EXECUTIVE SUMMARY
Investigators at Aurora West Allis Medical Center in West Allis, WI, recently unveiled the results of a study showing that providing acupuncture in the ED is feasible and beneficial as a nonpharmacological alternative for treating pain. Targeting patients triaged at Emergency Severity Index (ESI) level 3 and higher, researchers found that patients were largely receptive to receiving acupuncture and that the treatment was effective in easing symptoms of pain, stress, anxiety, and nausea. However, lack of reimbursement for acupuncture remains a significant barrier. Other EDs have found it difficult to sustain acupuncture programs largely because of funding difficulties.
• The study included more than 700 patients with acute pain who presented to the ED in 2017. More than half were receptive to receiving acupuncture.
• The acupuncturist received the autonomy to approach patients deemed appropriate for the treatment before a provider saw those patients.
• Specifically, the program targets patients who are triaged at ESI level 3 or above, a group that includes roughly 60% of patients who present to this ED.
• Abbott Northwestern Hospital in Minneapolis also used to offer acupuncture in the ED, but the program faced some challenges, including the lack of a dependable revenue stream.
As the opioid crisis continues, emergency providers are looking to nonopioid alternatives to treat pain. Acupuncture has been discussed as one potential alternative, but the lack of reimbursement for this technique has prevented most EDs from even considering it as an option.
However, armed with funding to study the potential benefits of offering acupuncture in the ED, investigators at Aurora West Allis Medical Center in West Allis, WI, have gathered data showing that acupuncture is feasible and beneficial as a nonpharmacological alternative for treating pain in the ED.
In a study that included more than 700 patients with acute pain who presented to the ED in 2017, investigators found that more than half were receptive to receiving acupuncture. Further, patients receiving acupuncture treatment reported significant declines in pain severity as well as reductions in stress, anxiety, and nausea.1 While the self-reported outcomes in this study are encouraging, the lack of any form of payer reimbursement for acupuncture continues to be a major stumbling block for EDs interested in trying the treatment. Indeed, the funding problem has prevented earlier trials of ED-based acupuncture from continuing beyond the study stage.
Nonetheless, armed with these data, investigators at Aurora West Allis Medical Center intend to push for higher-quality studies of the approach with the hope that more robust data will prove convincing to payers.
Meanwhile, with grant funding support, the ED continues offering acupuncture to appropriate patients with the enthusiastic support of the clinical staff. Further, investigators believe they have moved the ball forward with some valuable lessons on how to most effectively leverage acupuncture in a way that will not disrupt the ED flow. Originally, the ED-based acupuncture program was created to determine if acupuncture could be a viable alternative or adjunctive treatment for pain and other disorders that bring patients to the ED. Consequently, John Burns, DPT, MPT, MSOM, the manager of acupuncture, traditional Chinese modalities, and mind-body therapies in the department of integrative medicine at Aurora Health Care in Milwaukee, first completed a feasibility study to determine which patients should be considered for acupuncture.
“We found that 60% of the patients are basically triaged as a 3 or above [on the Emergency Severity Index], which means ... they do not have a life-threatening condition,” he explains. “We determined that these patients would be best-suited to receive acupuncture and not disrupt the flow in the ED.”
Proponents of the approach knew they might encounter some provider pushback to the idea, considering that acupuncture has not found its way into many EDs. Burns spent time networking in the ED before the program began. “I was in charge of going in and shadowing physicians in the ED during my feasibility study and getting to know them. They got to know me [as well], and we talked about how this might work,” he recalls.
Burns also met with physician assistants and nurses in the ED, providing them with evidence that acupuncture could be of some benefit. For instance, he notes there have been some studies on acupuncture as a treatment for low back pain, migraine, and a few other conditions. Further, Burns notes that the American College of Physicians recommends using nonpharmacological options such as acupuncture to treat acute or subacute low back pain before providing pharmacological solutions.2
When the Aurora program started, a provider would have to approve the acupuncture option before the acupuncturist could approach the patient. However, Burns noted that this approach changed quickly.
“After the physicians started to see the benefits of [acupuncture], including pain and stress reduction, our acupuncturist was given the autonomy to follow the tracking board to see which patients he thought he could help and to [approach] them,” Burns shares. “We were surprised that over 50% of the people we encountered did agree to it. We weren’t expecting that high of a number.”
Further, since most patients still were waiting to see a provider when they were approached by the acupuncturist, the added treatment did not disrupt the ED flow. “This plays a great role in addressing patient dissatisfaction and patient agitation that often happens when patients want help now,” Burns observes. “With the big problems of physician and nurse burnout, this is another way to help take stress off of those providers.”
