- Email: [email protected]
229 A Phase 1, Open-Label, Randomized, Single Ascending Dose Study to Evaluate the Pharmacokinetics and Safety of Fentanyl Sublingual Spray and Fentanyl Citrate Intravenous in Adult Opioid Naive Subjects
Research Forum Abstracts
227
Split-flow Emergency Department Layout Improves Operational Flow and Decreases Process Variation
Lisankie M, Saint-hilaire R, Wein DA, Wilson JW, Cole M/Division of Emergency Medicine, Morsani College of Medicine, University of South Florida, TEAMHealth, Tampa General Hospital, Tampa, FL; Tampa General Hospital, Tampa, FL
Study Objective: In December 2013, our ED and hospital leadership endeavored to optimize our ED flow with an ultimate goal of enhancing patient safety. We employed a “lean” methodology, seeking opportunities to remove waste from the processes between patient arrival and medical screening exam. The percentage of patients that present to the ED but leave before a medical screening exam is completed (%LWBS) and the median door to provider time (D2PT) are both commonly used markers of the quality of emergency department operations and were used as objective markers of progress toward improved safety and patient flow. We invoked continuous PDSA cycles and meetings with both front-line workers and management to generate, analyze, and improve successive interventions to enhance departmental efficiency as measured by %LWBS and median D2PT. We describe identification of key metrics and their role in ED process redesign. Next, we focus on the process of identifying potential areas of improvement by using PDSA cycles to guide our intervention. We then detail the collective changes in departmental processes and capital resource utilization that comprise the “split-flow” model. Finally, we discuss the decrease in variation of measured processes and explain how that decreased variation represents important positive changes for our operational model. Methods: We used our electronic medical record (Epic) to capture information regarding %LWOT, D2PT, and ED patient volume between the dates of September 2013 and December 2015. We then compared monthly %LWOT, monthly median D2PT, and monthly ED patient volume before and after institution of a split-flow system using non-parametric tests of significance given the non-normal distribution of our data. In addition, we externally validated our successes by comparing our work to best practices available in published literature. Results: In September 2013, our %LWOT was 7.98%, D2PT was 123 minutes, and patient satisfaction scores were in the 5th percentile. By December 2015,%LWOT decreased to < 2%. We also significantly decreased D2PT in both the median (<45 minutes) and the percent of patients that are able to see a physician or provider in less than 70 minutes (with a goal of seeing 80% of patients in< 70 minutes and currently at 65%). Most importantly, we witnessed a significant decrease in unexplained variation in our intake and triage process with a marked decrease in standard deviation of D2PT from 140 minutes to 20 minutes. The combination of these approaches have helped us improve our patient satisfaction scores to the 83rd percentile. Conclusion: An intradepartmental and interdisciplinary approach using lean methodology was used to create sustainable improvements in our department’s operational quality, as demonstrated by improvement of the metrics of %LWBS and D2PT. Our success is reflected in a significant decrease not only in absolute values of these metrics, but perhaps more importantly, a markedly significant decrease in variance of %LWBS and D2PT after implementation of a split-flow model. Additionally, we are confident that our strategy of using interdisciplinary PDSA cycles has provided our department with a robust operational toolset for addressing future problems.
