Chronic Pain in the Emergency Department: A Pilot Interdisciplinary Program Demonstrates Improvements in Disability, Psychosocial Function, and Healthcare Utilization

Objective. To evaluate the feasibility of an individualized interdisciplinary chronic pain care plan as an intervention to reduce emergency department (ED) visits and improve clinical outcomes among patients who frequented the ED with concerns related to chronic pain. Methods. A prospective cohort design was used in an urban tertiary care hospital. As a pilot program, fourteen patients with chronic pain who frequented the ED (i.e., >12 ED visits within the last year, of which ≥50% were for chronic pain) received a rapid interdisciplinary assessment and individualized care plan that was uploaded to an electronic medical record system (EMR) accessible to the ED and patient’s primary care provider. Patients were assessed at baseline and every three months over a 12-month period. Primary outcomes were self-reported pain and function assessed using psychometrically valid scales. Results. Nine patients completed 12-month follow-up. Missing data and attrition were handled using multiple imputation. Patients who received the intervention reported clinically significant improvements in pain, function, ED visits, symptoms of depression, pain catastrophizing, sleep, health-related quality of life, and risk of future aberrant opioid use. Discussion. Individualized care plans uploaded to an EMR may be worth implementing in hospital EDs for high frequency visitors with chronic pain.

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P097: The characteristics and effectiveness of interventions targeting chronic pain patients in the emergency department: A systematic review and meta-analysis

CJEM ◽

10.1017/cem.2019.288 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S98-S99

Author(s):

C. O'Rielly ◽

L. Sutherland ◽

C. Wong

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Chronic Pain ◽

Meta Analysis ◽

Grey Literature ◽

Opioid Prescription ◽

Care Plans ◽

Individualized Care ◽

High Utilizers ◽

Ed Visits

Introduction: Patients with chronic non-cancer pain (CNCP) and opioid-use disorders make up a category of patients who present a challenge to emergency department (ED) providers and healthcare administrators. Their conditions predispose them to frequent ED utilization. This problem has been compounded by a worsening opioid epidemic that has rendered clinicians apprehensive about how they approach pain care. A systematic review has not yet been performed to inform the management of CNCP patients in the ED. As such, the purpose of this project was to identify and describe the effectiveness of interventions to reduce ED visits for high-utilizers with CNCP. Methods: Included participants were high-utilizers presenting with CNCP. All study designs were eligible for inclusion if they examined an intervention aimed at reducing ED utilization. The outcomes of interest were the number of ED visits as well as the amount and type of opioids prescribed in the ED and after discharge. We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, Web of Science, and the grey literature from inception to June 16, 2018. Two independent investigators assessed articles for inclusion following PRISMA guidelines. Risk of bias will be assessed using the Cochrane ROBINS-I and RoB 2 tools for non-randomized and randomized trials, respectively. Results: Following review, 14 of the 5,018 identified articles were included for analysis. These articles assessed a total of 1,670 patients from both urban and rural settings. Interventions included pain protocols or policies (n = 5), individualized care plans (n = 5), ED care coordination (n = 2), a chronic pain management pathway (n = 1), and a behavioural health intervention (n = 1). Intervention effects trended towards the reduction of both ED visits and opioid prescriptions. The meta-analysis is in progress. Conclusion: Preliminary results suggest that interventions aimed at high-utilizers with CNCP can reduce ED visits and ED opioid prescription. ED opioid-restriction policies that sought to disincentivize drug-related ED visits were most successful, especially when accompanied by an electronic medical record (EMR) alert to ensure consistent application of the policy by all clinicians and administrators involved in the care of these patients. This review was limited by inconsistencies in the definition of ‘high-utilizer’ and by the lack of high-powered randomized studies.

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Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures

CJEM ◽

10.1017/cem.2020.50 ◽

2020 ◽

Vol 22 (4) ◽

pp. 486-493

Author(s):

Garrick Mok ◽

Hailey Newton ◽

Lisa Thurgur ◽

Marie-Joe Nemnom ◽

Ian G. Stiell

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Multivariable Analysis ◽

Prescription Data ◽

Care Hospital ◽

Total Dosage ◽

Opioid Prescription ◽

Prescription Practices ◽

Ed Visits

ABSTRACTBackgroundOpioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.MethodsWe conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016–April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.ResultsWe enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1–120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15–36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88–10.35)] had a significantly higher likelihood of opioid prescriptions.ConclusionsThe majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.

