Page 34 - Delaware Medical Journal - May/June 2020
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Quality Improvement Abstract Winner
Improving Guideline-Based Opioid Prescribing Practices in Our Resident Continuity Clinic: A Quality Improvement Initiative by Chris Canfield, PGY1
Introduction: The opioid epidemic has emerged as one of the major issues facing our medical community. Each year, deaths from opioid overdoses continue to rise. It is now estimated that an average of 130 Americans die daily from opioid overdose. National and state guidelines are in place to ensure the safety of our patients. Our goal was to assess opioid guideline adherence and to identify and address factors contributing to low adherence in our resident primary care clinic.
Methods: We composed a resident survey to assess provider-level barriers leading to lack of opioid guideline adherence. Our survey revealed both resident education and knowledge of current prescribing guidelines as major contributors to low adherence. Given our survey results, we created an education initiative that would focus on our survey. Our education initiative consisted of an attending-led lecture on management of patients prescribed chronic opioid therapy, and a resident-led workshop reviewing prescribing guidelines. We chose four criteria to monitor for guideline adherence. These criteria included documented bi-annual urine drug screen (UDS), annual patient-provider and four-month review of the prescription monitoring program (PMP). We monitored these criteria over a period of time (07/2018- 03/2019), during which our education initiative was presented.
Results: As mentioned, our resident survey did reveal guideline knowledge as a major barrier. Our residents were least familiar with the requirement for a six-month UDS. Only 40% (14/35) of residents knew of the bi-annual UDS requirement. Sixty percent (21/35) of residents were familiar with the need for an annual treatment contract, and
patients who were receiving chronic opioid therapy. In July 2018, 46.6% (28/60) of patients had documented UDS within six months, and 86% (52/60) of patients were The compliance rate for these two criteria remained stable through March 2019. However, after our education initiative, there was a stepwise increase in PMP compliance and contract compliance from 43% to 66% and from 34% to 52%, respectively.
Conclusion: quality improvement initiative, we were able to increase compliance in two of the four guideline components. Our next PDSA cycle will focus on system barriers to compliance. We hope to incorporate a “quick text” to ensure standardization of the four guideline components. We plan to continue to promote guideline adherence, and ultimately reduce morbidity and mortality associated with inappropriate opioid use.
CONTRIBUTOR
■ Chris Canfield is a second-year resident in the Internal Medicine Program at ChristianaCare. He received his medical degree from the Philadelphia College of Osteopathic Medicine.
RESIDENT POSTER WINNERS
Clinical Vignette Poster Winners
1st Prize, Poster
Crashing into a Diagnosis: Neurocysticercosis, A Cause of New- Onset Seizure by Fazad Mohamed, PGY1
Seizures have a wide differential, but neurocysticercosis is the leading cause
of adult-onset epilepsy worldwide. Neurocysticercosis is a parasitic infection in which larval cysts of the pork-tapeworm
Taenia solium coalesce within brain parenchyma. The following case illustrates
a common presentation of the disease and helps to clarify diagnosis and management
Spanish-speaking male with no past history presented to the emergency department (ED) following new-onset seizure and consequent motor vehicle collision. He reported a sudden syncopal episode followed by a return of consciousness in which he found himself within a crumpled car. During the moments leading up to loss of consciousness, he denied any headache, chest pain, dyspnea,
or diaphoresis. In the ED, the patient was hemodynamically stable but post-ictal. of 8.7, anion gap of 19, troponin less than 0.01, and mild leukocytosis at approximately 12. EKG depicted normal sinus rhythm. CT of abdomen and cervical spine depicted no traumatic injuries. CT of the head revealed a frontal lobe surrounded by vasogenic edema. The patient was given 1000 milligrams (mg) of levetiracetam in order to prevent further seizure activity. The patient explained that
he immigrated to the United States from Mexico 14 years ago and works as a horse groomer. He denied any sick contacts, recent travel, or tuberculosis exposure. The patient had always eaten a lot of pork, but he had no recent dietary or lifestyle changes. He denied steroids, illicit drug, alcohol, or tobacco use. He reported no weight loss, fevers, chills, or night sweats. During hospitalization, HIV and rapid plasma reagin (RPR) returned peripheral rim enhancement. Findings were consistent with neurocysticercosis rather than a primary malignancy, metastasis,
or vascular malformation. Per Infectious Diseases Society of America (IDSA) guidelines, no antiparasitic treatment was with 500mg of levetiracetam twice a day in order to prevent recurrent seizures. He was told to follow up with neurology and was given strict instructions to avoid driving upon
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Del Med J | May/June 2020 | Vol. 92 | No. 3