228
Implementation of Patient-Controlled Analgesia Creates Consistent Patient Expectations With No Negative Impacts on Operational Metrics or Patient Experience
Nappi A, Wilson J/Morsani College of Medicine, University of South Florida, TEAMHealth, Tampa General Hospital, Tampa, FL
Study Objective: Sickle cell disease (SCD) is a genetic, chronic blood disorder that effects 100,000 people in the United States1. The disease causes multiple medical problems including anemia, immune dysfunction, stroke, and frequent episodes of acute pain (sickling crises or vaso-occlusive crises (VOC)). There are no wellestablished, evidence-based treatment strategies for the management of VOCs and the practice guidelines that are available are not based on randomized controlled trials2. Treatment of VOC in the ED is difficult as there are no dependable clinical signs or laboratory tests to indicate the presence of pain due to VOC3. The pain reported by SCD patients does not correlate with changes in vital signs such as blood pressure, heart rate, and respiratory rate as is expected in other causes of pain. The annual cost of ED visits alone is approximately $356 million. There is a large cost associated with
Volume 68, no. 4s : October 2016
admission to the hospital for acute sickle pain that could theoretically be decreased if acute pain is able to be efficiently treated in the ED. Developing a safe, efficient and effective protocol for management of acute pain crises in the ED is important to improve patient care, expedite ED throughput and decrease health care costs. EDs that treat large volumes of SCD patients must balance length of stay, hospital admission rates, medical management, and patient satisfaction. PCA has been shown to have similar safety profiles and efficacy in pain control compared to bolus opiates. It has been shown that similar levels of pain control can be obtained with lower total doses of opiates in patients treat with PCA5. It has also been shown that SCD patients prefer PCA over scheduled doses of opiate analgesia Methods: In late 2015 our emergency department established a new protocol in conjunction with local hematologists for management of sickle cell patients presenting with VOC. In this analysis, we describe the PCA protocol for SCD patients and examine the relationship between patient experience, provider experience, ED length of stay (LOS), hospital length of stay, and overall admission rate before and after intervention (often in the same patient if a super-utilizer of the department). A retrospective chart review was performed on data prior to the implementation of the protocol and was compared to data after implementation of the protocol. Outcomes measured were proportion of patients receiving PCA in the ED, proportion of patients discharged from the ED vs proportion admitted to the hospital, time from arrival to first dose of opiate, improvement in pain, total time to disposition in emergency department, and length of stay for admitted patients. Results: Implementation of a standardized PCA dosing protocol has decreased variability across providers and has had no negative impact on patient satisfaction or ED LOS. Overall, admission rates may be decreased compared to pre-implementation and overall hospital LOS may be shorter. Conclusions: A standardized approach to analgesic dosing using a PCA does not negatively impact patient satisfaction and also allows patients to have realistic and consistent expectations to their ED experience.
229
A Phase 1, Open-Label, Randomized, Single Ascending Dose Study to Evaluate the Pharmacokinetics and Safety of Fentanyl Sublingual Spray and Fentanyl Citrate Intravenous in Adult Opioid Naive Subjects
Rauck RL, Oh DA, Parikh N, Smith CC, Koch C, Singla N, Yu J, Nalamachu S, Vetticaden S/Carolinas Pain Institute, Winston-Salem, NC; Insys Therapeutics, Chandler, AZ; Lotus Clinical Research, LLC, Pasadena, CA; Pain Management Institute, Overland Park, KS
Study Objective: To investigate the pharmacokinetics and safety of a novel use of fentanyl sublingual spray, currently indicated for the management of breakthrough cancer pain in adult opioid tolerant subjects, in adult opioid naïve subjects. Methods: A Phase 1, open-label, randomized, single ascending dose study in healthy opioid naïve subjects at a single study center designed to assess the pharmacokinetics and safety of single dose of fentanyl sublingual spray or fentanyl citrate intravenous. Five dose cohorts with 10 subjects in each were randomized. Eight subjects in each cohort received single dose of fentanyl sublingual spray (100 mcg, 200 mcg, 400 mcg, 600 mcg, or 800 mcg) and 2 subjects in each cohort received fentanyl citrate intravenous (50 mcg). All subjects fasted 10 hours pre and 4 hour post dose and were monitored in a closed unit with continuous pulse-oximetry, heart rate, respiratory rate, temperature, capnography, and blood pressure monitoring. Vital signs (blood pressure, pulse rate, respiration rate, and temperature) were measured 0 (pre-dose), 15, 30, 40 and 60 minutes post dose and every 2 hours until discharge. Respiratory function parameters (respiratory rate, pulse oximetry, capnography) were measured 0 (pre-dose), and at frequent intervals over a period of 24 hours post dose. Follow-up occurred 7 2 days after subjects’ discharge to assess adverse events. Dosing started at the lowest dose level. Upon completion of each cohort dosing proceeded to the next higher dose level upon recommendation of a safety review committee. Blood samples were collected at 17 specified time points and analyzed for plasma concentration of fentanyl by a validated LC/MS method. Results: Fifty subjects, aged 19 to 53 years with mean body mass index of 25.86 kg/m2 (18.6 – 31.5 kg/m2), met the study criterion. Based on mean AUC0-inf values, absolute bioavailability of fentanyl sublingual spray ranged from 37.7% to 80.5% with peak (Cmax) and total (AUC0-t and AUC0-inf) fentanyl exposures increased in linear but slightly greater than dose-proportional manner (Figure 1). All treatments were generally well tolerated (Table 1). No serious adverse events were observed. Hypoxia requiring nasal cannula oxygenation was observed at 600 mcg and 800 mcg doses.
