If you get a call from the ED about Suboxone while on service: CHECK LIST...
Hello Everyone,
Just a quick note to add to Krystal’s updates.
The ED has started to do inductions (giving people in withdrawal from opiates suboxone to help them with symptoms and encourage them to stop using narcotics) for patients they are seeing with other presenting issues.
Currently, they are calling the on-call FM OB pager as a first step in coordinating continuity of care. This is not the best system but it is the system they have chosen and will be in place until April of this year.
In order to feel prepared here is a quick check list so that if you get called to help coordinate follow up you can know what to ask and how to help.
Situation: ED calls stating they intend or have already started an induction with suboxone.
Your Checklist:
- Ask ED if they’ve done a readiness assessment and if they have decided the patient is appropriate for outpatient management at a clinic level:
- Specifically, are they using less than 90 meq of morphine a day? (if yes, induction appropriate, if no induction not appropriate)
- Does the patient currently drink or use benzos daily? (if yes, they should not be induced in the ED)
- Does the patient have an ongoing psychiatric diagnosis that makes them high risk? (if yes, they should be assessed for out-patient appropriateness before induction)
- Specifically, are they using less than 90 meq of morphine a day? (if yes, induction appropriate, if no induction not appropriate)
- Ask the ED if they willing to watch the patient for more than 2 hours after giving the first Suboxone dose?
- This came up with their first induction where they were insisting the patient leave after an hour. This is not generally how inductions are done or how to be successful in an induction. They should be re-assessing the COWs at 2 hours after first dose. Just as a general rule, most patients will end up on 8-12 mg of Suboxone after successful induction.
- This came up with their first induction where they were insisting the patient leave after an hour. This is not generally how inductions are done or how to be successful in an induction. They should be re-assessing the COWs at 2 hours after first dose. Just as a general rule, most patients will end up on 8-12 mg of Suboxone after successful induction.
- Please ask the ED to complete the following labs prior to induction (result from LFTs should be back before inducing, if high I would avoid induction in the urgent setting)
- LFTs
- HIV, Hep C, Hep B surface ag
- Urine Drug screen
- Urine Pregnancy screen
- LFTs
- If the ED completes an induction: route a message with the patient’s chart to Erica Feinman, Kim Insel, Sharry Veres, and Val Candia asking for intake to be performed and for temporary Rx for suboxone until patient can be seen in our clinic ASAP.
**If the patient is not appropriate for our level of care, the ED is supposed to be risk stratifying them to go to either Community Reach or Behavioral Health Group. I would encourage them NOT to do the induction in the ED if this is the case. Their liaison is supposed to coordinate follow up with BHG and CRC. Unfortunately, we still may be asked in this circumstance to cover a week (max) worth of the Rx for suboxone until they can be seen at CRC or BHG. If you are asked this, please explain it is their responsibility to coordinate follow up with CRC and BHG and that this may not be the best time for induction if this coordination cannot happen. Then route the patient’s chart to me, Erica Feinman, Val Candia, and Sharry Veres. **
Additional advice: Inductions rarely need to be an emergency. If a patient is interested and the circumstances that are present in the ED are not ideal to induce, they should wait and arrange follow up in our clinic. You can still encourage these patients establish care with us and be seen by a provider who has a suboxone X number. We can work with them on deciding what level of care may serve them best and coordinating pairing with BHG or CRC if our level is not appropriate.
If you have any questions email me or text me directly at 646-823-5708.
Kimberly Insel, MD MPH
From: Tamura, Krystal
Sent: Thursday, January 17, 2019 1:27 PM
