Implementation of an opioid reduction protocol utilizing alternatives for the treatment of pain in the emergency department of a level 1 trauma center
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Session F presented Friday, September 15, 2017
Purpose: Pain is the number one reason for emergency department visits in the United States. Many ED physicians find it quick and effective to prescribe opioids for patients that present complaining of pain. In many cases, opioids may be ineffective and do greater harm by contributing to abuse. By using an opioid-free, multimodal treatment approach to pain management, participants hoped to better control pain in patients entering the ED, as well as decrease the use of opioids in a population at high risk for abuse and misuse.
Design: This is a pre- and post- implementation analysis of an opioid reduction protocol in the emergency department.
Setting: This study was conducted in a 40-bed emergency department at an urban level 1 trauma center.
Participants/Subjects: Patients included in analysis included those seen in the emergency department during the following time periods: October-December 2015 (pre-implementation) and October-December 2016 (post-implementation).
Methods: For patients arriving in the emergency department with a chief complaint of pain, physicians were provided with a protocol containing a variety of non-opioid medication options organized by pain indication. Physicians received specialized training in the alternative therapy options and procedures. Prior to implementation, nurses were educated on the various pain treatment options including safety, administration, and side effects. Nurses received specific training on the use of AIDET-formatted scripting to "manage up" the alternative pain treatment options.
Total intravenous opioid medication use will be measured in morphine dose equivalents. Milligrams of morphine dose equivalents per patient seen will be collected for the study time period. Press Ganey results will be analyzed for the same time period, specifically questions regarding pain control. Chart review to identify numerical pain scores will be collected at baseline, 30 minutes, and 60 minutes for those patients treated with the opioid-free order set. Outcomes will be analyzed using the chi square and student t test.
Results/Outcomes: Preliminary results are being collected and analyzed. The post-implementation study period found a 30% reduction in IV opioid use compared to pre-implementation. Patient satisfaction scores remained consistent, even increasing from the pre-implementation period. Press Ganey scores specifically relating to pain control found an overall increase.
Implications: Preliminary results for this study conducted in a level 1 trauma center support a non-opioid approach to pain management in the ED. Education of the nursing and provider staff, in addition to the implementation of a new opioid-free alternative pain treatment order set in the CPOE system, led to a 30% overall reduction in intravenous opioid use. While concerns that the reduction in opioid use might lead to decreased patient satisfaction scores, the opposite occurred. Press Ganey patient satisfaction scores are at an all-time high. Survey responses to the question addressing pain control improved following the implementation of the initiative.
The key to making this program successful was nursing and provider buy-in. Staff embraced the change in practice and learned how to talk to their patients about the alternative treatment options. Rather than merely removing an option from pain management (opioids), pharmacists worked to provide alternative options that were easily accessible, effective, and evidence-based.