Annals of Emergency Medicine S89
Research Forum Abstracts Conclusion: Overall, a single dose administration of fentanyl sublingual spray at doses ranging from 100 mcg to 800 mcg was generally well tolerated in healthy opiodnaive subjects. A single dose up to 400 mcg may be safely administered without the need for supplemental oxygenation in a healthy opioid-naive population in an appropriately monitored and equipped setting.
visits were determined one year prior, and for five consecutive years following care plan, based on letter posting date. Exclusion criteria: unclaimed letter, incomplete data, or non-drug seeking care plan. Statistics: Two-tailed Wilcoxon signed-rank test with significance of p<0.05. This study was approved by our IRB. Results: Sixty patients were analyzed. Exclusion criteria: incomplete data (N¼3), did not receive letter (N¼2), and non-drug seeking care plan (N¼3). This left 52 patients for analysis. Mean age was 38 years, (IQR-27-46 yrs). Male sex comprised 48% of sample population. Overall, there were 425 visits for study patients the first year and 26 during the fifth year. Mean yearly ED visits prior to care plan initiation were 8.2 (95% CI 6.7-9.7). Mean visits following implementation of care plan were: one year, 2.5 (95% CI 1.6-3.3); two years, 1.5 (95% CI 0.9-2.2); three years, 1.1 (95 % CI 0.2-2.0); four years, 0.8 (95% CI 0.4-1.3); five years, 0.5 (95% CI 0.2-0.8) (p¼<0.0001). Overall, five-year reduction in visits was by 7.7 (p¼<0.0001). The mean reduction in visits one year following implementation was by 5.3 (p¼<0.0001). A significant reduction in visits occurred between one year and two years following implementation with a mean reduction of 0.9 (p¼0.01) and between two years and three years with a mean reduction of 0.4 (p¼0.02). There was no significant reduction in number of visits from three to four years with a mean reduction of 0.3 (p¼0.88), or four to five years with a mean reduction of 0.3 (p¼0.14). Conclusion: Care plans are effective as a long-term means of reducing ED visits in patients with drug-seeking behavior. ED visits were significantly decreased on an annual basis in three consecutive years following implementation of a care plan.
231
Are Non-pharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department?
Sakamoto JT, Burrell HA, Eucker SA/Duke University School of Medicine, Durham, NC
230
Reduction in Emergency Department Visits After Implementing a Care Plan in Patients With Drug-Seeking Behavior: Five-Year Analysis
Rapp KJ III, Fiesseler F, Salo D, Walsh B, Riggs R/Morristown Medical Center, Morristown, NJ; Robert Wood Johnson Medical School, New Brunswick, NJ
Study Objectives: Patients with drug seeking behavior can be both labor and resource-intensive to the emergency department (ED). We determined the change in number of ED visits for five consecutive years following a care plan initiation for individuals who displayed drug seeking behavior. Methods: A retrospective, cohort observational study. Location: a suburban teaching hospital with an annual census of 80,000 patients. A care plan was initiated for patients flagged by ED staff as concerning for drug-seeking behavior. An ED administrator then collaborated with the patient’s primary doctor. If the primary doctor concurred, a plan of care was initiated, which typically restricted narcotic administration. Patients subsequently received a certified letter regarding their plan. Copies of the letters were placed alphabetically by name in binders residing in the ED, and charts were flagged when patients presented to the ED. The first 20 patients in each of 3 binders were included in the study population (N¼60). The numbers of ED
S90 Annals of Emergency Medicine
Study Objectives: Pain is a common complaint in the emergency department (ED) and continues to present challenges for effective and efficient management. Treatment of pain in the ED consists mainly of pharmacologic interventions, namely nonsteroidal anti-inflammatory drugs (NSAIDS) and opioids. However, with recent research questioning the overuse of opioids, it is becoming more important to explore alternative methods for controlling pain. While non-pharmacologic interventions have not been part of mainstream ED pain treatment, they may have the potential to reduce the use of pharmacologic interventions. This systematic review aims to identify all studies that examine the use of non-pharmacologic interventions for pain management among adults in the ED, to assess what strategies have been attempted and/or implemented, and to assess the efficacy of the different categories of non-pharmacologic pain interventions in the ED. We hypothesize that non-pharmacologic interventions will demonstrate an overall effective pain reduction in adult patients in the ED. Methods: This systematic review is reported in accordance with the PRISMA Statement is registered in the PROSPERO database under the number CRD42015029671. The search was comprised of the MeSH terms “Complementary Therapies,” “Physical Therapy Modalities,” “Sociological Factors,” “Psychology, Applied,” “Psychotherapy,” “Self-Help Groups,” “Nutrition Therapy,” and their respective entry terms. Articles mentioning any one of a number of different non-pharmacologic interventions targeted at reducing pain in adults (18 years old) in the ED or at discharge from the ED were considered. The primary outcome was immediate and/or short-term follow-up measures of patient pain level. The secondary outcomes were measures of quality of life. