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Use interventions for drug seekers, those in pain
A sickle cell patient is in excruciating pain. A man who comes to your ED frequently always complains of different illnesses to obtain narcotic analgesics. These two patients have completely different needs, but you’ll need strategies to improve care for both.
To improve management of chronic pain patients, follow these steps proven to work:
• Give patients a "narcotic contract."
A narcotic contract was created for patients who frequently seek pain medications at the ED at Swedish Medical Center in Seattle, says Judy Street, RN, manager of emergency services. The contract informs patients that for future ED visits, the ED physician will evaluate whether pain medications are appropriate, says Street. Patients are asked to sign it and are given a copy, she adds. "The intent is to treat pain that is obviously not being managed by narcotic use, as well as to alert drug seekers that we will not assist in their continuation of abusing narcotics," Street says.
The contract is used at the discretion of the ED physician and nurse, she says. The ED’s social workers help to identify patients and explain the use of the contract, adds Street.
A discharge instruction sheet explains the appropriate use of narcotics and lists alternative therapies for management of pain such as heat, ice, and elevation, she says.
• Have a tracking system.
At Morristown (NJ) Memorial Hospital’s ED, a tracking system called EDIM (Emergency Department Information Manager) developed by Livingston, NJ-based Emergency Medical Associates is used to gauge the frequency of visits for pain, says Mark Mandell, MD, chairman of the department of emergency medicine. This system allows clinicians to see the patient’s complete history and physical, he adds.
"When a patient comes into the ED, it is easy to see how often the patient has been in the ED and why," he says. If something in the patient’s history alerts physicians that there could be a problem with narcotic abuse, the patient still will receive the medication, but the patient’s name is referred to the ED’s care manager, Mandell says. "Our procedure is that patients who come into the ED usually will get the benefit of the doubt and receive medication," he says.
However, the care manager will review the patient’s history, check with the patient’s doctors, and draw up a care plan for pain management, he explains. The care plan is placed in a book in the ED, and the patient’s chart is tagged with a code so the physician knows to look it up, Mandell points out. "The costs of the plan consist of having an individual who will call the patient’s physician and compose a care plan," he says. "I would guess that this would take no more than one hour per patient, maybe less."
The care plan also gives nurses a chance to educate patients who frequently come to the ED because they are unable to access appropriate follow-up care, says Richard Klemm, RN, the ED’s care manager. One man kept coming to the ED for pain medicines and antibiotics after surgery and told Klemm that he had to wait a long time for follow-up appointments. "At that time, I called the facility, made an appointment for him, documented it on the discharge instructions and in his care plan," he says. "We were able to decrease his visits from several each month to one visit every three or four months."
• Send patients a letter.
If a patient requests pain medication frequently, a letter is sent reviewing the patient’s history and informing him or her that no additional pain medications will be prescribed until further notice, Mandell says. (See sample pain management letter.) "It essentially cuts off the patient from narcotics unless we hear from the patient’s doctor that it is OK to continue," he says. This step discourages drug-seeking patients, Mandell explains. "Occasionally, we are able to steer patients with a drug problem to a treatment center," he says.
Some ED physicians tend to develop a following among certain individuals who come in on days when that physician is on duty, notes Mandell. This system avoids that problem, he says. "We are able to be generous with patients who require pain medication, knowing that we have a strategy to make sure that we do not attract drug seekers to the ED," he says.
The registered letters also reduce the frustration of nurses dealing with drug-seeking patients, Klemm says. If the registered letters sent to a patient are returned to Klemm, he places them in the care plan book located at the nurse’s station. Then when the patient returns to the ED, nurses will hand deliver the letter and then document it. "There is a sense of satisfaction among the staff when this occurs," he says. "The patients realize after the first or second visit that they will no longer be getting the narcotics and may choose not to return."
• Add a "special needs alert" at registration.
This alert helps to identify patients with chronic or episodic pain episodes, Street says. "The plans for these patients are on a shared drive requiring password access," she adds. For example, a sickle cell patient would be identified at registration as having an existing pain management plan in the ED, so treatment immediately can be started, Street explains. "We are able to identify patients for whom early intervention will improve outcome," she says. "As we all know, wait times in EDs are not going down."
For more information on improving care of patients with chronic pain, contact:
• Richard Klemm, RN, Emergency Department Care Manager, Morristown Memorial Hospital, Atlantic Health System, 100 Madison Ave., Morristown, NJ 07960. Telephone: (973) 971-5713. Fax: (973) 290-7209. E-mail: Richard.Klemm@ahsys.org.
• Mark Mandell, MD, Chairman, Department of Emergency Medicine, Morristown Memorial Hospital, 100 Madison Ave., Morristown, NJ 07960. Telephone: (973) 971-8919. Fax: (973) 290-7202. E-mail: Mark.Mandell@ahsys.org.
• Judy Street, RN, Emergency Services, First Hill Campus, Swedish Medical Center, 747 Broadway, Seattle, WA 98122. Telephone: (206) 386-2592. Fax: (206) 215-6520. E-mail: Judy.Street@swedish.org.