To: Diaz, Sara <SaraDiaz@Centura.Org>; Flint, Ryan <RyanFlint@Centura.Org>; Groff, Elizabeth <ElizabethGroff@Centura.Org>; Harrington, Trevor E <TrevorHarrington@Centura.Org>; Insel, Kimberly J <KimberlyInsel@Centura.Org>; Liegl, Sarah <SarahLiegl@Centura.Org>; Ludemann, Matthew MD <MatthewLudemann@Centura.Org>; McGee, Colleen M. <ColleenMcGee@Centura.Org>; Ochs, Genevieve <GenevieveOchs@Centura.Org>; Price, Bethany R <BethanyPrice@Centura.Org>; Strickland, Laura E. <LauraStrickland@Centura.Org>; Tamura, Krystal <KrystalTamura@Centura.Org>; Veres, Sharry <SharryVeres@Centura.Org>; Walter, Kimberly <KimberlyWalter@Centura.Org>; Zarza, Christina <ChristinaZarza@Centura.Org>; Beukema, Kylie <KylieBeukema2@Centura.Org>; Karozos, Stephanie <StephanieKarozos@Centura.Org>; Knaus, Chad J <ChadKnaus@Centura.Org>; Mathern, Seth A <sethmathern@centura.org>; Mettler, Lisa <LisaMettler@Centura.Org>; Rudolph, Michael R <MichaelRudolph@Centura.Org>; Baxter, Kelly <KellyBaxter@Centura.Org>; Blumberg, Drew T <DrewBlumberg@Centura.Org>; Bowie, James W <JamesBowie@Centura.Org>; Bross, Theodore L <TheodoreBross@Centura.Org>; Buehrer, Beth <BethBuehrer@Centura.Org>; Davies, Sofia <SofiaDavies@Centura.Org>; Hart, Taylor V <TaylorHart@Centura.Org>; Sherman, Kelsey J <KelseySherman@Centura.Org>; Troutman, Jesse E <jessetroutman@Centura.Org>; Weniger, Kate C <KateWeniger@Centura.Org>; Aquila, Emily C <EmilyAquila2@Centura.Org>; Baker, Stephanie <StephanieBaker2@Centura.Org>; Cammarano, Julian A <JulianCammarano@Centura.Org>; Del Moral, Spencer R <SpencerDelMoral@Centura.Org>; Galbraith, Bryce K <BryceGalbraith@Centura.Org>; Heng, Peter <PeterHeng@Centura.Org>; Holland, Hailey B <HaileyHolland@Centura.Org>; Maurer, David E <DavidMaurer@Centura.Org>; Pigott, Christine <ChristinePigott@Centura.Org>; Sterry, Brandon <BrandonSterry@Centura.Org>; Vollmer, Jeremy C <JeremyVollmer2@Centura.Org>; Zerba, Emily S <EmilyZerba@Centura.Org>; Brown, Cory J <CoryBrown@Centura.Org>; Dill, Jessica C <JessicaDill@Centura.Org>; Edwards, Gray K <grayedwards@Centura.Org>; Gayer, Corinn L <corinngayer@Centura.Org>; Mahony, Gwyn E <gwynmahony@Centura.Org>; Mathias, Tanner D <tannermathias@Centura.Org>; McClenahan, Kaitlin E <kaitlinmcclenahan@Centura.Org>; Neisler, Justin B <JustinNeisler@Centura.Org>; Pearson, Lindsey J <LindseyPearson@Centura.Org>; Saad, Amira O <amirasaad@Centura.Org>; Stowers, Lucas K <lucasstowers@Centura.Org>; Wendt, Rebecca A <rebeccawendt@Centura.Org>
Cc: Residency hub blog (Stanthonyresidency.north@blogger.com) <Stanthonyresidency.north@blogger.com>
Subject: Inpatient updates
Sorry it’s a little long. It’s been awhile since I sent out any updates.
Medicine:
ALTO (alternatives to opiates) implementation in ED
- This is a new program being rolled out at many EDs. Our ED has started to implement it to decrease the amount of opiates prescribed. Unique treatments being used by the ED are ketamine and lidocaine.
- At this time, these orders should be one-time only in the ED. We are unable to perform lidocaine or ketamine infusions on the floor until nursing/provider education is completed (date TBD). If they are ordered as infusions, you will need to cancel them as an inpatient.
At-Risk Patient Order (please see your required health stream module for more information)
- New “at-risk patient” order in epic
- Use in addition to M1 order or independently if not meeting M1 criteria, but need more precautions
- Needs to be renewed after 72 hours
- Doesn’t replace the M1 hold
- If patients are not on an M1 hold, there are options for excluding them from certain restrictions. Don’t pick these options if they are on an M1
- Physicians need to discontinue the order when no longer meeting criteria, d/c’d, or transferred
- In patient header, also add FYI Flag “At-risk” that will alert staff about he patient care. Cancel this flag on d/c
No kayexalate in hospital
- Need to use Valtessa for hyperkalemia instead
Discontinue prn medications if not effective or not using
- We have been cited multiple times by joint commission for duplicate prn medications for the same indication (ie: nausea, pain). Please make sure you discontinuing medications that are not effective or the patient is not using. If they are using all the medications provide a different indication for the medications (ie: mild, mod, or severe pain, use if Zofran not effective, etc)
Inpatient Note if Patient Doesn’t discharge
- The coders can use the discharge note as the progress note for that day if the patient does not discharge. In the attestation just explain why the patient stayed again
- No additional progress note is needed for the day the patient stayed
- For the actual day of discharge you will write another discharge note
OB:
AM C-section arrival time
- Please have patients arrive at 5:30 AM to L&D for 8 AM c-sections.
Chlorhexidine night before C-sections
- Please give chlorhexidine wash to C-section patients to use the night before or day of their scheduled section. We will be stocking these in clinic.
Transfer process for pregnant patients
- Make sure to request “Critical Care / Fetal Monitoring” from Centura Connect when transferring moms to outside facilities. This will ensure more timely transfer
Krystal Tamura
St. Anthony North Family Medicine Faculty
Inpatient Medical Director
St. Anthony North Health Campus | 14300 Orchard Pkwy Westminster, CO 80021
Office: 303.430.5560 | Cell: 720.352.4874
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