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Recurrent Emergency Department Users: Two Categories with Different Risk Profiles

Journal of Clinical Medicine ◽

10.3390/jcm8030333 ◽

2019 ◽

Vol 8 (3) ◽

pp. 333 ◽

Cited By ~ 4

Author(s):

Ksenija Slankamenac ◽

Meret Zehnder ◽

Tim Langner ◽

Kathrin Krähenmann ◽

Dagmar Keller

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Emergency Services ◽

Hospital Admissions ◽

Tertiary Care ◽

Chronic Obstructive ◽

Care Hospital ◽

Co Morbidity ◽

Ed Visits ◽

Morbidity Index

Recurrent emergency department (ED) visits are responsible for an increasing proportion of overcrowding. Therefore, our aim was to investigate the characteristics and prevalence of recurrent ED visitors as well as to determine risk factors associated with multiple ED visits. ED patients visiting the ED of a tertiary care hospital at least four times consecutively in 2015 were enrolled. Of 33,335 primary ED visits, 1921 ED visits (5.8%) were performed by 372 ED patients who presented in the ED at least four times within the one-year period. Two different categories of recurrent ED patients were identified: repeated ED users presenting always with the same symptoms and frequent ED visitors who were suffering from different symptoms on each ED visit. Repeated ED users had more ED visits (p < 0.001) and needed more hospital admissions (p < 0.010) compared to frequent ED users. Repeated ED users visited the ED more likely due to symptoms from chronic obstructive pulmonary diseases (p < 0.001) and mental disorders (p < 0.001). In contrast, frequent ED patients showed to be at risk for multiple ED visits when being disabled (p = 0.001), had an increased Charlson co-morbidity index (p = 0.004) or suffering from rheumatic diseases (p < 0.001). A small number of recurrent ED visitors determines a relevant number of ED visits with a relevance for and impact on patient centred care and emergency services. There are two categories of recurrent ED users with different risk factors for multiple ED visits: repeated and frequent. Therefore, multi-professional follow-up care models for recurrent ED patients are needed to improve patients’ needs, quality of life as well as emergency services.

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Chronic Pain in the Emergency Department: A Pilot Mixed-Methods Cross-Sectional Study Examining Patient Characteristics and Reasons for Presentations

Pain Research and Management ◽

10.1155/2016/3092391 ◽

2016 ◽

Vol 2016 ◽

pp. 1-10 ◽

Cited By ~ 25

Author(s):

Patricia A. Poulin ◽

Jennifer Nelli ◽

Steven Tremblay ◽

Rebecca Small ◽

Myka B. Caluyong ◽

...

Keyword(s):

Emergency Department ◽

Chronic Pain ◽

Mental Health Problems ◽

Pain Treatment ◽

Care Center ◽

Tertiary Care ◽

Care Physician ◽

Cross Sectional ◽

Interdisciplinary Pain Treatment ◽

Ed Visits

Background. Chronic pain (CP) accounts for 10–16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives. To describe patients with CP attending the ED and identify factors contributing to their visit. Methods. We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results. Fifty-eight patients (66% women; mean age 46.5, SD = 16.9) completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions. Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED.

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Characteristics of frequent users of the emergency department with chronic pain

CJEM ◽

10.1017/cem.2019.464 ◽

2020 ◽

Vol 22 (3) ◽

pp. 350-358

Author(s):

Yaadwinder Shergill ◽

Danielle Rice ◽

Catherine Smyth ◽

Steve Tremblay ◽

Jennifer Nelli ◽

...

Keyword(s):

Mental Health ◽

Emergency Department ◽

Chronic Pain ◽

Abdominal Pain ◽

High Frequency ◽

Tertiary Care ◽

Chronic Abdominal Pain ◽

Primary Concern ◽

Physical And Mental Health ◽

Ed Visits

ABSTRACTObjectivesTo identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain.MethodsWe reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details – number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either “chronic pain” or “not chronic pain” related.ResultsWe analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain.ConclusionsChronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.

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Combination pretest probability assessment and D-dimer did not reduce outpatient imaging for venous thromboembolism in a tertiary care hospital emergency department

CJEM ◽

10.2310/8000.2013.130986 ◽

2014 ◽

Vol 16 (01) ◽

pp. 53-62 ◽

Cited By ~ 1

Author(s):

Sarah Ingber ◽

Rita Selby ◽

Jacques Lee ◽

William Geerts ◽

Elena Brnjac

Keyword(s):

