Algorithms aid workers’ comp patients’ recovery
Road maps to proper care bring results
Getting emergency department (ED) physicians to treat workers’ compensation patients the same as you would in your occupational health program is never easy, but St. Vincent WorkSystems in Green Bay, WI, has found one solution. Develop step-by-step guidelines and post them right on the wall in the emergency department where they can’t be missed.
The idea is a little more complex than that, but the effect is the same. Once you get the ED physicians to understand the importance of following certain protocols with workers’ comp patients, most will comply if they remember what you want them to do, says Curtis Judd, director of the occupational health program that serves both St. Vincent and St. Mary’s Hospitals in Green Bay. Emergency physicians are oriented differently than occupational health physicians, so they might appreciate algorithms that help put patients on a treatment course similar to what would happen in your occupational health program.
"When a guy comes in with a back injury, for instance, all the emergency physicians might have a different opinion on exactly how to handle it," Judd explains. "With these algorithms, they just go down to the back injury algorithm and answer a few questions about the patient. Depending on the answers to those questions, the algorithm will tell them what we need to do with that person."
Protocols developed with ED doctors’ input
The algorithms have been in place for about a year, and Judd reports that the emergency physicians have adopted them well, using them in almost every case of a workers’ comp injury. Many physicians also will use them for non-workers’ comp injuries because they see them as representing the standard of care for such injuries. That confidence in the algorithms comes partly because the emergency physicians were involved in developing them.
Judd organized a committee of clinicians, including occupational health physicians, emergency physicians, physical therapists, physician assistants, and case managers to develop a set of algorithms that would cover almost all workers’ comp injuries. The algorithms help streamline the process and make each patient’s treatment more predictable.
"They make it easier for us to communicate with the physicians in the emergency department because they understand more what the employers are expecting and what an important role the employers play for us. It’s really opened their eyes," he says. "Prior to this, the emergency physicians didn’t care much if the patient was workers’ comp or not. That didn’t really affect them much, so they weren’t too concerned with addressing the employer’s needs."
Six algorithms developed
Implementing the algorithms revealed that the problem was not so much that emergency physicians didn’t care but that they were concerned with other matters that took precedence over, for instance, deciding whether modified duty or bed rest was a better first choice for most patients. The two EDs together treat about 15,000 workers’ comp patients a year, plus another 65,000 injuries and illnesses that are not work-related. By putting a lot of staff members in the same room to hash out many details of standardized care up front, much of the pressure is taken off the emergency physicians when the patient comes in the door.
The committee developed algorithms for six common types of workers’ comp injuries: shoulder, knee, wrist and hand, back and neck, ankle, and elbow and forearm. The algorithms are widely distributed in the EDs, and poster-size versions also are placed in treatment areas. Each one guides the physician through a series of questions that determine the appropriate treatment course.
Neurological symptoms are assessed
For a work-related back or neck injury, for instance, the algorithm first asks if a musculoskeletal back or neck injury has been diagnosed. If so, the physician determines whether there are neurological symptoms highly suggestive of a disc injury. If the answer is yes, the algorithm says the physician should consider referral to a specialist in 24 to 48 hours. But if the answer is no, the algorithm guides the physician through a series of other questions including whether there is a history of back or neck injury, whether the job requires lifting 50 lbs. or more, and whether there is significant pain. If all those questions are answered no, the final recommendation is light work for seven days and returning the patient to work immediately.
A "yes" answer to any of the last series of questions leads to the final recommendation that the physician address the patient’s pain, prescribe a maximum of 24 hours bed rest only if necessary, restrict work duties for seven days, and refer the patient to a primary care physician or specialist.
In all cases, the algorithms say the emergency physicians should "consider" those courses of action, leaving the ultimate decision to the doctor.
Some problems with too much customizing’
The use of the algorithms is further streamlined by making the algorithms the "default" treatment plan for all applicable workers’ comp patients, explains Scott Westenberg, MD, FACEP, assistant medical director at St. Vincent’s. Unless the doctor specifies otherwise, the nursing staff and physician assistant staff know the algorithms should be employed. That eliminates a few steps in prescribing the appropriate treatment plan for many patients, and it also encourages the physicians to use the algorithms.
Getting the physicians to use the algorithms routinely has not been much of a problem, Westenberg says, but he points out that there has been more customizing’ of the algorithms than hospital leaders would prefer. In some cases, the physicians feel that the algorithm is generally applicable but they think a particular patient needs something extra. They may use the general advice of the algorithm but supplement it with bed rest, additional work restrictions, or similar additions. While that can defeat the purpose of the algorithms if done too much, Westenberg says he is confident the customizing will taper off as the physicians get more used to the algorithms and see they work well.
"The idea is very sound, and they will be good in practice over time," he says. "Algorithms work fine as long as you follow them exactly, but if people are used to doing things the way they want, there will be some transition before the algorithms are fully used."
As part of the encouragement for physicians to use the algorithms, Westenberg and other hospital leaders point out that outcomes data for workers’ comp patients will be much more reliable if the algorithms are used routinely.
Good results in first year with algorithms
From the occupational health perspective, the algorithms already are working well. Before the algorithms were installed, the emergency physicians prescribed bed rest far more often than the occupational health physicians would have in the same situations. The group discussion over the current thinking in occupational health enlightened some emergency physicians about the need to keep workers active and the degree to which many workers can remain functional even with an injury.
The algorithms have worked "remarkably well," Judd says. Patients are getting back to work quicker, and employers love the fact that they can expect a standardized treatment response even if their workers go to the emergency departments.
"We used to get a lot of phone calls from employers asking why we did things the way we did," Judd notes. "Those calls have almost dried up completely. When a patient falls through the cracks and isn’t treated according to the algorithms, the more sophisticated companies will call us and let us know. They like them, and they want us to follow them every time."
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