Emergency physicians are frequently caught between the desire to relieve suffering and the need to protect patients from the destructive consequences of opioid misuse and addiction. Here's how the ED team at Northwest Community Hospital in Arlington Heights, Ill., works to ensure chronic pain patients have access to the best possible pain care.
The following is based on a poster presented at Vituity's 2015 conference.
Emergency providers at Northwest Community Hospital (NCH) often encounter patients who utilize the ED to manage their chronic pain. During exacerbations, many of these patients present to the department seeking narcotic medications like hydromorphone, hydrocodone, oxycodone and morphine.
Unfortunately, ED personnel are not in a position to monitor patients' pain and functioning over time and adjust medications accordingly. Lack of care continuity increases the risk of adverse effects, including dependence and addiction. For these reasons, best practices suggest that patients' chronic pain be managed by a single provider.
Inspired by an initiative at his previous hospital, emergency physician Scott Samlan, MD, proposed a proactive, compassionate approach to treating chronic pain in the ED. He worked with the ED team, case management, social workers, risk management and the hospital's patient advocate to design and implement a new pathway to assist patients who relied on the ED to manage their pain.
The Complex Pain Program received widespread support at NCH and was initiated in January 2015.
The goal of the Complex Pain Program is to promote both quality of life and safety for patients with chronic pain through improved management and care coordination. Central to this effort is an ED plan of care developed in consultation with the patient's primary care provider (PCP) and pain management provider.
When the Complex Pain Committee determines that a patient with chronic pain displays high-risk behaviors, the patient is given the option to enroll in the program. Participants are allowed two ED visits per month for chronic pain exacerbation and receive narcotics on those visits. At-risk patients who choose not to enroll are no longer given opioids in the ED (though other care is given).
Steps to the process include:
Patient selection. Concerned nurses and providers may anonymously nominate a patient for review by the Complex Pain Committee. This is done by placing a sticker in one of the "complex patient binders" located at triage or the physician workstation. (Binders are secured to protect patient privacy.)
Committee review. The providers of the Complex Pain Committee review the charts and prescription history of referred patients. Patients may be selected for the Complex Pain Program if they demonstrate:
- Documented chronic pain issues
- ED visits for exacerbation in the past six months
- Narcotics prescriptions written by different physicians (as identified through the Illinois controlled substance database.)
If a patient is determined to be at-risk, the committee sends a registered letter informing them of the intention to create a care plan and the reasons for this action. The letter also spells out the steps the patient needs to take in order to continue receiving opioid medications in the ED. (Patients are assured that the ED will always be available to them for emergencies.)
Nominated patients are also flagged in the EHR. If these patients return to the ED, emergency providers use scripted language to inform them of the committee's decision and the patient's responsibilities.
PCP designation. Within 30 days, the patient must name a PCP of record who will manage their chronic pain. (An ED social worker assists them as needed with identifying appropriate providers and making appointments.)
Care plan. In consultation with the patient's PCP and pain management physician (if applicable), the committee physician drafts a care plan that specifies:
- Current providers
- Current medications
- Breakthrough medications the patient has at home that should be tried before coming to the ED
- Medications, doses, routes and other treatments the patient will receive in the ED when presenting with chronic pain exacerbation
- Additional options available if the patient completes the plan in the ED
- What (if any) prescriptions and amounts the patient will be discharged home with after a visit for exacerbation of chronic pain
Once approved by the committee, the care plan is added to the patient's chart and also placed in the program binder. Thereafter, the plan is reviewed annually or upon request of the patient or PCP.
Emergency department visits. When a participating patient presents to the ED with chronic pain exacerbation, the triage nurse prints the care plan for the provider team.
Participants who visit the ED for exacerbation of chronic pain must inform their PCP within 72 hours to ensure proper follow-up and communicate any changes in medications.
To date, 33 patients have enrolled in the NCH Complex Pain Program.
These patients made an average of 17.8 visits to the ED in 2014. If year-to-date data is annualized to the end of 2015, this number will drop to 7.8 visits per patient, representing a 56 percent reduction in this population's ED utilization.
Having a predetermined care plan in place has also reduced the number of tests and medications the participating patients receive in the ED. As a result, average ED length of stay (LOS) for this group has declined 14.7 percent from 3.4 hours to 2.9 (when data is annualized through 2015):
In addition, CT utilization among the participating patients declined by more than one-third (when data is annualized through 2015):
Conclusions and Updates
Since this poster was presented in September 2015, ED utilization, CT utilization and LOS have continued to drop among patients enrolled in the Complex Pain Program. Several of the participating patients have reported a marked improvement in their quality of life and reduction in narcotic-related side effects.
One imperative of running a Complex Pain Program is to keep the focus on compassion. It's important for patients and team members to understand that none of what we do is intended to be punitive. On the contrary, the program is designed to help our patients access the best possible chronic pain care. We hope that this intervention can represent the first step toward a healthier, more comfortable life for this vulnerable population.