- Email: [email protected]
Recidivism among ED super users after implementation of a pain protocol
584
Correspondence
Recidivism among ED super users after implementation of a pain protocol☆ Super users who frequent the emergency department (ED) with recurring pain complaints pose a number of challenges for ED staff. Our system defines super users as patients with greater than 20 ED visits annually. In 2013, there were 144 super users in our 2 hospital system, accounting for 4405 visits. The diagnosis of 'pain' has been shown to be a driver of ED use. The more frequently a patient visits the ED annually, the higher likelihood there is a diagnosis of pain (chronic, musculoskeletal, neuropathic, generalized, etc) [1]. The routine use of intravenous (IV) or intramuscular (IM) opiates for the management of chronic pain may actually worsen chronic pain syndromes [2]. Unfortunately, this is often the strategy ED providers adopt when caring for the recidivist patient with chronic pain. This highlights the need for successful chronic pain management strategies [3–7] within the super user population. Therefore, a restrictive pain protocol was implemented to minimize the overuse of the ED and potentially decrease cost and hospital admissions among a super user cohort. An interdisciplinary committee reviewed super user charts from our system (160 000 ED visits) to determine if pain and the routine administration of IV or IM opiates was the predominant factor driving ED use. The 14 patients with the highest ED visits were notified of their enrollment in the pain management protocol which recommended oral as opposed to IV and IM opiates for treatment of chronic pain (Figure). The study was a prospective cohort trial. To investigate protocol effectiveness, ED visits, ED charges, inpatient days, and total charges per patient per month were recorded. These data were divided into 3 distinct time periods: a “preprotocol” period lasting 16 months and 2 distinct “follow-up” periods of 6 months (short term or “follow-up 1”) followed by an additional 23 months (long term or “follow-up 2”). Differences in ED use, inpatient days, ED costs, and total costs over time were examined using a multivariate repeated measures analysis of variance. Protocol compliance was determined through measurement of the percentage of visits where patients received IV or IM hydromorphone and number of doses/visit for the preprotocol and follow-up periods. For cohort demographics, see Table 1. After implementation of our pain protocol, there was a statistically significant decrease in ED use and ED costs, but not inpatient days or total cost (Table 2). Protocol compliance measures also showed a statistically significant decrease for both study periods (Table 3). Our goal was to determine the impact of a restrictive pain protocol implemented among an ED super user cohort. Theoretically, the implementation of a consistent restrictive pain management strategy that discourages the use of parenteral medications for the treatment of chronic pain will dissuade patients from using the ED and encourage outpatient follow-up. Data at follow-ups 1 and 2 demonstrated a statistically significant reduction in ED visits per patient per month. When the 2 follow-up periods were compared, there was no degradation of effect. Through the entire duration of the protocol, ED charges decreased by more than $200 000. It therefore appears that our pain protocol was effective in establishing a long-term reduction of ED visits and charges. However, this did not translate into decreased inpatient days or total charges (Table 2). Use of ED is driven by a number of factors, and institutions are approaching the super user population in varied fashion. This study demonstrates that a targeted restrictive approach can
☆ No grant or source of support.
easily be implemented to reduce excessive ED visits in patients with recurrent pain. This study is limited by several factors. A small sample size, lack of a control group, unknown ED usage outside our system, and implementation within a single hospital system makes it difficult to extrapolate these results. Also, the administration of even small quantities of opiates may have encouraged ED usage. Finally, this study did not take into account the natural variability in the usage patterns among this patient population. Often super users with greater than 20 visits per year do not maintain their frequent usage patterns on a year-over-year basis [8]. The implementation of a restrictive pain protocol within our 2hospital system resulted in both a short- and long-term reduction in ED visits and total charges among a cohort of 14 super users with recurrent pain complaints. A statistically significant reduction in ED visits seen at 6 months was sustained during an additional 23-month follow-up period. This study suggests that a consistent restrictive approach to pain management in super users with pain as their primary complaint may dissuade against excessive ED use.