Emergency Department ◽

Venous Thromboembolism ◽

False Positive Rate ◽

Tertiary Care ◽

Real Life ◽

Pretest Probability ◽

Care Hospital ◽

Ed Visits ◽

The Impact ◽

D Dimer

ABSTRACTIntroduction:Venous thromboembolism (VTE) is difficult to diagnose yet potentially life threatening. A low-risk pretest probability (PTP) assessment combined with a negative Ddimer can rule out VTE in two-thirds of outpatients, reducing the need for imaging. Real-life implementation of this strategy is associated with several challenges.Methods:We evaluated the impact of introducing a standardized diagnostic algorithm including a mandatory PTP assessment and D-dimer on radiologic test use for VTE in our emergency department (ED). A retrospective review of all ED visits for suspected VTE in the year prior to and following the introduction of this algorithm was conducted. VTE diagnosis was based on imaging. Guideline compliance was also assessed.Results:ED visits were investigated for suspected VTE in the pre- and postintervention periods (n 5 1,785). Most D-dimers (95%) ordered were associated with a PTP assessment, and 50% of visits assigned a low PTP had a negative D-dimer. The proportion of imaging tests ordered for VTE in all ED visits was unchanged postintervention (1.9% v. 2.0%). The proportion of patients with suspected VTE in whom VTE was confirmed on imaging decreased postintervention (10.2% v. 14.1%).Conclusion:In spite of excellent compliance with our algorithm, we were unable to reduce imaging for VTE. This may be due to a lower threshold for suspecting VTE and an increase in investigation for VTE combined with a high false positive rate of our D-dimer assay in low–pretest probability patients. This study highlights two common real-life challenges with adopting this strategy for VTE investigation.

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Epidemiological profile of non-urgent patient visits to emergency department in a tertiary care hospital in South India

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20195841 ◽

2019 ◽

Vol 7 (1) ◽

pp. 128

Author(s):

Arun Anbumani ◽

Moses Kirubairaj Amos Jegaraj ◽

Reka Karruppusami

Keyword(s):

Emergency Department ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Significant Proportion ◽

Admission Rate ◽

Urgent Care ◽

Minor Trauma ◽

Care Hospital ◽

Ed Visits ◽

Epidemiological Profile

Background: Non-urgent visits to emergency department (ED) form a significant proportion of ED visits. The reasons vary from minor injuries, fever of short duration, parental anxiety, and even serious conditions like myocardial infarctions presenting atypically. Non-urgent visits stress the ED services while prolonged waiting affects the patients. The aim was to study the profile of non-urgent visits to emergency department of a tertiary care hospital in South India.Methods: Prospective and descriptive study of patients aged 15 years and above categorized as non-urgent after triage was conducted. Data such as age, gender, reason for visit, time of presentation during the day, duration of ED stay and need for referral were recorded. Quantitative variables were presented as Mean±SD and frequency with percentage for qualitative variables.Results: Non-urgent visits contributed to 47.1% of total ED visits. Reasons for non-urgent visits were fever (15.4%), vomiting (13.9%), breathlessness (7.6%), minor trauma (7.3%), giddiness (7.0%) and dysuria (5.5%). 80.8% of all non- urgent visits were seen by ED doctor within two hours of being triaged. Most patients were treated for their immediate symptoms and 64.8% needed follow-up out-patient appointments. Admission rate was 1.2%. Majority of non-urgent visits (55.7%) were daytime visits and 13% were after-hours.Conclusions: Non-urgent visits contribute to about half of all ED visits and can stress ED. A local triage guideline is necessary to run these services in ED. Extended general practice or family physician run urgent care can relieve the stress on ED while rendering to patients accessible and affordable care.

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P026: Opioid use and dependence three months after an emergency department visit for acute pain

CJEM ◽

10.1017/cem.2018.224 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S66-S66

Author(s):

R. Daoust ◽

J. Paquet ◽

J. Morris ◽

A. Cournoyer ◽

E. Piette ◽

...

Keyword(s):

Emergency Department ◽

Chronic Pain ◽

Acute Pain ◽

Opioid Dependence ◽

Tertiary Care ◽

Structured Interview ◽

Prescription Opioid ◽

Opioid Use ◽

Opioid Prescription ◽

Convenience Sample

Introduction: Most studies evaluating prescription opioid dependence or misuse are retrospective and are based on prescription filling rates from pharmaceutical databases. These studies cannot evaluate if opioids are really consumed nor differentiate if used for a new pain, chronic pain, or for misuse/dependence. The aim of this study was to assess the opioid consumption in emergency department (ED) patients three months after discharge with an opioid prescription. Methods: This prospective cohort study was conducted in the ED of a tertiary care centre with a convenience sample of patients aged 18 years and older, recruited 24/7, who consulted and were discharged for an acute pain condition ( 2 weeks). We excluded patients who: did not speak French or English, were using opioid medication prior to their ED visit, with an ED stay > 48 hours, or suffering from cancer or chronic pain. Three months post-ED visit, participants were contacted by phone for a structured interview on their past two-week opioid use, their reasons for consuming them, and also answered the Rapid Opioid Dependence Screen (RODS) questionnaire. Results: In the 524 participants interviewed at three months (mean age ± SD: 51±16 years, 47% women), 44 (8.4%) patients consumed opioids in the previous two weeks. Among those, 72% consumed opioids for their initial pain, 19% for a new unrelated pain, and 9% for another reason. In this entire cohort, only five patients (1%) tested positive to opioid dependence from the RODS test. The low dependence incidence could be affected by a social desirability bias. Conclusion: This study suggests that opioid use at 3-month, for patients initially treated for acute pain, is associated with opioid dependency in 1% or possible misuse in only 9%. Additional prospective studies using multiple methods to measure opioids consumption, misuse, and dependence are needed.

