Long before the COVID-19 pandemic, frontline providers were confronting an epidemic of patients struggling with opioid use disorders (OUD). It appears the pandemic has exacerbated the problem, with rising numbers of opioid overdose deaths.
Recognizing the urgent need for improvement in this area, the American College of Emergency Physicians (ACEP) is rolling out a new accreditation program that is aimed at nudging EDs across the country to up their game when it comes to both the treatment of pain and the way they manage patients who present with OUD.
Called Pain and Addiction Care in the ED (PACED), the program sets benchmarks for best practice in these two intertwined areas while recognizing EDs vary widely in terms of size and the populations they serve.
Program developers are sensitive to the fact that resources are strained in many areas hit hard by the pandemic, but they are nonetheless urging frontline providers to stay open to make long-needed improvements.
“We have to remember that [EDs] are open 24 hours a day for anyone who comes and sees us. The majority of our patients come to see us for pain,” observes Alexis LaPietra, DO, FACEP, chair of the PACED board of governors. “Pain and addiction are rampant. The opioid epidemic is not going anywhere, and it does not have an expiration date. We feel that COVID-19 does.”
Highlight Best Practice
While treating pain is a bread-and-butter issue for emergency providers, ACEP maintains there is ample room to progress. “We know EDs are good at lots of things, but we also know there is a lot of practice variability from physician to physician,” observes LaPietra, chief of pain management and addiction medicine at St. Joseph’s University Medical Center in Paterson, NJ.
With the opioid epidemic raging, emergency providers must adopt better prescribing habits because they do play a role. “We are not the main prescribers of opioids nationally, but sometimes we are the first place that patients touch down after a painful experience. Sometimes, we can really drive the care they receive based on the medication we give them in the ED,” LaPietra says. “The goal [of the accreditation program] is really to elevate bread-and-butter [practice] through evidence, through support like an accrediting body of a national professional organization, and [through understanding] that the department and the hospital should be behind you in this effort.”
For example, LaPietra notes PACED developers do not want one physician who is trying to engage in best practice to feel like he or she does not have the support of executive leadership. Developers also do not want these providers to struggle to access medicines he or she knows can be effective.
“We want hospitals, EDs, physicians, and all frontline staff to understand what is the best-case scenario for these pain management issues,” LaPietra explains. “We all have a united front knowing that we are serving our communities in ... the best way possible with the constant reminder that we need to reduce opioid harms.”
LaPietra stresses opioids remain a vital part of pain management, but providers need to be judicious in prescribing them. “Let’s treat [opioids] like high-risk medicines because they are,” she says. “We cannot live without these medicines. Patients need these medicines, but we should never give them out without appropriate education on the provider’s part and appropriate education for the patient.”
Considering the different characteristics of EDs across the country, it took time to develop the array of accreditation options available through PACED. The board of governors spent three years sifting through the literature, discussing what constitutes best practice, and determining how the program should be built.
“There is a lot of detail that goes into this, and we wanted to constantly have the focus be on opioid harm reduction,” LaPietra reports. “We wanted opioids to be used, but we wanted them to be used really judiciously.”
Pain and addiction are mutually exclusive, but a patient does not develop an OUD if he or she has never seen an opioid drug. Consequently, while program developers wanted to help frontline providers use opioids appropriately, they also wanted them to have the tools to properly treat a patient who presents with OUD.
Program developers solicited input from emergency medicine practitioners working in academic settings, small community hospitals, and critical access settings. “We tried to have a cross section of all different providers to see how all of [the evidence] could be pared down and translated into a best practice program that can be implemented at different levels,” LaPietra says.
Choose from Three Levels
Ultimately, developers settled on three levels of accreditation: Gold, Silver, and Bronze.1 Each level is associated with a range of capabilities. For instance, EDs seeking Gold-level accreditation need to maintain large, multidisciplinary pain and addiction management teams that involve nursing, information technology, pharmacy, quality improvement, and emergency providers.