Brent Passarello, MD Zachary Levy, MD Brian Levine, MD⁎ Department of Emergency Medicine Christiana Care Health System, Newark, DE ⁎Corresponding author. Department of Emergency Medicine 4755 Ogletown-Stanton Road, Newark, DE 19718 Tel.:+1 302 733 3901 E-mail addresses: [email protected] [email protected] Mia Papas, PhD Department of Behavior Health and Nutrition College of Health Sciences, University of Delaware, Newark, DE E-mail address: [email protected] Neil Jasani, MD Department of Academic Affairs Christiana Care Health System, Newark, DE E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.12.039 References [1] Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med 2013;62(2):151–9. [2] Grover CA, Close RJ. Frequent users of the emergency department: risky business. West J Emerg Med 2009;10(3):193–4. [3] Grover CA, Close RJ, Villarreal K, Goldman LM. Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography. West J Emerg Med 2010;11(4):336–43. [4] Hansen GR. The drug-seeking patient in the emergency room. Emerg Med Clin North Am 2005;23(2):349–65. [5] Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA 2009;301(17):1771–8. [6] Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26(2):155–64. [7] Althaus F, Paroz S, Hugli O, Ghali WA, Daeppen JB. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg Med 2011;58(1):41–52 [e42]. [8] Peabody CR, Gruber PF, Menchine MD, McCollough M. The persistent emergency department superuser: defining a population to target limited resources. Ann Emerg Med 2013;62(4):S60.
Correspondence
Figure. Superuser Pain Protocol.
585
586
Correspondence
Table 1 Patient demographics Patient
Age (y)
Sex
Ethnicity
Most common pain complaint
Medical comorbidities
Psychiatric comorbidities
Illicit drug use
ETOH abuse
Homelessness
Insurance
1
58
M
African American
Abdominal pain
Bipolar
Yes
No
No
Medicaid
2
36
M
African American
None
Yes
No
No
3 4
47 48
M M
African American African American
HTN, chronic pancreatitis HIV, CAD, HTN, NIDDM
None Bipolar
Yes Yes
Yes Yes
No No
Medicare/ Medicaid Medicaid Medicaid
5 6
44 30
M M
White African American
Seizures SCD
None None
No Yes
Yes No
Yes No
Medicaid Medicaid
7 8
33 52
M M
White White
Back and leg pain— sickle cell crisis Abdominal pain Chest pain, dental pain Headache Back pain—sickle cell crisis Abdominal pain Abdominal pain
Chronic pancreatitis, HTN, ESRD, cardiomyopathy SCD, DVT
Depression Depression
Yes Yes
No No
Yes Yes
Medicaid Medicaid
9
64
M
African American
Abdominal pain
Crohn disease, PUD CAD, ESRD, NIDDM, chronic pancreatitis HTN, hepatitis C
Yes
Yes
No
Medicaid
10
59
F
African American
HTN
Yes
No
No
Medicaid
11
56
F
African American
Chest pain, extremity pain Chest pain
Depression/Bipolar disorder Personality disorder
HTN
Schizophrenia
Yes
No
No
12 13
54 52
F F
Hispanic White
No Yes
No No
No No
38
F
African American
HTN, angioedema COPD, HTN, NIDDM, DDD IDDM, CAD, PCOS
None None
14
Facial pain Back pain, abdominal pain Abdominal pain
Medicare/ Medicaid Medicaid Medicaid
Depression, borderline
No
No
No
Medicaid
CAD, coronary artery disease; CRI, chronic renal insufficiency; ESRD, end-stage renal disease; HTN, hypertension; PUD, peptic ulcer disease; SCD, sickle cell disease; PCOS, polycystic ovarian syndrome; NIDDM, non–insulin-dependent diabetes mellitus; HIV, human immunodeficiency virus.
