Appropriate, effective opioid use requires regular monitoring—not only pharmacological monitoring but systems checks as well. “After your interdisciplinary team has reviewed facility systems and ensured good practices are in place, it’s important to monitor: Are they working? What’s breaking down?” says Barbara Bates, RN, MSN, DNS-CT, RAC-CT, QCP, a nurse consultant and dementia care specialist based in Bergen, NY.
“For example, if a pain assessment that is supposed to be done on admission is actually done a week after admission, there needs to be a process for identifying that error and why it occurred,” explains Bates. “You have to make sure that the process happened the way you established it should. And when practices don’t work, you have to do a root-cause analysis to find out what happened so you can revise appropriately if needed.”
Taking the following steps can help DNSs implement strong monitoring and audit processes:
Involve unit nurses in monitoring
“Staff nurses on the unit need to be educated on actively monitoring for the effectiveness of pharmacological interventions,” says Susan LaGrange, RN, BSN, NHA, CIMT, director of education for Pathway Health in Lake Elmo, MN. “This should include monitoring for side effects that are expected from any given opioid or other analgesic—and also taking a look at the potential for adverse consequences, which are not necessarily expected.”
Staff nurses also should do oversight of nonpharmacological interventions, says LaGrange. “Staff nurses most often fail to monitor nonpharmacological interventions provided by unlicensed staff, such as exercise or massage. They need to do that oversight: identify whether those interventions are in fact being done, and whether they are successful or other interventions should be tried.”
On the pain management side, nurses face a lot of demands in their everyday work, so DNSs might need to stress the importance of monitoring for indicators of potential problems, says LaGrange. “For example, nurses should monitor residents’ sleep patterns and changes in their ADL function (e.g., Are they eating? Are they walking). Staff need to look for and report those types of indictors that the resident might be developing a pain-related issue.”
Check your documentation for front-line input
Feedback from front-line staff play a critical role in monitoring medication use, says Joan Baird, PharmD, BCGP, FASCP, director of pharmacy practice and government affairs for the American Society of Consultant Pharmacists in Alexandria, VA. “Consultant pharmacists aren’t able to go in and observe every single resident. They rely a lot on documentation to make recommendations.”
So the observations of front-line staff need to be included in the notes and other documentation, says Baird. “In particular, with residents who have dementia or who aren’t vocal, the observations of front-line staff can provide a lot of information about where the pain is, what the pain is like, the quality of the pain, and other important information.”
Include front-line staff in audits too
“Front-line staff should be involved in the facility’s audit system in every area, but particularly in pain management and opioid use,” suggests LaGrange. “All staff members should be able to take an audit sheet and review whether documentation shows that: the medication is documented; staff are using an appropriate pain scale according to facility protocol; staff are following the care plan (e.g., using nonpharmacological interventions); the resident is having concerns; and staff are going back to determine if the medication is effective.
Completing these audits on several charts gives front-line staff a chance to learn, says LaGrange. “They get an opportunity to audit from the facility protocol, so on repeated use they learn what that protocol really means. They learn that ‘Next time, I need to do this this way because I know someone will audit me too.’”
Do daily rounds
Many DNSs are dealing with significant staffing challenges, points out LaGrange. “Some facilities don’t have the luxury of consistent assignment like they did several years ago. Therefore, there needs to be that one person who is overseeing what is happening throughout the facility. My recommendation would be for the DNS to do daily rounds.”
Daily round activities could include identifying new admissions or new orders for opioids and other critical medications, as well as evaluating existing orders to see if the use is still necessary, says LaGrange. “The DNS also could do a quick chart review to look at, for example, what nonpharmacological interventions have been attempted: Are these interventions successful? Are they care planned? Are staff documenting that they are utilizing those interventions to either reduce or complement opioids? Also, it’s a good idea to look at whether the interventions and documentation are consistent with today’s standards of practice and professional standards.”
Conducting these daily rounds will put DNSs in a great position to initiate discussion with staff, says LaGrange. “The DNS will be able to make suggestions for alternatives and ensure that staff practice is consistent with the facility protocols.”
Don’t forget to address diversion
Diversion is a common issue with many controlled substances, including opioids, says LaGrange. “The DNS needs to be aware of the potential drug diversion indicators and make sure the facility has good systems, including follow-up, in place to monitor for and deal with that.” Note: A case of opioid drug diversion is listed as an example of Severity Level 3 noncompliance (actual harm that is not immediate jeopardy) for F608 (Reporting of Reasonable Suspicion of a Crime) in Appendix PP of the State Operations Manual.
Monitoring opioids and adverse consequences: What the SOM says
Inadequate opioid monitoring can have a cascade effect that results in providers meeting the one or all of the adverse consequences in the Key Elements of Noncompliance for F757 (Unnecessary Drugs) in Appendix PP of the State Operations Manual:
· Failure to act upon (i.e., discontinue a medication or reduce the dose or provide clinical justification for why the benefit outweighs the adverse consequences) or report the presence of adverse consequence(s); or
· Failure to monitor for the presence of adverse consequences related to the use of medications (particularly high risk medications, such as warfarin, insulin, opioids, or medications requiring monitoring of blood work); or
· Failure to respond to the presence of adverse consequences related to the use of medications (particularly high risk medications, such as warfarin, insulin, or opioids).
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