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Team strategies and tools to enhance performance and patient safety training: The effect of training on both nursing staff perceptions regarding physician behaviors and patient satisfaction scores in the ED

Journal of Hospital Administration ◽

10.5430/jha.v4n2p48 ◽

2015 ◽

Vol 4 (2) ◽

pp. 48 ◽

Cited By ~ 3

Author(s):

Shari I. Brand ◽

Kristen M. Slee ◽

Yu-Hui Chang ◽

Meng-Ru Cheng ◽

Christopher A. Lipinski ◽

...

Keyword(s):

Emergency Department ◽

Patient Safety ◽

Patient Satisfaction ◽

Nursing Staff ◽

Tertiary Care ◽

Patient Perceptions ◽

Care Hospital ◽

Care Plans ◽

Before And After ◽

Improve Patient

Introduction: Background: Program used to enhance teamwork and communication among health professionals to improve patient safety and employee satisfaction. Objective: We hypothesized that Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training would improve communication between physicians and nurses and between physicians and their patients and family members, and that it would improve patient perceptions of emergency department teamwork.Methods: Design: Before and after prospective observational study. Setting: Tertiary Care Hospital Emergency Department. Participants/Subjects: Twelve core physicians and 43 nurses underwent two, 4-hour TeamSTEPPS training sessions in July 2011 and July 2012. The first session consisted of didactic instruction using the TeamSTEPPS material. The second session was comprised of simulations focusing on the content of the initial training course. Nurses were asked to rate individual physicians on five distinct aspects of communication, both before and after the training sessions. Statistical Methods: Survey results were compared using theWilcoxon signed rank test. Patient satisfaction survey questions regarding teamwork (4th Quarters 2010 and 2011) were analyzed using two-sample t-tests.Results: TeamSTEPPS improved nurse’s perception regarding physician communication with patients and their families (post: 4.28 ± 0.37 vs. pre: 4.16 ± 0.42, p = .0479), with a trend towards improvement in nurse’s perception of physician’s communication with nursing staff regarding changes in patient care plans (post: 3.94 ± 0.38 vs. pre: 3.81 ± 0.5, p = .0942). TeamSTEPPS was also associated with a significant improvement in patient’s rating of teamwork between doctors and nurses as “excellent” (post: 62.9% vs. pre: 48.3%, p = .0132).Conclusions: Team training with the TeamSTEPPS program improved selected aspects of nursing and patient perceptions of teamwork and communication between emergency department physicians and nurses.

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A Promising Step in Fighting the Opioid Epidemic, Care Plan Implementation for those Presenting to the Emergency Department

European Journal of Medical and Health Sciences ◽

10.24018/ejmed.2020.2.6.586 ◽

2020 ◽

Vol 2 (6) ◽

Author(s):

F. Fiesseler ◽

R. Riggs ◽

D. Salo ◽

D. Feldman ◽

R. Shih

Keyword(s):

Emergency Department ◽

Care Plan ◽

Rank Test ◽

Opioid Epidemic ◽

Plan Implementation ◽

Care Plans ◽

Opioid Administration ◽

Ed Visits ◽

One Year

Background: The opioid epidemic has both financial implications and ethical confounders affecting emergency departments across the country. Additionally, patients presenting to the emergency department (ED) seeking opioid administration and prescriptions can be both disruptive and time intensive. Objective: To determine long-term effectiveness of ED care plans designed to improve medical care for ED opioid-seeking patients with chronic painful conditions. Methods: A retrospective, cohort observational study. Location: a suburban teaching hospital with an annual census of 90,000 patients. The number of ED visits were tallied one year prior (control), and for five consecutive years following initiation. The primary outcome was the number of yearly ED visits in subjects meeting criteria. Statistics: Two-tailed Wilcoxon signed-rank test with significance of p<0.05, two tailed. Results: One hundred and twenty patients were enrolled. Twelve were excluded, leaving 108 patients for analysis. Mean yearly ED visits prior to care plan initiation were 7.6 (95% CI 11.9-3.3). Following care plan initiation, mean visits were: one year, 2.3 (95% CI 4.3-0.3); two years, 1.3 (95% CI 2.7-0.0); three years, 1.1(95 % CI 3.1-0.0); four years, 0.8 (95% CI 2.1-0.0); five years, 0.6 (95% CI 1.7-0.0). The five-year total mean reduction in visits was 7.0 (95% CI 8.1- 6.2) (p=0.0001). Conclusions: ED care plans are an effective long-term method to reduce visits in patients with chronic painful conditions who present seeking opioid treatment.

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