Table 2 ED and inpatient use
ED visits/patient/mo Inpatient days/patient/mo Average ED charges/patient/mo Average total charges/patient/mo
Preprotocol, mean (SD)
Follow-up 1, mean (SD)
Follow-up 2, mean (SD)
Preprotocol vs follow-up 1, P value
Preprotocol vs follow-up 2, P value
Follow-up 1 vs follow-up 2, P value
3.98 (1.8) 1.4 (2.2) $1505 ($742) $6468 ($7416)
2.0 (1.7) 0.86 (1.1) $907 ($590) $3657 ($3205)
2.4 (1.8) 1.3 (1.7) $1015 ($785) $4987 ($5648)
.0003 .32 .007 .17
.005 .44 .038 .33
.63 .07 .67 .72
Table 3 Protocol compliance
Visits receiving hydromorphone Total visits during period % of visits receiving (IV/IM) hydromorphone P
Preprotocol
Follow-up 1
Follow-up 2
416 929 45%
30 189 16% b.001
89 758 12% b.001
The accuracy of sonographic confirmation of intraosseous line placement vs physical examination and syringe aspiration☆,☆☆
To the Editor, Intraosseous infusion (IO) is a critical resuscitation procedure, providing rapid and reliable vascular access in patients with difficult intravenous access or in time-critical situations. Correct placement of the IO needle can be confirmed in several ways including the needle standing firmly upright, aspiration of bone marrow, and the infusion of fluid without visible or palpable soft tissue swelling. In addition to the importance of ensuring intravascular delivery, there are complications of fluid extravasation from malpositioning, including compartment syndrome [1,2] and tissue necrosis [3,4]. ☆ This has not been presented or submitted elsewhere. ☆☆ There is no grant support involvement.
A 2007 study on the 8 tibias of 4 unembalmed adult human cadavers demonstrated that when compared with the flow of crystalloid by gravity into the intravenous tubing drip reservoir, power Doppler ultrasound could be used to determine flow within the IO space of the tibia with 100% sensitivity and specificity [5]. Another case series of 6 patients demonstrated that color Doppler ultrasound could be used to determine the location of IO devices that were placed by both manual insertion as well as automated placement [6]. Extravasated fluid, which disrupts the regular appearance of soft tissue, can be easily visualized with ultrasound. Interstitial fluid appears hypoechoic or anechoic, can separate tissue planes and thicken layers, or cause “cobblestoning,” when the subcutaneous fat lobules and fascial planes become surrounded by fluid. This allows ultrasound to potentially identify fluid extravasation from a misplaced IO line. A study was performed in an animal care facility on an approximately 20-kg live anesthetized Yorkshire swine. Institutional Animal Care and Use Committee approval was obtained. The primary investigator placed 8 IO lines; 4 needles were inserted with the needle tip in the bone marrow cavity, and 4 were placed malpositioned with the needle tip in the soft tissues.
Correspondence
Recidivism among ED super users after implementation of a pain protocol☆ Super users who frequent the emergency department (ED) with recurring pain complaints pose a number of challenges for ED staff. Our system defines super users as patients with greater than 20 ED visits annually. In 2013, there were 144 super users in our 2 hospital system, accounting for 4405 visits. The diagnosis of 'pain' has been shown to be a driver of ED use. The more frequently a patient visits the ED annually, the higher likelihood there is a diagnosis of pain (chronic, musculoskeletal, neuropathic, generalized, etc) [1]. The routine use of intravenous (IV) or intramuscular (IM) opiates for the management of chronic pain may actually worsen chronic pain syndromes [2]. Unfortunately, this is often the strategy ED providers adopt when caring for the recidivist patient with chronic pain. This highlights the need for successful chronic pain management strategies [3–7] within the super user population. Therefore, a restrictive pain protocol was implemented to minimize the overuse of the ED and potentially decrease cost and hospital admissions among a super user cohort. An interdisciplinary committee reviewed super user charts from our system (160 000 ED visits) to determine if pain and the routine administration of IV or IM opiates was the predominant factor driving ED use. The 14 patients with the highest ED visits were notified of their enrollment in the pain management protocol which recommended oral as opposed to IV and IM opiates for treatment of chronic pain (Figure). The study was a prospective cohort trial. To investigate protocol effectiveness, ED visits, ED charges, inpatient days, and total charges per patient per month were recorded. These data were divided into 3 distinct time periods: a “preprotocol” period lasting 16 months and 2 distinct “follow-up” periods of 6 months (short term or “follow-up 1”) followed by an additional 23 months (long term or “follow-up 2”). Differences in ED use, inpatient days, ED costs, and total costs over time were examined using a multivariate repeated measures analysis of variance. Protocol compliance was determined through measurement of the percentage of visits where patients received IV or IM hydromorphone and number of doses/visit for the preprotocol and follow-up periods. For cohort demographics, see Table 1. After implementation of our pain protocol, there was a statistically significant decrease in ED use and ED costs, but not inpatient days or total cost (Table 2). Protocol compliance measures also showed a statistically significant decrease for both study periods (Table 3). Our goal was to determine the impact of a restrictive pain protocol implemented among an ED super user cohort. Theoretically, the implementation of a consistent restrictive pain management strategy that discourages the use of parenteral medications for the treatment of chronic pain will dissuade patients from using the ED and encourage outpatient follow-up. Data at follow-ups 1 and 2 demonstrated a statistically significant reduction in ED visits per patient per month. When the 2 follow-up periods were compared, there was no degradation of effect. Through the entire duration of the protocol, ED charges decreased by more than $200 000. It therefore appears that our pain protocol was effective in establishing a long-term reduction of ED visits and charges. However, this did not translate into decreased inpatient days or total charges (Table 2). Use of ED is driven by a number of factors, and institutions are approaching the super user population in varied fashion. This study demonstrates that a targeted restrictive approach can
☆ No grant or source of support.