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, time-series, and systematic chart reviews published in full in peer-reviewed journals were considered for this systematic review. First, studies clearly not meeting inclusion criteria were excluded based on title and abstract. The remaining studies were assessed based on full text articles and selected if they met the inclusion criteria. All screens were performed by two separate reviewers with discrepancies settled by a third moderator. Following this initial search and screen, we manually searched the references and performed a citation analysis of the included studies to identify any additional articles that met inclusion criteria. Results: There are several non-pharmacologic interventions that have demonstrated effectiveness for reducing pain in the ED. These include acupuncture, aromatherapy, guided imagery, music, and cognitive behavioral therapy. For musculoskeletal injuries, exercise therapy, physical therapy, osteopathic manipulative treatment, homeopathy, and transcutaneous electrical stimulation were effective. Conclusion: There are non-pharmacologic interventions that are effective for reducing pain in the ED. Additional research should be conducted regarding their effective implementation in the ED, as well as their effectiveness compared to or in combination with pharmacologic interventions in reducing acute and chronic pain, reducing readmission to the ED, and improving quality of life.
Volume 68, no. 4s : October 2016
227
Split-flow Emergency Department Layout Improves Operational Flow and Decreases Process Variation
Lisankie M, Saint-hilaire R, Wein DA, Wilson JW, Cole M/Division of Emergency Medicine, Morsani College of Medicine, University of South Florida, TEAMHealth, Tampa General Hospital, Tampa, FL; Tampa General Hospital, Tampa, FL
Study Objective: In December 2013, our ED and hospital leadership endeavored to optimize our ED flow with an ultimate goal of enhancing patient safety. We employed a “lean” methodology, seeking opportunities to remove waste from the processes between patient arrival and medical screening exam. The percentage of patients that present to the ED but leave before a medical screening exam is completed (%LWBS) and the median door to provider time (D2PT) are both commonly used markers of the quality of emergency department operations and were used as objective markers of progress toward improved safety and patient flow. We invoked continuous PDSA cycles and meetings with both front-line workers and management to generate, analyze, and improve successive interventions to enhance departmental efficiency as measured by %LWBS and median D2PT. We describe identification of key metrics and their role in ED process redesign. Next, we focus on the process of identifying potential areas of improvement by using PDSA cycles to guide our intervention. We then detail the collective changes in departmental processes and capital resource utilization that comprise the “split-flow” model. Finally, we discuss the decrease in variation of measured processes and explain how that decreased variation represents important positive changes for our operational model. Methods: We used our electronic medical record (Epic) to capture information regarding %LWOT, D2PT, and ED patient volume between the dates of September 2013 and December 2015. We then compared monthly %LWOT, monthly median D2PT, and monthly ED patient volume before and after institution of a split-flow system using non-parametric tests of significance given the non-normal distribution of our data. In addition, we externally validated our successes by comparing our work to best practices available in published literature. Results: In September 2013, our %LWOT was 7.98%, D2PT was 123 minutes, and patient satisfaction scores were in the 5th percentile. By December 2015,%LWOT decreased to < 2%. We also significantly decreased D2PT in both the median (<45 minutes) and the percent of patients that are able to see a physician or provider in less than 70 minutes (with a goal of seeing 80% of patients in< 70 minutes and currently at 65%). Most importantly, we witnessed a significant decrease in unexplained variation in our intake and triage process with a marked decrease in standard deviation of D2PT from 140 minutes to 20 minutes. The combination of these approaches have helped us improve our patient satisfaction scores to the 83rd percentile. Conclusion: An intradepartmental and interdisciplinary approach using lean methodology was used to create sustainable improvements in our department’s operational quality, as demonstrated by improvement of the metrics of %LWBS and D2PT. Our success is reflected in a significant decrease not only in absolute values of these metrics, but perhaps more importantly, a markedly significant decrease in variance of %LWBS and D2PT after implementation of a split-flow model. Additionally, we are confident that our strategy of using interdisciplinary PDSA cycles has provided our department with a robust operational toolset for addressing future problems.
