HCA Healthcare Shows Up

Crush the Crisis

Jeffrey T Hodrick, MD and Sara Stedman, RN nurse navigator

Jeff Hodrick: My name is Jeff Hodrick, I’m an orthopedic surgeon who’s fellowship trained in joint replacement and adult reconstruction, I work here at TriStar Centennial, in Nashville Tennessee, did my training at Duke University and then did one year of fellowship at the University of Utah under Dr. Aaron Hoffman and all with the same practice. I think the way that I have thought about pain has come full circle, so I think what we’re doing now is better for the patient and really what we’ve come to understand is that although at times strong narcotic opioid pain medicines are necessary after a joint replacement, I think most patients do better not taking them, and I think when I have that honest conversation with them, and I bring that up they say you know what I don’t do well on that stuff. And I’m like you know what I totally understand, because often times the side effects of the medicine – constipation, nausea, sleep disturbance are worse than the discomfort.

And I also it’s for me it’s a lot easier to have the conversation and be honest and say OK, here’s the best news, we do a surgery, that relieves pain reliably, OK so the pain that your in now is your arthritis pain, we taking out all the arthritis so, all that pain will be gone, you’ll be left with the soreness of the surgery which will get better with time, fairly quickly and we can do some other things around inflammation that can help with that.

So, being able to have that honest conversation instead of saying OK we’re gonna get you through this without any pain telling them you're going to be uncomfortable but it’s going to be reasonable. And when patients can you know buy into that process and say ok, I’m going to get better with time, this is going to be hard, but I can make it you kinda give them hope rather than set them up to fail and say we’re going to keep you completely pain free, and they go home and then they have what is realistic pain after a joint replacement and kinda lose their mind. I would do the same thing, and that's when all the anxiety and all the other factors kind of come into play, and it's easy to get spun up and just makes the situation worse, it’s kind of their experience of pain rather than the actual physical manifestation of the nerves being triggered, it’s all the other things that go into the brain how that black box. I think that determines how much pain you experience after surgery and that’s kinda where our opportunity has been I think that’s what were doing differently.

Sara Stedman: I’m Sara Stedman, I am an RN nurse navigator, we kinda have to talk through what kinda pain there having, is it a functional pain, is this something that we can look at other alternatives to try, but then also advise them on how to properly take pain medication after surgery. I know that when I first came on here the idea was the patients go home on a certain dose and they stay on that for the full 6 weeks. And that 6 weeks is when you start weening the patient, and that’s not the case anymore now. We talk about it, it’s a conversation we have with them before hand, when they need a refill and they call in then we start discussing about the weening process and kinda titrating them down, and then we’ve also introduced some other therapies that can be alternatives. And allied health professionals and everyone down to the front desk staff that are all in it for the right reason and that's taking care of patients.

In the end I think what makes it easier to do all of these things especially for me as a surgeon is its just better care. It's just better care for the patient and the patient feels better and does better so it has a better outcome, which is reassuring not only to the patient but also to us and patients family. I mean theres just all good things like it's the win-win that everybody’s always after. We just happen to be interested in it. We didn’t mind doing the work and a lot of this grew out of the conference that we had that I attended with HCA that was really about recovery, but kind of what everyone took out of that I think all over the country kind of started these little cells of like OK, we can do better on the opioid reduction side of things, you know we were a little bit further down the road to start cause we were very protocol driven when you’re taking care of patients and kind of have more of an algorithm, we have a database that we can look at monthly and it’s live information about morphine equivalence, length of stay, side effects such as nausea, emesis, how far they walked on the first day of surgery all these things, if you get them off on the right foot, patients just do better after joint replacement. So, I feel that we are doing so much better with our rehab, our length of stay, out patient surgery, because of how we manage their pain.

So, it started in 2016 maybe that we started having the interdisciplinary meetings and just brought up ways that we could do better, and so during that we thought up crush the crisis. And it truly just started as like a grass roots effort, let’s have a day here at Centennial for people to bring back their medications, and I think that first one, it happened in 2017, I think we got like 18 pounds which we thought was huge. It’s certainly grown beyond what we ever thought it would. We’ve gone from a take back of 18 pounds to a total of over 13,000 pounds nation wide this past year.

Jeff Hodrick: So what is the real danger here, the real danger is diversion, so if that medicine falls into the wrong hands, and this is where this conversation become real and personal. Because most people know someone, unfortunately a lot have someone in their family, I do have someone in my family that have been a victim of opioid overdose. And that then becomes real because that then how things get started. That’s what we’ve learned. That’s the true gateway. When you read about whether it’s kids, or adults, or grandchildren, that have a heroine overdose, or a synthetic fentanyl overdose, most of them unfortunately started with prescription pain medicine that was not their own.

So that’ the true opportunity to make a difference, by getting way upstream before it’s a problem. And there’s no reason to have it in the cabinet, because I assure you if you have a condition or something happens where you need pain medicine, I mean your physician will provide that for you. So it’s a common sense thing, let’s get it out of the house, just like having a gun cabinet, or not having a firearm in the house. That’s kind of what it’s akin to cause it can be that dangerous and so it’s kind of a common sense thing, that’s very simple, I give Sara the credit, I mean, Joe Hagen was involved, I mean there were a lot of people obviously involved early on that made it successful.

We’ve had a lot of other folks that have helped, the support from Scott Cihak, our CEO all the way up to division have been extremely supportive of the effort. I think it’s something that’s pretty easy to do if you think about it, I think it’s going further now you’ve probably have been to drugstores or in Walmart where they have receptacles, I think that’s the next step, if the pharmacists gives you the medicine, like OK if you’re not going to use this you know bring it back and put it in this receptacle and we’ll dispose of it properly. For me and I think for our team I think it was probably a combination of the things so right like OK here’s an opportunity to make a difference, everybody’s always kinda looking for those things right and we were motivated to do it and it was reassuring because patients were doing better. So that made it very easy to investigate new ways to do it. And luckily we’re in a situation where we can have data to support that, so that I can actually make sure that my patients still doing as well if not better in the hospital and after surgery cause we’re pretty data driven in our practice.

So as a provider, I’m most interested in making sure my patient has an excellent outcome, and if I can do that by prescribing less pain medicine, at the root of the problem then it’s kind of a no brainer. Just do something, same thing as show up right? Sometimes a problem is so big, New you’re like oh man, what can I possibly do to change that, well just do something, do anything, just bring back one bottle of pills, you gotta believe that that makes a difference. So I think that’s why crush the crises probably makes sense.