easily be implemented to reduce excessive ED visits in patients with recurrent pain. This study is limited by several factors. A small sample size, lack of a control group, unknown ED usage outside our system, and implementation within a single hospital system makes it difficult to extrapolate these results. Also, the administration of even small quantities of opiates may have encouraged ED usage. Finally, this study did not take into account the natural variability in the usage patterns among this patient population. Often super users with greater than 20 visits per year do not maintain their frequent usage patterns on a year-over-year basis [8]. The implementation of a restrictive pain protocol within our 2hospital system resulted in both a short- and long-term reduction in ED visits and total charges among a cohort of 14 super users with recurrent pain complaints. A statistically significant reduction in ED visits seen at 6 months was sustained during an additional 23-month follow-up period. This study suggests that a consistent restrictive approach to pain management in super users with pain as their primary complaint may dissuade against excessive ED use.
Brent Passarello, MD Zachary Levy, MD Brian Levine, MD⁎ Department of Emergency Medicine Christiana Care Health System, Newark, DE ⁎Corresponding author. Department of Emergency Medicine 4755 Ogletown-Stanton Road, Newark, DE 19718 Tel.:+1 302 733 3901 E-mail addresses: [email protected] [email protected] Mia Papas, PhD Department of Behavior Health and Nutrition College of Health Sciences, University of Delaware, Newark, DE E-mail address: [email protected] Neil Jasani, MD Department of Academic Affairs Christiana Care Health System, Newark, DE E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.12.039 References [1] Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med 2013;62(2):151–9. [2] Grover CA, Close RJ. Frequent users of the emergency department: risky business. West J Emerg Med 2009;10(3):193–4. [3] Grover CA, Close RJ, Villarreal K, Goldman LM. Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography. West J Emerg Med 2010;11(4):336–43. [4] Hansen GR. The drug-seeking patient in the emergency room. Emerg Med Clin North Am 2005;23(2):349–65. [5] Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA 2009;301(17):1771–8. [6] Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26(2):155–64. [7] Althaus F, Paroz S, Hugli O, Ghali WA, Daeppen JB. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg Med 2011;58(1):41–52 [e42]. [8] Peabody CR, Gruber PF, Menchine MD, McCollough M. The persistent emergency department superuser: defining a population to target limited resources. Ann Emerg Med 2013;62(4):S60.
Correspondence
Figure. Superuser Pain Protocol.