228
Implementation of Patient-Controlled Analgesia Creates Consistent Patient Expectations With No Negative Impacts on Operational Metrics or Patient Experience
Nappi A, Wilson J/Morsani College of Medicine, University of South Florida, TEAMHealth, Tampa General Hospital, Tampa, FL
Study Objective: Sickle cell disease (SCD) is a genetic, chronic blood disorder that effects 100,000 people in the United States1. The disease causes multiple medical problems including anemia, immune dysfunction, stroke, and frequent episodes of acute pain (sickling crises or vaso-occlusive crises (VOC)). There are no wellestablished, evidence-based treatment strategies for the management of VOCs and the practice guidelines that are available are not based on randomized controlled trials2. Treatment of VOC in the ED is difficult as there are no dependable clinical signs or laboratory tests to indicate the presence of pain due to VOC3. The pain reported by SCD patients does not correlate with changes in vital signs such as blood pressure, heart rate, and respiratory rate as is expected in other causes of pain. The annual cost of ED visits alone is approximately $356 million. There is a large cost associated with
Volume 68, no. 4s : October 2016
admission to the hospital for acute sickle pain that could theoretically be decreased if acute pain is able to be efficiently treated in the ED. Developing a safe, efficient and effective protocol for management of acute pain crises in the ED is important to improve patient care, expedite ED throughput and decrease health care costs. EDs that treat large volumes of SCD patients must balance length of stay, hospital admission rates, medical management, and patient satisfaction. PCA has been shown to have similar safety profiles and efficacy in pain control compared to bolus opiates. It has been shown that similar levels of pain control can be obtained with lower total doses of opiates in patients treat with PCA5. It has also been shown that SCD patients prefer PCA over scheduled doses of opiate analgesia Methods: In late 2015 our emergency department established a new protocol in conjunction with local hematologists for management of sickle cell patients presenting with VOC. In this analysis, we describe the PCA protocol for SCD patients and examine the relationship between patient experience, provider experience, ED length of stay (LOS), hospital length of stay, and overall admission rate before and after intervention (often in the same patient if a super-utilizer of the department). A retrospective chart review was performed on data prior to the implementation of the protocol and was compared to data after implementation of the protocol. Outcomes measured were proportion of patients receiving PCA in the ED, proportion of patients discharged from the ED vs proportion admitted to the hospital, time from arrival to first dose of opiate, improvement in pain, total time to disposition in emergency department, and length of stay for admitted patients. Results: Implementation of a standardized PCA dosing protocol has decreased variability across providers and has had no negative impact on patient satisfaction or ED LOS. Overall, admission rates may be decreased compared to pre-implementation and overall hospital LOS may be shorter. Conclusions: A standardized approach to analgesic dosing using a PCA does not negatively impact patient satisfaction and also allows patients to have realistic and consistent expectations to their ED experience.
