KY SOS Needs Assessment Question Title * 1. Please enter your contact information Name Hospital Email Address Phone Number Question Title * 2. Please indicate your hospital type Acute Care Critical Access Inpatient Behavioral Health Long-term Acute Care Inpatient Rehab Other (please specify) Question Title * 3. Who is your accrediting body? The Joint Commission DNV HFAP CIHQ Other (please specify) Question Title * 4. Who is your EMR vendor? EPIC Meditech Cerner CPSI Allscripts None Other (please specify) Question Title * 5. What version on EMR are you on? Question Title * 6. Please indicate if your Pharmacy System vendor is different from EMR Question Title * 7. Does your organization have an individual responsible for Opioid Stewardship/Safe Opioid Use? Yes No Comments: Question Title * 8. Does your organization track metrics regarding opioid use and safety? Yes No Other (please specify) Question Title * 9. Has your facility implemented evidence-based non-pharmacologic pain management techniques such as aromatherapy, acupuncture, a "Comfort Menu," etc.? Yes No If yes, please briefly explain Question Title * 10. Do you have education in place regarding safe opioid use and pain management for providers? Yes No Comments: Question Title * 11. Has your facility conducted or participated in community outreach regarding safe opioid use? (e.g. table at health fair, drug take-back, working with health department on syringe exchange program, etc.) Yes No Comments: Question Title * 12. Does your facility have an ED-specific evidence-based protocol/program for non-opioid pain management such as Alternative to Opioids (ALTO)? Yes No If yes, please briefly describe Question Title * 13. Do you offer Enhanced Recovery after Surgery (ERAS) and/or other opioid-sparing perioperative analgesic regimens? Yes No Comments: Question Title * 14. Does your facility utilize e-prescribing for controlled substances (EPCS)? Yes No Comment: Question Title * 15. Does your facility have opioid prescribing guidelines for inpatient and/or ambulatory settings? Inpatient Ambulatory/Outpatient None of the Above Question Title * 16. If yes, are the guidelines above integrated into the EMR? Yes No Comment: Question Title * 17. Does your organization monitor prescribing patterns of opioids? Yes, at the prescriber level Yes, but not at the prescriber level No Question Title * 18. Please select which of the following you currently collect data: Morphine Milligram Equivalent (MMEs) per 1,000 inpatient days MMEs per 1,000 ED visits Percent of inpatients given an opioid on day of discharge Percent of ED patients discharged with a prescription for opioids Percent of patients with opioid prescriptions co-prescribed naloxone Percent of patients discharged with prescription for both opioids and benzodiazepines Percent of inpatients discharged with opioid prescription for more than three days Percent of patients requiring naloxone reversal while inpatient Other metrics, please describe Question Title * 19. Are there other additional opioid or pain-related initatives at your institution that you would like to mention? Question Title * 20. Does your facility screen ED patients for Substance Use Disorder (SUD) Yes No Question Title * 21. For ED patient with SUD, does your facility have a process to arrange or offer SUD treatment (e.g. MAT, Bridge Clinic, etc.)? Yes No Other (please specify) Question Title * 22. Does your facility have a program/policy/protocol for referring ED patients with complex pain management needs to pain management professionals or programs? Yes No Question Title * 23. Does your organization include any of the following treatments for Opioid Use Disorder (OUD) on your pharmacy formulary? Select all that apply Naltrexone/Vivitrol Buprenorphine/Suboxone Methadone None of the above Question Title * 24. Does your organization track adherence to House Bill 333? (HB 333 - Changes to prescribing rules in 2017, including limiting prescribing of Schedule II controlled substances to three days when used to treat acute pain.) Yes No Question Title * 25. Please describe in one word how you feel about the KY SOS project! Done