Michael Urban, MD, FACEP, FAAEM, director of emergency services at Aurora West Allis Medical Center, says the acupuncture program has greatly benefited patients.
“Our data show that patients receiving ED acupuncture [here] had a 50% reduction in their pain levels. Acupuncture also decreased nausea and anxiety levels by two-thirds. Equally important is that acupuncture is an alternative to opioids for pain relief,” he explains. “Along with other nonopiate-based pain reduction methods, it is terrific to be able to provide this effective acupuncture treatment to our patients, which supports our efforts to markedly limit opioid use.”
Urban acknowledges that he and several other members of the staff were skeptical about the utility of acupuncture in the ED. Now, most are big supporters. “One of the first patients I cared for who received acupuncture was a gentleman with chronic back pain. After his acupuncture treatment, he waved me into the room where I expected he was going to ask me what in the world we were doing and criticize our new offering,” Urban shares. Instead, the patient said he had not felt this good and relaxed in years. “I have been a believer since [that case], and many of our ED staff members have had similar experiences.”
Burns notes there is a strong case to be made that acupuncture is well suited to emergency medicine. “We need to address acute pain better. What could be a better place to address acute pain than the ED?” he offers. “With regard to the opioid crisis, more than 100 people a day are dying from overdosing on narcotics.”
Abbott Northwestern Hospital in Minneapolis used to offer acupuncture in the ED, too. An observational, retrospective study, completed in 2016, showed that the treatment was both well-received by patients and effective in alleviating pain and anxiety.3 However, the program encountered some challenges.
“The biggest barrier that we had was the hours of availability. We didn’t offer [acupuncture] 24/7, but rather Monday through Friday, 40 hours a week,” explains Jennifer McAnnany, MBA, BAN, RN, director of patient care in emergency services at the hospital. “It was challenging for staff to know and remember if the acupuncturist was working on a given day.”
The acupuncturist involved with the program, Adam Reinstein, recalls one effective tactic for gaining acceptance of the treatment among staff. “I would shadow the staff and work around them. If someone said they had a headache, I would give them some acupuncture,” he says. “I gave a lot of experiential treatment so that people would know what it was like. Several of the nurses would go and start getting courses of acupuncture once I introduced them to it.”
Ultimately, the ED-based acupuncture program could not be sustained. “We used acupuncture for pain, nausea, and anxiety, and it worked very well for migraines,” McAnnany notes. “Patients and staff found value, but it is an expensive service to offer with no revenue generation.”
Looking back, Reinstein suggests the program might have been more successful if clearly defined goals had been established at the outset. “When you work in a hospital system, everyone wants to measure everything. If they don’t have a good sense of what you are doing, why you are doing it, and how effective is, it is very hard to convince the people who pay the bills to support it,” he says. “Starting the process isn’t [difficult]. It is just coming up with a consistent strategy ... that is the thing we lacked: really trying to figure out what our goal was.”
Urban, who still offers acupuncture in his ED, offers some recommendations for other emergency medicine professionals interested in providing the service. First, he notes it is important to keep an open mind. “Although many of us had doubts about how acupuncture would work in the ED, I’m glad we allowed a trial to occur,” he says. “What our patients tell us supports what the data show: acupuncture works to decrease acute pain, nausea, and anxiety.”
Further, considering the success of an acupuncture program will depend on patients’ openness to it, Urban suggests sharing information with them about how it has helped other patients. “I tell my patients that acupuncture has not helped every patient, but it significantly helps at least half of them,” he says. “Many patients are afraid of needles, but most patients actually find the process painless.”
Finally, patients tend to be more receptive to acupuncture if you share with them that the treatment is part of an effort to decrease the use of addictive opioid medications, Urban explains. “I have had several patients who are recovering opioid addicts thank me for providing other options for their pain control,” he says.
REFERENCES
- Burns JR, Kram JJF, Xiong V, et al. Utilization of acupuncture services in the emergency department settings: A quality Improvement Study. J Patient Cent Res Rev 2019;6:172-178.
- Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166:514-530.
- Reinstein AS, Erickson LO, Griffin KH, et al. Acceptability, adaptation, and clinical outcomes of acupuncture provided in the emergency department: A retrospective pilot study. Pain Medicine 2017;18:169-178.
Researchers found that patients were largely receptive to receiving acupuncture and that the treatment was effective in easing symptoms of pain, stress, anxiety, and nausea. However, lack of reimbursement for acupuncture remains a significant barrier.
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