229
A Phase 1, Open-Label, Randomized, Single Ascending Dose Study to Evaluate the Pharmacokinetics and Safety of Fentanyl Sublingual Spray and Fentanyl Citrate Intravenous in Adult Opioid Naive Subjects
Rauck RL, Oh DA, Parikh N, Smith CC, Koch C, Singla N, Yu J, Nalamachu S, Vetticaden S/Carolinas Pain Institute, Winston-Salem, NC; Insys Therapeutics, Chandler, AZ; Lotus Clinical Research, LLC, Pasadena, CA; Pain Management Institute, Overland Park, KS
Study Objective: To investigate the pharmacokinetics and safety of a novel use of fentanyl sublingual spray, currently indicated for the management of breakthrough cancer pain in adult opioid tolerant subjects, in adult opioid naïve subjects. Methods: A Phase 1, open-label, randomized, single ascending dose study in healthy opioid naïve subjects at a single study center designed to assess the pharmacokinetics and safety of single dose of fentanyl sublingual spray or fentanyl citrate intravenous. Five dose cohorts with 10 subjects in each were randomized. Eight subjects in each cohort received single dose of fentanyl sublingual spray (100 mcg, 200 mcg, 400 mcg, 600 mcg, or 800 mcg) and 2 subjects in each cohort received fentanyl citrate intravenous (50 mcg). All subjects fasted 10 hours pre and 4 hour post dose and were monitored in a closed unit with continuous pulse-oximetry, heart rate, respiratory rate, temperature, capnography, and blood pressure monitoring. Vital signs (blood pressure, pulse rate, respiration rate, and temperature) were measured 0 (pre-dose), 15, 30, 40 and 60 minutes post dose and every 2 hours until discharge. Respiratory function parameters (respiratory rate, pulse oximetry, capnography) were measured 0 (pre-dose), and at frequent intervals over a period of 24 hours post dose. Follow-up occurred 7 2 days after subjects’ discharge to assess adverse events. Dosing started at the lowest dose level. Upon completion of each cohort dosing proceeded to the next higher dose level upon recommendation of a safety review committee. Blood samples were collected at 17 specified time points and analyzed for plasma concentration of fentanyl by a validated LC/MS method. Results: Fifty subjects, aged 19 to 53 years with mean body mass index of 25.86 kg/m2 (18.6 – 31.5 kg/m2), met the study criterion. Based on mean AUC0-inf values, absolute bioavailability of fentanyl sublingual spray ranged from 37.7% to 80.5% with peak (Cmax) and total (AUC0-t and AUC0-inf) fentanyl exposures increased in linear but slightly greater than dose-proportional manner (Figure 1). All treatments were generally well tolerated (Table 1). No serious adverse events were observed. Hypoxia requiring nasal cannula oxygenation was observed at 600 mcg and 800 mcg doses.
Annals of Emergency Medicine S89
Research Forum Abstracts Conclusion: Overall, a single dose administration of fentanyl sublingual spray at doses ranging from 100 mcg to 800 mcg was generally well tolerated in healthy opiodnaive subjects. A single dose up to 400 mcg may be safely administered without the need for supplemental oxygenation in a healthy opioid-naive population in an appropriately monitored and equipped setting.
visits were determined one year prior, and for five consecutive years following care plan, based on letter posting date. Exclusion criteria: unclaimed letter, incomplete data, or non-drug seeking care plan. Statistics: Two-tailed Wilcoxon signed-rank test with significance of p<0.05. This study was approved by our IRB. Results: Sixty patients were analyzed. Exclusion criteria: incomplete data (N¼3), did not receive letter (N¼2), and non-drug seeking care plan (N¼3). This left 52 patients for analysis. Mean age was 38 years, (IQR-27-46 yrs). Male sex comprised 48% of sample population. Overall, there were 425 visits for study patients the first year and 26 during the fifth year. Mean yearly ED visits prior to care plan initiation were 8.2 (95% CI 6.7-9.7). Mean visits following implementation of care plan were: one year, 2.5 (95% CI 1.6-3.3); two years, 1.5 (95% CI 0.9-2.2); three years, 1.1 (95 % CI 0.2-2.0); four years, 0.8 (95% CI 0.4-1.3); five years, 0.5 (95% CI 0.2-0.8) (p¼<0.0001). Overall, five-year reduction in visits was by 7.7 (p¼<0.0001). The mean reduction in visits one year following implementation was by 5.3 (p¼<0.0001). A significant reduction in visits occurred between one year and two years following implementation with a mean reduction of 0.9 (p¼0.01) and between two years and three years with a mean reduction of 0.4 (p¼0.02). There was no significant reduction in number of visits from three to four years with a mean reduction of 0.3 (p¼0.88), or four to five years with a mean reduction of 0.3 (p¼0.14). Conclusion: Care plans are effective as a long-term means of reducing ED visits in patients with drug-seeking behavior. ED visits were significantly decreased on an annual basis in three consecutive years following implementation of a care plan.
