EHR Tools for Acute Pain Management Vanessa Hennes, PharmD Clinical Pharmacist Analyst Rady Children’s Hospital – Inpatient Pharmacy

EHR Tool Kit Ambulatory/Discharge Acute Pain Order Set Ambulatory BPA for concurrent opioid & benzodiazepine prescriptions AVS Handout for patients prescribed an opioid Inpatient Acute Pain Protocol Emergency Care Plans Live demo following case studies

Ambulatory Order Set Search by order set name, or search any pain medication Found in Orders Activity, as well as Medication Reconciliation

Ambulatory Order Set Clean, stream-lined build Offers a step-wise approach to pain management Supportive care medications built into each panel where appropriate This protocol was a collaborative effort between providers, nurses and the Pain Service. It was developed by the Pain and Opioid Task Force and has been piloted by Ortho since August. The long-term goal is to standardize acute pain management across the organization and we will eventually be replacing pain medication orders in other order sets (where appropriate). No clutter – all order groups are collapsed. This helps direct the provider’s attention to one decision point at a time, rather than having all orders display all at once – can be overwhelming and distracting. This order set is meant to be used in more of a “stepwise” fashion. It is designed to guide providers through a decision-making process. As Drs. Huang and Ulma discussed earlier today, you will see a new approach highlighted here – using scheduled (round-the-clock) medications for a period of time, followed by PRN, with additional breakthrough medications. You will see later on during the live demo there are supportive care medications build into each panel that differ depending on which medications are ordered.

(1) Choose appropriate pain therapy approach. (2) Select Primary Pain Medication Class. (3) Choose medication & form. Adjust any defaults if needed (dose, duration, special instructions, etc.) (4) Add breakthrough medications as necessary. (5) Order supportive care medications as appropriate. This is an example of how the order set flows – the provider is guided through a decision-making process. Select the appropriate pain medication orders based on the patient’s clinical presentation – what is the severity of the patient’s pain? How long is the pain expected to last? Would the patient benefit from having scheduled pain medications for a period of time or will PRN suffice? Select the primary pain medication class based on severity of pain, patient preference, etc. Select the medication & formulation most appropriate for the patient. There are certain defaults built into the order set – i.e. The scheduled duration for these orders is 48 hours, followed by PRN for a total of 5 days of therapy. However, providers can always change any defaults as necessary to fit their patient’s needs. Select any additional breakthrough pain medications (note this is multi-select) Supportive care as appropriate Additional orders for antiemetics if needed (6) Option to add anti-emetics as appropriate.

No combination analgesic-opioid products. Tramadol only appears for patients 13 years or older Additional notes: Combination analgesic-opioid products excluded from build – order each med separately Tramadol only appears for patients 13 years old or greater Naloxone is suggested only for patients who meet certain criteria that put them at higher risk of respiratory depression – otherwise will not appear in the order set Naloxone suggested for patients meeting certain criteria who might be at higher risk of respiratory depression.

Opioid/Benzodiazepine BPA Triggered when prescribing an opioid if the patient has any active prescriptions for an opioid and/or benzodiazepine If provider chooses to keep the new prescription, they must select an acknowledge reason Often times, providers are unaware of existing prescriptions written by other providers/services. Report shows patient’s active orders that triggered the BPA to fire. When BPA fires, providers can choose to keep or removing the prescription they are entering. If choosing to keep the prescription you are writing, you must select an acknowledge reason indicating that you intend to discontinue the patient’s existing prescription, or that all prescriptions (existing and new) are appropriate. The Pain/Opioid Task Force will be monitoring this BPA to see how often it fires, and what actions are taken, if any.

Opioid Patient Education Handout (1) Automatically prints with Inpatient and Outpatient AVS when an opioid is prescribed (2) Available in English & Spanish

Inpatient Acute Pain Management Protocol Search by order set name, or search any pain medication Found in Orders Activity, as well as Medication Reconciliation This protocol was a collaborative effort between providers, nurses and the Pain Service. It was developed by the Pain and Opioid Task Force and has been piloted by Ortho since August. The long-term goal is to standardize acute pain management across the organization and we will eventually be replacing pain medication orders in other order sets with these orders (where appropriate).

Inpatient Acute Pain Management Protocol Similar build structure to Ambulatory Order Set Includes non-pharmacologic pain management, consult orders and all necessary supportive care medications This protocol was a collaborative effort between providers, nurses and the Pain Service. It was developed by the Pain and Opioid Task Force and has been piloted by Ortho since August. The long-term goal is to standardize acute pain management across the organization and we will eventually be replacing pain medication orders in other order sets (where appropriate). No clutter – all order groups are collapsed. This helps direct the provider’s attention to one decision point at a time, rather than having all orders display all at once – can be overwhelming and distracting. This order set is meant to be used in more of a “stepwise” fashion. It is designed to guide providers through a decision-making process. The first decision is to select the appropriate pain medication orders based on the patient’s clinical presentation – are they actively in pain? or anticipated to have pain following a procedure? For patients not anticipated to have pain – there are “ONCE PRN” orders for acetaminophen and ibuprofen with instructions for RN to contact provider if patient requires additional pain management – if unexpected onset of pain during admission RN has at least one order to cover until provider can be reached. Often times patients have unnecessary PRN orders placed on admission that clutter up the MAR and can lead to duplicate orders. As Drs. Huang and Ulma discussed earlier today, you will see a new approach highlighted here – using scheduled (round-the-clock) medications for a period of time, followed by PRN, with additional breakthrough medications. You will see later on during the live demo there are supportive care medications build into each panel that differ depending on which medications are ordered.

(1) Choose appropriate pain therapy approach. (2) Select Primary Pain Medication Class. (3) Choose medication & form. Adjust any defaults if needed (dose, duration, special instructions, etc.) (4) Add breakthrough medications as necessary. (5) Order supportive care medications as appropriate. (6) Option to add anti-emetics as appropriate.

No combination analgesic-opioid products. Additional notes: Combination analgesic-opioid products excluded from build – order each med separately Standard naloxone panel required for all admitted patients with active opioid orders Again – includes laxatives for opioid-induced constipation Standard naloxone orders for all patients with active opioid orders.

Emergency Care Plan

Feedback & Questions The Pain/Opioid Task Force welcomes any feedback you have regarding the build discussed. We are always looking to improve EHR tools and workflows. Please send feedback to Vanessa Hennes vhennes@rchsd.org Dr. Jeannie Huang jshuang@ucsd.edu