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KY SOS Needs Assessment
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1.
Please enter your contact information
(Required.)
Name
Hospital
Email Address
Phone Number
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2.
Please indicate your hospital type
(Required.)
Acute Care
Critical Access
Inpatient Behavioral Health
Long-term Acute Care
Inpatient Rehab
Other (please specify)
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3.
Who is your accrediting body?
(Required.)
The Joint Commission
DNV
HFAP
CIHQ
Other (please specify)
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4.
Who is your EMR vendor?
(Required.)
EPIC
Meditech
Cerner
CPSI
Allscripts
None
Other (please specify)
5.
What version on EMR are you on?
6.
Please indicate if your Pharmacy System vendor is different from EMR
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7.
Does your organization have an individual responsible for Opioid Stewardship/Safe Opioid Use?
(Required.)
Yes
No
Comments:
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8.
Does your organization track metrics regarding opioid use and safety?
(Required.)
Yes
No
Other (please specify)
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9.
Has your facility implemented evidence-based non-pharmacologic pain management techniques such as aromatherapy, acupuncture, a "Comfort Menu," etc.?
(Required.)
Yes
No
If yes, please briefly explain
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10.
Do you have education in place regarding safe opioid use and pain management for providers?
(Required.)
Yes
No
Comments:
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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.)
(Required.)
Yes
No
Comments:
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12.
Does your facility have an ED-specific evidence-based protocol/program for non-opioid pain management such as Alternative to Opioids (ALTO)?
(Required.)
Yes
No
If yes, please briefly describe
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13.
Do you offer Enhanced Recovery after Surgery (ERAS) and/or other opioid-sparing perioperative analgesic regimens?
(Required.)
Yes
No
Comments:
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14.
Does your facility utilize e-prescribing for controlled substances (EPCS)?
(Required.)
Yes
No
Comment:
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15.
Does your facility have opioid prescribing guidelines for inpatient and/or ambulatory settings?
(Required.)
Inpatient
Ambulatory/Outpatient
None of the Above
16.
If yes, are the guidelines above integrated into the EMR?
Yes
No
Comment:
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17.
Does your organization monitor prescribing patterns of opioids?
(Required.)
Yes, at the prescriber level
Yes, but not at the prescriber level
No
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18.
Please select which of the following you currently collect data:
(Required.)
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
19.
Are there other additional opioid or pain-related initatives at your institution that you would like to mention?
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20.
Does your facility screen ED patients for Substance Use Disorder (SUD)
(Required.)
Yes
No
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21.
For ED patient with SUD, does your facility have a process to arrange or offer SUD treatment (e.g. MAT, Bridge Clinic, etc.)?
(Required.)
Yes
No
Other (please specify)
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22.
Does your facility have a program/policy/protocol for referring ED patients with complex pain management needs to pain management professionals or programs?
(Required.)
Yes
No
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23.
Does your organization include any of the following treatments for Opioid Use Disorder (OUD) on your pharmacy formulary? Select all that apply
(Required.)
Naltrexone/Vivitrol
Buprenorphine/Suboxone
Methadone
None of the above
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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.)
(Required.)
Yes
No
25.
Please describe in one word how you feel about the KY SOS project!