Along with a broad array of pain medicine, Gold-level EDs should offer non-pharmacological interventions, such as ice and elevation.
“We are also asking the Gold-level EDs to address special populations. That would include pediatric, geriatric, and pregnant patients,” LaPietra says.
For addiction care, Gold-level EDs must employ physicians who have obtained their DATA 2000 X waivers and can provide buprenorphine or naloxone when patients present in opioid withdrawal. Collaboration with outpatient treatment centers also is a must.
“Then we know exactly where the patient is going, and exactly what day and time they will receive follow-up care,” LaPietra says. “[Patients] are not just discharged, and we say ‘good luck.’”
Gold-level EDs also need to offer harm-reduction education to patients. For example, patients who are not interested in buprenorphine treatment need to be informed about where they can go if they decide to stop using, and where they can obtain clean needles.
In short, the Gold-level EDs should offer the highest level of pain and addiction care that may even go beyond pharmacological interventions. These might include ultrasound-guided regional anesthesia, nerve blocks, trigger point injections, and osteopathic manipulative therapy.
The Silver and Bronze accreditation levels each follow a similar pathway, but include fewer requirements. For instance, while the Gold level requires EDs to use at least four different pain management protocols, the Silver level requires two protocols, and the Bronze level requires one protocol.
Similarly, where the Gold level requires EDs to offer at least six nonopioid medication protocols, the Silver level requires four such protocols, and the Bronze level requires two protocols.
When specifying the requirements for Bronze-level EDs, program developers were thinking about the resources available at many small critical access hospitals.
“The Bronze level does not require a physician champion, and does not require that a physician lead the pain and addiction care team,” LaPietra says. “This can be a clinician or provider who is willing to at least review some cases looking at pain and addiction.”
Further, these individuals need to understand the possibility of nonopioid alternatives for treating musculoskeletal pain, such as over-the-counter anti-inflammatories. Bronze-level EDs will reach for non-pharmacological interventions as much as possible.
They will provide information about OUD, and they will contact any treatment facilities within a reasonable drive to see if they can establish a relationship.
“We basically want the Bronze-level EDs to know there is still something that can be done,” LaPietra says. “No, they may not be doing nerve blocks and, no, they may not have their X waivers, but they can still use opioid-sparing strategies.”
Involve the Team
The PACED board also includes members from the Emergency Nurses Association (ENA), the American Society of Health-System Pharmacists, the Society of Emergency Medicine Physician Assistants, and the American Association of Nurse Practitioners.
“Emergency medicine is a team sport,” LaPietra notes. “We have our physician side of things, and then we have nursing, pharmacy, and mid-level provider input. When hospitals are applying [to PACED], we want to make sure we are addressing the needs of each those frontline providers.”
Cathlyn Robinson, MSN, RN, CEN, a clinical education specialist in the ED at St. Joseph’s University Medical Center, is serving as ENA’s representative for the PACED program. She worked alongside LaPietra in implementing the Alternatives to Opiates (ALTO) program at St. Joseph’s several years ago.
Robinson testifies to the importance of making such programs interdisciplinary. “When we were developing that program, I developed the nursing education component that went along with it,” she explains. “[That involved] teaching nurses how to identify a patient who would be appropriate for an ALTO approach, and how to communicate with these patients and families. Many patients do not necessarily understand why we are not going to give an opioid first.”
Much of that work has carried over into PACED. Of particular importance to nurses is education about how to use the medications in a way that is not particularly conventional. For example, Robinson notes nurses generally are accustomed to administering lidocaine for a cardiac condition, but the drug also can be used for pain control.
“Teaching nurses why this works, how it works, and how we administer it is completely different,” she says.
Another non-opioid therapy that can be used effectively in some patients is nitrous oxide. Robinson encourages nurses to suggest this option to the treating provider.
“I can’t give nitrous myself as a nurse, but I can certainly go get the machine, and set it up for the physician,” she says.
Robinson says nurses often encounter pushback from patients when a physician prescribes a non-opioid drug for pain.
