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

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.

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

2018 ◽  
Vol 2018 ◽  
pp. 1-10 ◽  
Author(s):  
Joshua A. Rash ◽  
Patricia A. Poulin ◽  
Yaadwinder Shergill ◽  
Heather Romanow ◽  
Jeffrey Freeman ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chronic Pain ◽  
Pain Catastrophizing ◽  
Tertiary Care ◽  
Care Plan ◽  
Care Hospital ◽  
Opioid Use ◽  
Care Plans ◽  
Individualized Care ◽  
Ed Visits

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.

scholarly journals US Emergency Department Visits for Adverse Drug Events From Antibiotics in Children, 2011–2015

2018 ◽  
Vol 8 (5) ◽  
pp. 384-391 ◽  
Author(s):  
Maribeth C Lovegrove ◽  
Andrew I Geller ◽  
Katherine E Fleming-Dutra ◽  
Nadine Shehab ◽  
Mathew R P Sapiano ◽  
...  
Keyword(s):  
Emergency Department ◽  
Adverse Drug Events ◽  
Emergency Department Visits ◽  
Drug Event ◽  
Injury Surveillance System ◽  
Adverse Event Data ◽  
Systemic Medication ◽  
Ed Visits ◽  
Pharmacy Dispensing Data

Abstract Background Antibiotics are among the most commonly prescribed medications for children; however, at least one-third of pediatric antibiotic prescriptions are unnecessary. National data on short-term antibiotic-related harms could inform efforts to reduce overprescribing and to supplement interventions that focus on the long-term benefits of reducing antibiotic resistance. Methods Frequencies and rates of emergency department (ED) visits for antibiotic adverse drug events (ADEs) in children were estimated using adverse event data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project and retail pharmacy dispensing data from QuintilesIMS (2011–2015). Results On the basis of 6542 surveillance cases, an estimated 69464 ED visits (95% confidence interval, 53488–85441) were made annually for antibiotic ADEs among children aged ≤19 years from 2011 to 2015, which accounts for 46.2% of ED visits for ADEs that results from systemic medication. Two-fifths (40.7%) of ED visits for antibiotic ADEs involved a child aged ≤2 years, and 86.1% involved an allergic reaction. Amoxicillin was the most commonly implicated antibiotic among children aged ≤9 years. When we accounted for dispensed prescriptions, the rates of ED visits for antibiotic ADEs declined with increasing age for all antibiotics except sulfamethoxazole-trimethoprim. Amoxicillin had the highest rate of ED visits for antibiotic ADEs among children aged ≤2 years, whereas sulfamethoxazole-trimethoprim resulted in the highest rate among children aged 10 to 19 years (29.9 and 24.2 ED visits per 10000 dispensed prescriptions, respectively). Conclusions Antibiotic ADEs lead to many ED visits, particularly among young children. Communicating the risks of antibiotic ADEs could help reduce unnecessary prescribing. Prevention efforts could target pediatric patients who are at the greatest risk of harm.

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

CJEM ◽  
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.

scholarly journals P083: Why do older adults in assisted living facilities use the emergency department: are all these visits necessary?

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S106-S106
Author(s):  
E. Losier ◽  
A. McCollum ◽  
P. Jarrett ◽  
R. McCloskey ◽  
P. Nicholson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Assisted Living ◽  
Demographic Data ◽  
Care Home ◽  
Functional Decline ◽  
Retrospective Chart Review ◽  
Community Services ◽  
Level 3 ◽  
Ed Visits ◽  
One Year

