Repeat chronic pain visits reduced from 19 to two
Six out of the top 10 chief complaints of frequent ED users are related to pain, according to a new study.1 To reduce repeat visits of chronic pain patients, ED nurses at University of Wisconsin (UW) Hospital and Clinics in Madison use a "non-narcotic protocol." Of 15 patients who averaged 19 ED visits over the previous year for pain-related complaints who were notified about the new protocol, ED visits decreased to an average of two visits per year.2
"Some patients with chronic pain may need to be on narcotics," says Tom Meyer, MD, an ED physician at UW and coordinator of the Madison Citywide ED Chronic Pain Quality Improvement Initiative. "But these should be prescribed by a single practitioner. The patient should be monitored to be sure that the medication is enhancing function both at home and at work. And if we have evidence that the patient is acquiring drugs from other physicians in order to increase their dose, then they should be reassessed."
If ED nurses identify patients at risk for inappropriate use of narcotics, they alert Meyer by e-mail or verbally and ask him to review the patient's chart. According to Sue Wolfe, RN CEN, care team leader for the UW's ED, at times ED nurses "begin to get that 'I know I'm being taken for a ride' feeling, and the patient may be abusing the system. This gives the doc a heads up to look a bit further into this, or we may talk to the person's primary care physician to come up with a plan."
She adds, "The computer system that we use is very helpful in alerting the staff that the patient may have a pain contract with another physician. We are also able to see easily the number of ED visits and the reason they are coming."
Next, Meyer assesses whether the patient is primarily coming in for chronic management of pain. If that is the case, the patient is sent a letter stating that narcotics no longer will be given in the ED.
After the patient receives the letter, he or she often comes back to the ED seeking narcotics once or twice afterward.
"The ED nursing role is to explain that we want to help the patient and assign them a practitioner," says Meyer. "We'd do the same thing if a patient asked for antibiotics every time he or she had an earache, sore throat, or congestion."
If the patients return with a complaint of chronic pain, they are reminded by ED nurses or physicians that they have been sent a letter stating that they will not get narcotics while in the ED. Instead, the patient may be given a non-narcotic medication along with a nonpharmacologic intervention. For example, a migraine patient may be placed in a quiet, dark room, given cold packs to the head and neck, and given instructions on dietary changes.
"The patient is discharged to follow up with their primary care physician," says Wolfe. Many of the ED's chronic pain patients did set up a pain management contract with their personal physician.
"When patients come in asking for pain medications right away, we need to be more aware of the possible need for education and behavior modification for pain control," says Wolfe. "It is very hard to take care of patients with a recurring pain problem that they feel would best be served with additional narcotics, knowing that this does not seem to help in the long run in many cases."
As for patient reactions to the ED's new protocol, these vary widely. "Some do get angry, though not nearly as many as we would have guessed," says Meyer. "We explain that we really are not trying to stop the use of medication. We are just trying to do the safest thing for them, which is not escalating doses."
References
- Milbrett, P, Halm, M. Characteristics and predictors of frequent utilization of emergency services. J Emerg Nurs 2009; 35:191-198.
- Svenson JE, Meyer TD. Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain.Am J Emerg Med 2007; 25:445-449.
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