New guidelines create an 'Oxy-free' ED
Aim is reduced deaths from prescription narcotics
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The EDs at several Swedish Medical Center hospitals in the Seattle area have adopted guidelines aimed at significantly restricting the dispensing of Schedule II narcotics such as oxycodone, dilaudid, morphine, methadone, and fentanyl in an effort to combat the dramatic rise in abuse and overdose deaths associated with those drugs.
"For most ED doctors there's a kind of battle with people who are seeking opiates," notes Russell Carlisle, MD, director of the ED at Swedish Medical Center/Cherry Hill.
While noting that such medications are certainly needed for treating acute pain, and that they might be required on occasion for chronic pain, although the cause is often multi-factorial, "it usually is not," says Carlisle. Therefore, he notes, you have to be careful with who gets these addictive and dangerous drugs.
"Our guidelines actually came from the Washington ED Opioid Abuse Workgroup, which was started by Darren Neven, an ED doctor from Spokane," Carlisle says. While Neven's guidelines were directed more toward the opioid abuse group of patients, "we applied it to not only abusers, but across the spectrum," Carlisle says. (A copy of the guidelines can be found, here.)
Patients are tiered into two separate groups: "opiate tolerant," who are people who have had opiates before, and "opiate naive." "So if I go into an ED and I am opiate naïve, I do not need to be knocked over with the strongest opiate. A mild drug would probably be OK for me, even with strong pain," says Carlisle. "And, I do not need 30 pills. Maybe five would be more appropriate."
For such patients, evidence-based medicine is used to explain why they're not getting a stronger drug. "Studies show if you have these drugs for more than a week, the risk of disability is doubled. If you get more than 150 morphine doses, your risk of disability is doubled," Carlisle explains. In addition, he notes, 30% of people have a predilection for addition and 15% have "a very strong one."
These are guidelines, not rules, he emphasizes. "There are clear exceptions written in them," he notes. "If you think pain is exceptional, you can use the drug. If you come in with a severe injury, you get IV morphine." For patients who are opiate tolerant, however, the only exception would be a chronic pain patient on a protocol, he notes. "It's generally the wrong thing to do, because it tends to increase the risk of addiction and reward your coming to the ED," he explains. "These patients generally do worse on narcotics." (Carlisle says sharing data with his physicians helped ensure compliance. See the story, below.)
Laurie Kates, MD, an ED staff physician at Swedish Cherry Hill, says that because "nothing is set in stone" the doctor's evaluation plays a key role in whether patients receive these drugs. "If it's something objective like a broken bone, that makes it easier," Kates says. "There's nothing wrong with narcotic medications for certain indications, but having a policy that we will not refill them or treat chronic pain conditions does make it simpler."
To help ensure clear communications with patients, signs in the ED explain to patients that due to the recent increase in nationwide deaths related to abuse of narcotics, the Swedish doctors are following guidelines designed to significantly limit prescriptions for narcotics. The explanation also is printed on a sheet of paper, and when patients come in, the doctors review it with them. Carlisle says, "We ask them to read it while we do our assessment. That actually sets a platform or boundary." (For more on the value of this boundary, see the story, below.)
Although the program does help staff deal with those patients who are seeking drugs, "It's not really directed at them, but at everyone," says Carlisle.
Still, says Kates, she appreciates the fact that the guidelines take away any potential conflict. "If you think a patient is drug-seeking, it's easier just to say this is our policy. It really reduces any confrontation that may have come up in the past," she says. "More importantly, people understand we're trying to reduce the overall amount of narcotics leaving the ED. It's not meant to be punitive to any one individual, and I don't feel people take it that way, either." (To help ensure this program's success, ED nurses received inservices. See the story below.)
For more information on rolling narcotics policies, contact:
- Russell Carlisle, MD, ED Director, Laurie Kates, MD, ED Staff Physician, Swedish Medical Center/Cherry Hill, Seattle. Phone: (206) 320-2000.
Inservice helps prepare nurses
Nurses played a "minimal" role in the implementation of new guidelines restricting use of Schedule II narcotics in the EDs at several Swedish Medical Center hospitals in the Seattle area, says Melody Schlaman, RN, nurse manager for the ED at Swedish Cherry Hill. However, inservices for nurses played an important role in preparing them for the new process, Schlaman says.
"It was a verbal inservice, telling them that our doctors, based on trends both nationally and statewide with deaths related to oxycodone, decided to take a chance and no longer prescribe these medications to take home," Schlaman says. "We showed them the reasons why and gave them access to the supporting documentation."
This education was important, she says, because "sometimes as nurses we need something to back up what we tell patients. If you have a drug-seeking patient and realize this is a physician practice decision, you need to share that with patients." If the patients start escalating, says Schlaman, "all our staff has very strong de-escalation training and can partner that with the Schedule II training they received."
For more information on nursing inservices, contact:
Show docs data to achieve buy-in
Data can be a powerful tool for gaining physician buy-in, says Russell Carlisle, MD, director of the ED at Swedish Medical Center/Cherry Hill in the Seattle area. Carlisle used such an approach quite effectively recently when implementing guidelines that severely restricted the use of Schedule II narcotics in the ED.
"We have an EMR, and we share data with the doctors," he explains. "For each doctor we track the number of prescriptions per month and the number of pills per prescription."
While the physicians' names do not appear on the reports, their numbers do, and every physician knows his or her number. With this system, they can glance at the report and see how their performance matches up against that of their colleagues. "No one wants to be an outlier," Carlisle says.
He knows from experience that this approach works. "I used it for length of stay," he recalls. "The slower doctors got faster."
'Platform' helps avoid conflicts
When dealing with chronic pain patients, it's important to initially set a platform or boundary in the discussion, says Laurie Kates, MD, staff physician in the ED at Swedish Medical Center/Cherry Hill in the Seattle area.
"You establish right off that you have a program and it has guidelines based on what's best for patients and the community and that you probably will not be able to deviate from those guidelines," says Kates. "Otherwise, you'll be in a fight, and you want to avoid a fight."
It's good to show any of your chronic pain patients not just drug-seekers these guidelines because it increases their awareness of the problem, she says. "These medications that they may go home with are in fact quite dangerous. The worst thing to have happen would be for some of your teen-age children's friends to discover them in your medicine cabinet during a party, and pretty soon one or two of those kids who have a tendency to have an addiction take some."