Introduction: Special Care Home (SCH) residents require supervision for activities of daily living but not regular nursing care. Emergency Department (ED) use by seniors in SCHs is poorly studied. A recent study in Nova Scotia found seniors represented over 20% of ED visits. We studied SCH resident ED visits in a community with a population of 30,000 aged over 65 years and with 785 SCH beds, to define reasons for ED visits to a tertiary ED, and if these could be avoided. Methods: We performed a retrospective chart review of SCH residents’ visits to an ED (SCH-ED) which has 56,000 total ED (TED) visits over one year. Reasons for visit, admission data, and avoidability were collected. A geriatrician and ED physician independently reviewed visits. Initial disagreement on avoidability (27%) was adjudicated through case discussion. Results: Demographic data revealed 344 ED visits by 111 SCH residents over one year; 37% of visits resulted in admission. 13.9% of residents visited the ED on at least one occasion (average 3.1 visits); mean age 78.4 years; female 66.7%; ambulance arrival 91.0%. The three most common chief complaints were shortness of breath, weakness and abdominal pain. Most SCH-ED visits were Canadian Triage and Acuity Scale (CTAS) Level 3 (63.4%, TED 53.3%). Of CTAS Level 3 visits, 35.3% were admitted (TED 12.9%). SCH-ED visits were avoidable in 40.6% of cases. Gastrointestinal (18%), pain (16.5%), falls, functional decline or injury (14%) and respiratory (12%) were the most common avoidable diagnostic groups, accounting for 57% of total SCH visits. Conclusion: ED visits by SCH residents demonstrated increased acuity and admission rates with a high number of repeat visits. Of all SCH-ED visits, 40% were potentially avoidable. Further study may determine if improved community services reduces ED visits or hospital admission. Gastrointestinal, respiratory, falls and pain diagnoses may be important areas of focus.

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

CJEM ◽  
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.

Prevalence and Benefits of Care Plans and Care Planning for People with Long-Term Conditions in England

2012 ◽  
Vol 17 (1_suppl) ◽  
pp. 64-71 ◽  
Author(s):  
Jenni Burt ◽  
Martin Roland ◽  
Charlotte Paddison ◽  
David Reeves ◽  
John Campbell ◽  
...  
Keyword(s):  
Patient Survey ◽  
Care Plan ◽  
Care Planning ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Long Term Conditions ◽  
Patient Reports ◽  
Care Plans ◽  
Interpersonal Care

Objectives Among patients with long-term conditions, to determine the prevalence and benefits of care planning discussions and of care plans. Methods Data from the 2009/10 General Practice Patient Survey, a cross sectional survey of 5.5 million patients in England. Outcomes were patient reports of: care planning discussions; perceived benefit from care planning discussions and resultant care plans. Patient and practice variables were included in multilevel logistic regression to investigate predictors of each outcome. Results Half the respondents (49%) reported a long-term condition and were eligible to answer the care planning questions. Of these, 84% reported having a care planning discussion during the last 12 months and most reported some benefit. Only 12% who reported a care planning discussion also reported being told they had a care plan. Patients who reported having a care plan were more likely to report benefits from care planning discussions. Several factors predicted the reporting of care planning and care plans of which the most important was patients' reports of the quality of interpersonal care. Conclusions There is a gap between policy and current practice which might reflect uncertainty as to the benefits of care plans. There is, therefore, a need for rigorous evaluation of care plans.

Who is receiving survivorship care plans? Findings from the 2012 Livestrong survey.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 9608-9608
Author(s):  
Ruth Rechis ◽  
Carla Bann ◽  
Stephanie Nutt ◽  
Linda Squiers ◽  
Naveen Rao
Keyword(s):  
Medical Center ◽  
Care Plan ◽  
Cancer Center ◽  
Survivorship Care Plans ◽  
Institute Of Medicine ◽  
Survivorship Care ◽  
Long Term Effects ◽  
Care Plans ◽  
Key Stakeholders

