The emergency room is a hotbed for opioid abuse. Patients visiting the ER often are treated for pain, and opioids are a traditional remedy for doing that.
Colorado ERs work together to lower opioid prescribing by 36%
But as opioid addiction ravages communities across the U.S., a group of ER clinicians in Colorado have changed how they treat pain, recognizing the contribution they have made to the crisis by their prescribing patterns.
“What we were doing with opioids was harming our population instead of helping,” said Dr. Don Stader, an ER physician at Swedish Medical Center in Englewood and architect of the Colorado Opioid Safety Pilot. “We helped create this epidemic.”
The pilot project, which includes ERs from Swedish Medical and nine other hospitals across the state, focuses on using opioid alternatives for treating pain. The project is led and supported by the Colorado Hospital Association and the Colorado chapter of the American College of Emergency Physicians.
The results so far are promising. The 10 ERs decreased opioid usage by 36% from June to November 2017. That's 35,000 fewer opioid prescriptions during the 2017 pilot versus the 2016 baseline period. The effort required the ERs to make significant changes, the biggest being cultural, Stader said. “For us physicians and nurses, we had all been so used to using opioids for everything regarding pain, so trying to change and use the opioids sparingly was a significant cultural change.”
Train ER staff on alternative medicines that can be used in lieu of opioids to treat pain.
Direct physicians and nurses to discuss with patients the harms of opioids and what other treatment options might be available to them.
Track through data collection how the practice changes have affected opioid prescribing patterns.
The first step of the project was to train clinical teams to use other medications like ibuprofen and lidocaine. The training was both in-person and through webinars. The pilot focuses on using alternative medicines to treat five ailments: headache, abdominal or musculoskeletal pain, kidney stones and extremity fractures. Stader said the ERs quickly applied the alternative medicines to other conditions as well.
Data-reporting stipulations were established so ERs could watch their progress and share it with the Colorado Hospital Association, which tracked progress at the pilot sites.
A critical component to successful adoption of the experiment was buy-in from clinicians, said Dr. Adam Barkin, an ER physician at Sky Ridge Medical Center, Lone Tree, Colo., part of the pilot.
Support from pharmacists was key because they had to ensure the alternative medicines were adequately stocked and readily available to patients in the ER, he said. “Our goal is to control the patient's pain and control it quickly.”
Nurses were also essential to the project, Stader said. Patients interact with the nurse more than anyone else on the care team, so they are more likely to tell nurses if the alternative medicine isn't adequately treating their pain.
Communication with patients about their pain levels went through a transformation because of the project. Physicians don't typically ask patients many questions about their pain before they order an opioid. Physicians in the pilot were trained to inquire if the patient even wants something for the pain. Some patients will opt not to take a drug if it can be avoided, Stader said.
Then if the physician decides an opioid alternative is the best option, that will be discussed with the patient. The caregiver will also explain the possible adverse effects of opioids. Stader said patients have been supportive. “Patients have been enthusiastically open to trying alternative medications.”
Although both Stader and Barkin haven't heard negative reactions from patients about the experiment, the Colorado Hospital Association asked the pilot sites to add two questions to their patient experience surveys: How well was your pain controlled, and what is your likelihood of recommending the ER? Those results aren't yet available.
Given the pilot's positive results, the hospital association hopes to get more ERs in the state to adopt the practice.
Barkin said the experience has been so great for staff and patients that the ER will continue using alternatives when possible.
“It has become ingrained in our practice. There is still more work we can do, but fundamentally the practice of ER medicine at Sky Ridge, and I think at all the pilot hospitals, has changed,” he said.
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