or relative for free 11.4% Purchased from friend or relative 4.8% Took from friend or relative without asking 4.4% From a drug dealer or stranger 0.4% Internet 17.3% From one doctor Source: National Survey Drug Use and Health, Sept. 2011

8. Education and Awareness of a.Locking up household Rx b.Medication Disposal. Community Tactics

9. CSR were entering the streets of our community from Rx written from our medical staff. Reality Check

10. STEP #2: Investigate “What can we do within our health system?”

11. DETERMINE MEASURABLE DATA # units of OCCS were administered hospital wide # of doses of OCCS were administered in ED % of patients prescribed OCCS # pills prescribed in ED # average pills per patient in ED # of OCCS Rx written in the Primary Care/Specialty Offices STEP #2: Self Evaluation

12. In 2012-2013 –27,000 Doses (30,000 tablets) of hydrocodone containing pain reliever –10,000 Hydromorphone injections –7,000 Fentanyl injections –11,000 Morphine injections Over 63,000 units of OCCS were administered hospital wide Over 9,600 doses of OCCS were administered in ED 2,343 (21%) patients prescribed OCCS 36,400 pills prescribed 15.5 – average pills per patient Largest single prescription – Lortab 5-500 #60 for rib fracture Second largest prescription – Norco 5-325 #40 for toothache STEP #2: Self Evaluation

13. MGH Prescribing Guidelines in the ED Not to take place of clinical judgment Provide UNIFORM guidance to emergency care providers Treat the pain until they could see the referring specialty (3 days vs. 45 days) Appropriate treatment of acute pain Appropriate treatment of chronic pain

14. ED Prescribing Guidelines (cont.) Attempt to obtain photo ID or patient photograph upon arrival Once triage complete ALL patients will receive a copy of “Pain Management in our Emergency Department” Use of INSPECT – 100% employed 80% non-employed Urine Drug Screen if indicated

15. MGH Outpatient CSR Rx Guidelines: First Do No Harm The Indiana Healthcare Providers Guide to the Safe, Effective Management of Non-Terminal Pain Recommendations

16. MGH Journey towards Education Education for area Physicians, MGH Staff & Community July 2012INSPECT – IN Board of Rx JEAN Team & Judge Spitzer Sept 2013Howard County Dep. Prosecutor “4 Doctors jailed for Opioid Prescribing Patterns” Jan. 2014INSPECT – IN Board of Rx for ED team Feb. 2014MGH Rx Guidelines Education CME for all ED Staff & Physicians, all medical Practitioners and MGH staff Service Line meetings (Medical & Surgical) MGH Primary Care Physicians Meeting MGH Board of Directors Community Discussion and Education – 25 local organizations Mar. 20145 sessions at MPD yearly officer training

17. Communication Timeline Community Roundtable – Feb. 25, 2014 –Law Enforcement Agencies –Healthcare Providers –JEAN Team –Grant Co. Courts and Prosecutor’s Office –Local Pharmacies –Substance Abuse Treatment Providers –Social Services –Medical Providers –Grant County Health Department

18. Community Support a Priority Our mission to provide a safer community is supported by:

19. MGH OOCS (Opioid & Other Controlled Substances) Prescribing Guidelines Launched APRIL 1, 2014 STEP #3

20. How are we doing in Grant County: 1 year later? STEP #5: Evaluate and Awareness

22. > 64,900 pills

23. Estimated decrease in Pills > 64,900 pills in MGH ED @ 34,000 pills in MGH Inpatient DC Inpatient DC & Physician Practices @ 100,000 pills in one year

25. Monitoring Addictive Behaviors in Grant Count: Changes in Drug of Choice

26. Total since 2013 = 53 Repeat patients = 6

27. Narcan Use – Reversal Agent for Opioid Overdose EMS started administering intra-nasal Narcan June of 2014 –EMS administered Narcan 56 times in 2014 (beginning in June) Average 8 per month –EMS 2015 Year-to-Date has administered Narcan 89 times (average 10 per month) 96 annualized 118 annualized Oct to Dec Estimated June to Dec = 56 Jan to Sept = 89 Jan to May Estimated

28. MGH Data Notes: MGH data: Preliminary cases, labs we report to ISDH. Does not deduct transmission or contracted through intravenous drug use. May not be newly diagnosed, but new to our system. Age breakout ISDH confirmed

29. JEAN Team Drug Task Force Statistics

30. Rise in Heroin – Community Task Force for Evaluation -Held July/August CME offerings - Presentation – 1 year later - Climate of Heroin abuse Continuous Education

31. September 29, 2015 Broke into Committees: 1. Data Collection 2. Public Health Response –Education, Outreach & Communication –Grant county resources available 3. Syringe Exchange Program (Logistics) Heroin Task Force

32. Tammy Cornelious, RN Administrative Director MGH Emergency Department John Kauffman, Detective Sargent, Marion Police Dept, JEAN Team Joint Effort Against Narcotics Mark Spitzer, Judge of Grant Superior Court 3 Steve Kroh, PharmD Local Pharmacist Meet Some of my Team Members

33. Our mission to provide a safer community is supported by: Are your communities seeing similar climates? Were your physicians interested in education on INSPECT, CSR abuse, Heroin rise? Obstacles and Opportunities? Roundtable Discussion & Questions