“The patient will say that drug is not going to work for him. Then, it is up to the nurse to communicate why [the care team] wants to use this drug, how it works, and how to take it,” she explains. “Generally, with that sort of communication, patients better understand how we are trying to treat their pain.” When it comes to addiction care, nurses play a critical role in assessing whether a patient is ready to engage in treatment, and then explaining to the patient how a warm handoff will work. Robinson says whether a patient enrolls in treatment depends on whether the nurse has engaged and connected with him or her during their encounter.
Nurses may be the first providers to identify patients who are in withdrawal from an opioid. Such patients may be candidates for buprenorphine. Further, if a physician orders buprenorphine for a patient, a nurse usually will administer the drug, a task that requires appropriate education.
“It is an interesting drug to administer because it is given under the tongue,” Robinson explains, noting the nurse needs to direct the patient to avoid swallowing the drug because it deactivates in the stomach.
However, Robinson stresses nurses need to understand buprenorphine carries much street value. “If you don’t go back and check on the patient in about 10 to 15 minutes after you have given them the drug, they may take it out of their mouths and stick it in their pockets to sell on the street,” she shares. “If the drug is not under their tongue — it takes a while to dissolve — we will know that the patient has either pocketed it or swallowed it.”
Sometimes, an initial buprenorphine dose is not enough to provide sufficient recovery to a patient in withdrawal. A nurse may observe a second dose is necessary.
“Make sure that the physicians and nurses are all on the same page, and that we are constantly thinking about opportunities to help these patients, whether that is through a warm handoff or considering buprenorphine as an option,” Robinson says.
Start the Process
EDs interested in becoming PACED-accredited must complete an application.2 LaPietra advises ED leaders to review the requirements for each accreditation level to see where their facility fits. The cost to become accredited is $2,500 for Bronze, $5,000 for Silver, and $10,000 for Gold.
Two members of PACED’s board of governors review applications, which include proof facilities have met each requirement for the desired accreditation level.
“There is also an opportunity for [applicants] to comment or [correspond] with the review team as they are going through the process,” Robinson says. “We, too, reserve time to reach back out to the institution if things are not clear.”
The reviewers selected for each application always work outside the applicant’s region. “We do not want anyone to be reviewing colleagues or places where they work,” Robinson says.
After reviewing the application, the two governors will score it. “If there is a discrepancy between the reviewers, the [application] will then be opened up to the entire board of governors for a formal review,” LaPietra explains.
If there is no discrepancy, the reviewers will provide their reasons for accepting or rejecting the application. Then, the full board will vote. “If it is determined that the institution fulfills all criteria, then we will formally accredit it,” LaPietra says. “We also have a marketing team available to [successful applicants] if they need some assistance on how to let their communities know ... that they have just been recognized [for pain and addiction care quality].”
Additionally, following an initial accreditation designation, EDs can reapply after three years to seek a higher-level designation. LaPietra’s facility recently became the first Gold-level ED. There were at least two other EDs working toward Gold certification. At least two other facilities are working toward Bronze-level accreditation.
Ultimately, LaPietra is hopeful the new program will disseminate best practices for pain and addiction care nationally, and help frontline providers understand there is a mechanism available to guide them toward improvement in this area. “We would like to present EDs with a checklist that has been thoroughly reviewed by a national, professional organization,” LaPietra observes. “It is hard for EDs to digest all of the evidence and to know what exactly is best practice right now for pain and addiction care. We wanted to take that work out of it.”
For EDs that are lacking in certain areas, the PACED program offers educational resources that can be leveraged to help them improve. “If an ED is close to Gold, and [department leaders] are just lacking in one thing, they can click on an array of tools, educational podcasts, and different publications so that they can do some quality improvement work to get them to that Gold,” LaPietra reports.
LaPietra sees the new process as similar to national guidelines that have been established for other conditions like stroke and heart attack.
“Now, we have pain and addiction guidelines,” she says. “We wanted to make it that easy [for EDs] to provide the best pain and addiction care that they can for their communities.”