9608 Background: There are more than 14 million cancer survivors in the US – a number that is on the rise. Care coordination resources will be essential to provide support to this growing population. Key stakeholders, including the Commission on Cancer (CoC) and the Institute of Medicine, have proposed survivorship care plans (SCPs) as a way to extend support. However, limited research has been conducted to date on SCPs. Methods: In 2012, the LIVESTRONG Foundation (LIVESTRONG) administered a survey to understand the role of a treatment summary (TS) and SCPs and how they fit into survivors’ care. Logistic regression models were conducted to identify factors associated with receiving SCPs or TS. Results: 5,303 survivors responded to these questions (Table). While 92% of these respondents received information about where to return to for cancer check-ups, only 51% reported receiving a TS and 17% reported receiving a SCP. Survivors who were more likely to receive SCPs if they had a navigator (p<.001) and if they were male, Black, had finished treatment within the past year, or received care at a university-based medical center or community cancer center (p < 0.05). Also, those receiving a SCP were significantly more likely to have had a detailed discussion with a provider regarding long-term side effects, emotional needs, and lifestyle recommendations. Specifically, 60% of those with a SCP discussed long-term effects compared to 39% who did not. Conclusions: Results here indicate that few survivors receive SCPs but survivors reported benefits from receiving them. Currently many workflow barriers impede delivering SCPs, and LIVESTRONG is working with key stakeholders including the CoC to automate the LIVESTRONG Care Plan powered by Penn Medicine’s OncoLink through a registry and EMR system to understand how to address this issue. [Table: see text]

Ensuring head and neck oncology patients receive recommended pretreatment dental evaluations.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 100-100
Author(s):  
Danielle Nina Margalit ◽  
Stephanie Losi ◽  
Roy B. Tishler ◽  
Jonathan Daniel Schoenfeld ◽  
JoAnn Fugazzotto ◽  
...  
Keyword(s):  
Head And Neck ◽  
Dental Care ◽  
Care Plan ◽  
Community Based ◽  
Pareto Chart ◽  
Care Plans ◽  
Primary Responsibility ◽  
Pre Treatment

100 Background: Pre-treatment dental evaluations are recommended for head and neck (H&N) cancer patients (pts) prior to radiation therapy (RT) to minimize the risk of acute and long-term side effects of treatment. We previously created a dental instructional guide (DIG) outlining the necessary components of the pre-radiation dental evaluation for pts undergoing community-based dental evaluation. Yet our program did not have a system for documenting which pts received the DIG. We aimed to create a system to ensure that pts are given the DIG early in their care-plan and that such pts are readily identifiable so we can follow-up and confirm that the recommended dental care is complete prior to starting RT. Methods: Chart review was performed to determine the percentage of eligible pts with documented provision of the DIG. A diagnostic survey of H&N oncology clinicians was analyzed with a Pareto chart to determine common barriers to DIG provision and documentation. Clinicians were surveyed on potential ways to document DIG provision to eligible pts. The Model for Improvement and DMAIC (Six Sigma) methodologies were used and multiple Plan-Do-Study-Act (PDSA) cycles were performed to implement the intervention and monitor change. Change data was analyzed using a P-chart, 3-sigma. Results: We used a process map to identify 3 potential care-plans within the H&N oncology program and assist in defining which providers had primary responsibility for providing the DIG. We then designed and implemented a template within the electronic medical record that documents the clinician who gave the DIG and the date it was given. There was an improvement in the rate of DIG documentation from a baseline of 0% (range 0-0%) to a mean of 40% (range 0-100%) over 3-months (p<0.01). This improvement was sustained through last follow-up at 5 months. Conclusions: Through a multidisciplinary approach, we implemented an intervention to identify pts undergoing community-based dental evaluation prior to RT for H&N cancer. Further efforts are focused on increasing the DIG documentation rate and increasing our interaction with community dentists to promote expeditious pre-radiation dental care.