231
Are Non-pharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department?
Sakamoto JT, Burrell HA, Eucker SA/Duke University School of Medicine, Durham, NC
230
Reduction in Emergency Department Visits After Implementing a Care Plan in Patients With Drug-Seeking Behavior: Five-Year Analysis
Rapp KJ III, Fiesseler F, Salo D, Walsh B, Riggs R/Morristown Medical Center, Morristown, NJ; Robert Wood Johnson Medical School, New Brunswick, NJ
Study Objectives: Patients with drug seeking behavior can be both labor and resource-intensive to the emergency department (ED). We determined the change in number of ED visits for five consecutive years following a care plan initiation for individuals who displayed drug seeking behavior. Methods: A retrospective, cohort observational study. Location: a suburban teaching hospital with an annual census of 80,000 patients. A care plan was initiated for patients flagged by ED staff as concerning for drug-seeking behavior. An ED administrator then collaborated with the patient’s primary doctor. If the primary doctor concurred, a plan of care was initiated, which typically restricted narcotic administration. Patients subsequently received a certified letter regarding their plan. Copies of the letters were placed alphabetically by name in binders residing in the ED, and charts were flagged when patients presented to the ED. The first 20 patients in each of 3 binders were included in the study population (N¼60). The numbers of ED
S90 Annals of Emergency Medicine
Study Objectives: Pain is a common complaint in the emergency department (ED) and continues to present challenges for effective and efficient management. Treatment of pain in the ED consists mainly of pharmacologic interventions, namely nonsteroidal anti-inflammatory drugs (NSAIDS) and opioids. However, with recent research questioning the overuse of opioids, it is becoming more important to explore alternative methods for controlling pain. While non-pharmacologic interventions have not been part of mainstream ED pain treatment, they may have the potential to reduce the use of pharmacologic interventions. This systematic review aims to identify all studies that examine the use of non-pharmacologic interventions for pain management among adults in the ED, to assess what strategies have been attempted and/or implemented, and to assess the efficacy of the different categories of non-pharmacologic pain interventions in the ED. We hypothesize that non-pharmacologic interventions will demonstrate an overall effective pain reduction in adult patients in the ED. Methods: This systematic review is reported in accordance with the PRISMA Statement is registered in the PROSPERO database under the number CRD42015029671. The search was comprised of the MeSH terms “Complementary Therapies,” “Physical Therapy Modalities,” “Sociological Factors,” “Psychology, Applied,” “Psychotherapy,” “Self-Help Groups,” “Nutrition Therapy,” and their respective entry terms. Articles mentioning any one of a number of different non-pharmacologic interventions targeted at reducing pain in adults (18 years old) in the ED or at discharge from the ED were considered. The primary outcome was immediate and/or short-term follow-up measures of patient pain level. The secondary outcomes were measures of quality of life. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, time-series, and systematic chart reviews published in full in peer-reviewed journals were considered for this systematic review. First, studies clearly not meeting inclusion criteria were excluded based on title and abstract. The remaining studies were assessed based on full text articles and selected if they met the inclusion criteria. All screens were performed by two separate reviewers with discrepancies settled by a third moderator. Following this initial search and screen, we manually searched the references and performed a citation analysis of the included studies to identify any additional articles that met inclusion criteria. Results: There are several non-pharmacologic interventions that have demonstrated effectiveness for reducing pain in the ED. These include acupuncture, aromatherapy, guided imagery, music, and cognitive behavioral therapy. For musculoskeletal injuries, exercise therapy, physical therapy, osteopathic manipulative treatment, homeopathy, and transcutaneous electrical stimulation were effective. Conclusion: There are non-pharmacologic interventions that are effective for reducing pain in the ED. Additional research should be conducted regarding their effective implementation in the ED, as well as their effectiveness compared to or in combination with pharmacologic interventions in reducing acute and chronic pain, reducing readmission to the ED, and improving quality of life.
Volume 68, no. 4s : October 2016