585
586
Correspondence
Table 1 Patient demographics Patient
Age (y)
Sex
Ethnicity
Most common pain complaint
Medical comorbidities
Psychiatric comorbidities
Illicit drug use
ETOH abuse
Homelessness
Insurance
1
58
M
African American
Abdominal pain
Bipolar
Yes
No
No
Medicaid
2
36
M
African American
None
Yes
No
No
3 4
47 48
M M
African American African American
HTN, chronic pancreatitis HIV, CAD, HTN, NIDDM
None Bipolar
Yes Yes
Yes Yes
No No
Medicare/ Medicaid Medicaid Medicaid
5 6
44 30
M M
White African American
Seizures SCD
None None
No Yes
Yes No
Yes No
Medicaid Medicaid
7 8
33 52
M M
White White
Back and leg pain— sickle cell crisis Abdominal pain Chest pain, dental pain Headache Back pain—sickle cell crisis Abdominal pain Abdominal pain
Chronic pancreatitis, HTN, ESRD, cardiomyopathy SCD, DVT
Depression Depression
Yes Yes
No No
Yes Yes
Medicaid Medicaid
9
64
M
African American
Abdominal pain
Crohn disease, PUD CAD, ESRD, NIDDM, chronic pancreatitis HTN, hepatitis C
Yes
Yes
No
Medicaid
10
59
F
African American
HTN
Yes
No
No
Medicaid
11
56
F
African American
Chest pain, extremity pain Chest pain
Depression/Bipolar disorder Personality disorder
HTN
Schizophrenia
Yes
No
No
12 13
54 52
F F
Hispanic White
No Yes
No No
No No
38
F
African American
HTN, angioedema COPD, HTN, NIDDM, DDD IDDM, CAD, PCOS
None None
14
Facial pain Back pain, abdominal pain Abdominal pain
Medicare/ Medicaid Medicaid Medicaid
Depression, borderline
No
No
No
Medicaid
CAD, coronary artery disease; CRI, chronic renal insufficiency; ESRD, end-stage renal disease; HTN, hypertension; PUD, peptic ulcer disease; SCD, sickle cell disease; PCOS, polycystic ovarian syndrome; NIDDM, non–insulin-dependent diabetes mellitus; HIV, human immunodeficiency virus.
Table 2 ED and inpatient use
ED visits/patient/mo Inpatient days/patient/mo Average ED charges/patient/mo Average total charges/patient/mo
Preprotocol, mean (SD)
Follow-up 1, mean (SD)
Follow-up 2, mean (SD)
Preprotocol vs follow-up 1, P value
Preprotocol vs follow-up 2, P value
Follow-up 1 vs follow-up 2, P value
3.98 (1.8) 1.4 (2.2) $1505 ($742) $6468 ($7416)
2.0 (1.7) 0.86 (1.1) $907 ($590) $3657 ($3205)
2.4 (1.8) 1.3 (1.7) $1015 ($785) $4987 ($5648)
.0003 .32 .007 .17
.005 .44 .038 .33
.63 .07 .67 .72
Table 3 Protocol compliance
Visits receiving hydromorphone Total visits during period % of visits receiving (IV/IM) hydromorphone P
Preprotocol
Follow-up 1
Follow-up 2
416 929 45%
30 189 16% b.001
89 758 12% b.001
The accuracy of sonographic confirmation of intraosseous line placement vs physical examination and syringe aspiration☆,☆☆
To the Editor, Intraosseous infusion (IO) is a critical resuscitation procedure, providing rapid and reliable vascular access in patients with difficult intravenous access or in time-critical situations. Correct placement of the IO needle can be confirmed in several ways including the needle standing firmly upright, aspiration of bone marrow, and the infusion of fluid without visible or palpable soft tissue swelling. In addition to the importance of ensuring intravascular delivery, there are complications of fluid extravasation from malpositioning, including compartment syndrome [1,2] and tissue necrosis [3,4]. ☆ This has not been presented or submitted elsewhere. ☆☆ There is no grant support involvement.
A 2007 study on the 8 tibias of 4 unembalmed adult human cadavers demonstrated that when compared with the flow of crystalloid by gravity into the intravenous tubing drip reservoir, power Doppler ultrasound could be used to determine flow within the IO space of the tibia with 100% sensitivity and specificity [5]. Another case series of 6 patients demonstrated that color Doppler ultrasound could be used to determine the location of IO devices that were placed by both manual insertion as well as automated placement [6]. Extravasated fluid, which disrupts the regular appearance of soft tissue, can be easily visualized with ultrasound. Interstitial fluid appears hypoechoic or anechoic, can separate tissue planes and thicken layers, or cause “cobblestoning,” when the subcutaneous fat lobules and fascial planes become surrounded by fluid. This allows ultrasound to potentially identify fluid extravasation from a misplaced IO line. A study was performed in an animal care facility on an approximately 20-kg live anesthetized Yorkshire swine. Institutional Animal Care and Use Committee approval was obtained. The primary investigator placed 8 IO lines; 4 needles were inserted with the needle tip in the bone marrow cavity, and 4 were placed malpositioned with the needle tip in the soft tissues.