The role of chronic disease in the costs of potentially preventable emergency department use during treatment: A regional study.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. 6505-6505 ◽  
Author(s):  
Laura Elizabeth Panattoni ◽  
Catherine R. Fedorenko ◽  
Karma L. Kreizenbeck ◽  
Stuart Greenlee ◽  
Julia Rose Walker ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chronic Disease ◽  
Chronic Conditions ◽  
Healthcare Research ◽  
Future Research ◽  
Regional Study ◽  
Diagnosis Codes ◽  
Ed Visits ◽  
One Year

6505 Background: The Centers for Medicare and Medicaid Services (CMS) released a quality metric for potentially preventable chemotherapy-associated emergency department (ED) use, effective in 2020. This metric excludes diagnoses with emerging evidence for outpatient management, such as proactive symptom management (PSM) and those for ambulatory care sensitive chronic conditions. Little is known about the intersection between potentially preventable ED visits due to cancer vs. other chronic disease. This study characterized the number and costs of ED visits during treatment. Methods: Western Washington cancer registry records from 2011- 2015 were linked with claims from two commercial insurers. Patients with newly diagnosed solid tumors undergoing initial treatment with chemotherapy or radiation were eligible. ED use was tracked one year post treatment initiation. ED diagnosis codes for fields 1-10 from the CMS metric and the PSM literature were labeled “Potentially Preventable” (Pp). Codes from the Agency for Healthcare Research and Quality’s Prevention Quality Indicators (PQI) for Chronic Conditions were labeled “Potentially Preventable-Chronic Disease” (PpChronic). Costs were adjusted to $2016. Results: Of the 7,053 eligible patients, 2,543 (36.1%) visited the ED (median # visits [IQR]: 1 [1-2]). The most commonly listed codes included Pain (1,054 visits) and Dyspnea (279 visits) for Pp, Hypertension-PQI (652 visits) and COPD-PQI (206 visits) for PpChronic, and Diabetes (247 visits) and Hyperlipidemia (181 visits) for the other codes. Spending on ED visits including both potentially preventable cancer and chronic disease diagnoses totalled $706,552 (20% of ED costs). Conclusions: One fifth of ED costs potentially resulted from simultaneous poor cancer symptom and chronic disease management. Future research should explore the role of chronic illness in categorizing which ED visits are potentially preventable during cancer treatment. [Table: see text]

Survivorship care plan visits: Mixed methods analysis of patient surveys.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 174-174
Author(s):  
Natalie Garces ◽  
Daisuke Goto ◽  
Carol J. Farhangfar ◽  
Tara Eaton
Keyword(s):  
Qualitative Analysis ◽  
Head And Neck ◽  
Subgroup Analysis ◽  
Statistical Significance ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Rank Test ◽  
Survivorship Care ◽  
Care Plans ◽  
Patient Reported

174 Background: Survivorship Care Plans (SCPs) are endorsed by cancer advocacy groups and required for accreditation, yet benefits are unclear. The purpose of this quality initiative was to assess the benefit of SCPs. Methods: From June 2015 to September 2017, survivors who had a SCP visit were surveyed to report their understanding of key survivorship topics pre/post visit; the most valuable information learned and plans to use the information. Descriptive statistics and qualitative analysis were performed. Subgroup analysis was performed for age, insurance, marital status, and race. Wilcoxon signed-rank test computed statistical significance. Results: Of 794 surveys, 657 (83%) were complete and evaluable. Surveys were collected from breast (436 [66%]), lung (45 [7%]), colorectal (33 [5%]), head and neck (25 [4%]), melanoma (24 [4%]), endometrial and ovarian (20 each [3%]), and other (54 (8%) cancer survivors. Statistically significant ( p<0.05) improvements in all questions (Table 1) were noted across nearly all disease sites. Exceptions were endometrial, head and neck, and melanoma, which already had > 75% answering “completely understand” for selected questions pre- SCP visit. Subgroup analysis found no significant differences. Self-management was a theme in the “other” insurance status subgroup (14) qualitative analysis. Four (36%) indicated an interest in information about programs to improve healthy behaviors. Conclusions: There was major positive impact of the SCP visit on patient-reported understanding of all survivorship topics. Providers may benefit from focusing SCP discussion on areas the survivor reports as “some” or “no” understanding pre- SCP visit. Providers should connect survivors to resources to support self-identified needs. [Table: see text]

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