The Hospital for Special Surgery (HSS) is a national leader in the field of orthopedics and performed approximately 32,000 surgical cases in 2018. In this guest post, Dr. Seth Waldman, Roberta Stack and Lisa Goldstein (see bios at end of article), detail how the hospital successfully implemented a pain management program incorporating clinicians across the care continuum, and how it overcame challenges to ensure this goal became a cornerstone of the hospital’s culture.
Since the U.S. government declared the opioid crisis a national public health emergency, the death rate has continued to climb. Over 72,000 Americans died this year alone from an opioid overdose, outnumbering American soldiers who lost their lives during the entirety of the Vietnam War.
More than 40% of all U.S. opioid overdose deaths in 2016 involved a prescription opioid, and orthopedic surgery generates among the highest volumes of opioid prescriptions nationwide. As one of the busiest orthopedic hospital in the U.S., HSS recognizes its responsibility in managing the unique challenge of keeping patients safe and comfortable throughout the perioperative period, while also encouraging conservative opioid prescribing practices. To this end, administrators, clinicians and researchers worked together to inspire a culture promoting the standardized, safe use of opioids.
But a culture isn’t enough; many hospitals are grappling with institutionalizing a similar program throughout all levels of care. At HSS, the goals are to prescribe opioids responsibly and promote conservative use. HSS optimizes each patient’s surgical experience and tailors treatment plans to individual complex pain needs. It also provides education and supporting resources to prescribers, patients and the community via multiple channels.
HSS began by appointing a medical advisor for opioid prescribing practices and creating an enterprise-wide, interdisciplinary Controlled Substances Task Force. The Task Force was charged with implementing and monitoring the progress of institutional controlled substances initiatives, which spanned broad categories including: education, safe perioperative prescribing practices and close management of the most at-risk complex patients.
Educating the workforce
The Controlled Substances Task Force led the development and provision of educational resources for prescribers, patients and the community. Initially, the most pressing needs were to ensure that all clinicians were up to date with developments in opioid management, including the Centers for Disease Control and Prevention (CDC) guidelines, and had an evolving understanding of addiction and other conditions which are made worse by exposure to opioids, as well as the rapidly changing legal requirements.
The program began with a mandatory presentation for clinicians, which met New York State’s requirement for opioid education, to establish a baseline of understanding among those most involved in patient care. In addition, HSS developed toolkits and fact sheets to reinforce key learning among the entire workforce and provide guidance for communicating with patients receiving opioids. These efforts were further supported with patient-facing materials designed to educate patients and ensure they’re an active and aware participant in their treatment program.
Implementing standard prescription practices
In partnership with HSS surgeons, the Task Force developed novel service-specific guidelines to standardize opioid prescribing practices, patient monitoring and documentation via electronic health records, which can be accessed across all points of care. In the first 18 months of implementation, the program reduced short-acting opioids issued at discharge by more than 500,000 pills.
Creating a structure to guide new initiatives
It’s not enough to change prescribing practices, so the Task Force took a step back and considered how to provide the right kind of care for each patient. Now, patients with complex pain needs are identified pre-surgically (particularly where opioid use or misuse may be of concern) by asking a series of simple questions about medication use. High-risk patients are then referred for a comprehensive assessment by HSS’s Perioperative Controlled Substances Clinical Team, which includes three board-certified pain specialists supported by a social worker with training in addiction treatment and several mid-level practitioners.
After further evaluation, the team creates an individualized plan for pain management and recovery, tailored to that patient’s specific needs and history. Up to 30 preoperative patients are identified and screened per week, all of whom would otherwise be at higher risk for opioid overdose and associated opioid use complications. This pre-screening allows the team to determine which patients will benefit from increased monitoring and optimization (from their preoperative visit, through their inpatient experience and beyond discharge) to ensure the best outcomes for even the most challenging patients.
Sharing resources with the healthcare community
To promote better prescribing practices outside HSS, it continues to create tactical materials that educate healthcare leaders on implementing programs within their organizations. Its 17 opioid-related courses on HSS E-Academy are available for access nationwide. Most recently, HSS convened a national forum to discuss opioid-free arthroplasty and developed a special issue of The HSS Journal, released in February, which will summarize the hospital’s position on these matters including original research.
HSS’s efforts to educate patients spans patient complexity, and the culture at HSS now lends itself toward a conservative, educated approach to prescribing opioids. These improvements have only been possible because of the sincere engagement of the HSS clinical and administrative teams in these controlled substance initiatives, the highly effective administrator-clinician partnership at HSS, and the support of senior physician and executive leadership.
While regulatory measures and law-enforcement enhance efforts to stem illegal drug diversion and stop the flow of high-potency synthetic opioids into the country, these efforts will fall short without partnerships between healthcare administrators and clinicians that help eliminate excessive opioid prescribing and unnecessary medical exposure to opioids. HSS believes the interdisciplinary programs its developed work well together, are medically and ethically sound, fiscally responsible and could be adopted widely.
Dr. Seth Waldman is an anesthesiologist, and the director of the Pain Management Center at HSS. He is a physician consultant to the U.S. Department of Justice and Drug Enforcement Administration, and a master’s candidate in bioethics at Columbia University.
Lisa Goldstein is executive VP and COO at HSS since 1997.
Roberta (Bobby) Stack, MS, is an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force since 2017.