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Leah Steckler, MD

November 20th, 2017

According to the Centers for Disease Control, opioids were involved in 33,091 deaths in 2015 and overdoses have increased four-fold since 1999, including both illicit and prescribed opioid medications (1). This dramatic increase in mortality has persisted despite prescribers writing fewer prescriptions for opioids in the past few years (2).  It is possible that fewer opioid prescriptions may lead to more patients experiencing withdrawal.  Current practice approaches in the emergency department (ED) tend to focus more on symptomatic treatment with anti-emetic and anti-diarrheal agents, and referral to rehabilitation services (3).  The standard of care does not currently include opioid agonist-antagonists, like buprenorphine, in the acute period for the management of these patients. The unpleasant effects of withdrawal undoubtedly contribute to opioid addiction. As such, improving pharmacologic methods to control withdrawal symptoms may provide another means of fighting this epidemic.

An article in Annals of Emergency Medicine by Love et al. (4) presents an emergency medicine-focused snapshot of a recent Cochrane Review assessing our current opioid withdrawal treatments (5). This Cochrane Review analyzed data from 27 studies comparing buprenorphine to tapered methadone, and studies comparing buprenorphine with clonidine (an alpha-2 adrenergic agonist used commonly to treat withdrawal symptoms).

Love and colleagues suggest that buprenorphine administration in the ED may be an appropriate intervention for opioid withdrawal. Fourteen of the studies compared buprenorphine and alpha-2 adrenergic agonists as pharmacologic withdrawal management. Using data extraction, subgroups were analyzed and the results showed that patients treated with buprenorphine had significantly lower withdrawal scores and greater number of days in treatment than patients treated with alpha 2-adrenergic medications. The authors concluded that the number of patients needed to treat with buprenorphine was four in order for one additional patient to reach withdrawal treatment (4) (Figure 1).

Figure 1: Buprenorphine versus alpha2-adrenergic agonists for acute opioid withdrawal (4)

Upon reviewing the above information, it is clear that limitations still exist with the use of buprenorphine to treat opioid withdrawal. Buprenorphine is not without risk and may cause dangerous adverse effects including hypotension, derangements in liver function, and respiratory depression (6). It is important that prescribers are comfortable with the evidence behind a medication, that they understand appropriate dosing regimens, and that the medications are safe for patients. Further, a provider cannot prescribe buprenorphine without taking an 8-hour course and receiving a certificate from the Drug Enforcement Agency (7). Additionally, this topic has not been well studied in the ED population, and there is always the risk of patients becoming addicted to the treatment for their addiction (8). Starting withdrawal treatment in the ED may help to bridge opioid users to outpatient treatment and contribute to our country’s mission to stave off future opioid abuse. Continued research on buprenorphine use in the ED is certainly worthwhile.

Resources:

  1. Drug Overdose Death Data. 2014-2015 Death Increases. CDC. Available from: https://www.cdc.gov/drugoverdose/data/statedeaths.html
  2. S. Prescribing Rate Maps. Total number and rate of opioid prescriptions dispensed, United States, 2006-2016. CDC. Available from: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html
  3. Tintinalli Burillo-Putze G, Miro O. Opioids. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.proxygw.wrlc.org/content.aspx?bookid=1658&sectionid=109414267. Accessed November 10, 2017.
  4. Love, J, Perrone, J, Nelson, L. Should Buprenorphine Be Administered to Patients with Opioid Withdrawal in the Emergency Department? Ann Emerg Med. Published online November
  5. Gowing L, Ali R, White JM, et al. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017;2:CD002025.
  6. Epocrates. Available from: https://online.epocrates.com/drugs/7468/Belbuca
  7. Buprenorphine Waiver Management. Available from: https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management
  8. Addicted to a Treatment for Addiction. New York Times. 2016. https://www.nytimes.com/2016/05/29/opinion/sunday/addicted-to-a-treatment-for-addiction.html

Leah Steckler, MD is an Emergency Medicine Resident at The George Washington University Hospital

 

Ameer Khalek
November 13, 2017

 

If you haven’t heard by now, Urgent Matters holds an annual meeting at the American College of Emergency Physicians (ACEP) Scientific Assembly. While the exact theme changes from year to year, the meeting serves to bring together thought-leaders and innovators from the emergency medicine community. Thanks to Philips Blue Jay Consulting and Schumacher Clinical Partners, we are also able to acknowledge teams for developing and implementing effective solutions to common issues facing the emergency care community through our “Emergency Care Innovation of the Year Award.” This year, we received over 20 submissions and our reviewers narrowed them down to one winner and three honorable mentions.

Jesse Pines, MD MBA MSCE – Program Director, Urgent Matters
Rahul Sharma, MD MBA CPE – EM Physician-in-Chief & Medical Director, Strategic Initiatives
Hansen Hsu, MD – Director, EM Informatics & Co-Director, EM Telehealth Services
Peter Greenwald, MD MSC – Director, Telehealth QA & Co-Director, EM Telehealth Services
(Left to Right)

This year’s winner was New York Presbyterian/Weill Cornell Medical Center’s Emergency Department (ED) Telehealth Express Care Service. The ED Telehealth Express Care Service is an innovative ED-based telehealth program designed to streamline emergency care, reduce length of stay (LOS), and improve patient experience for patients with low acuity complaints.

The process for ED Telehealth Express Care patients begin as it would for any other ED patient: an in-person triage and assessment. A registered nurse speaks with the patient and categorizes the severity of their medical complaint. Next, an Advanced Practice Provider (Physician Assistant or Nurse Practitioner) evaluates the patient, performs the Medical Screening Exam which is required for all ED visits, and decides whether the Telehealth program would be medically appropriate. Qualification for the Telehealth Express Care Service is based on set criteria (available in the UM Toolkit). Participation by the patient is voluntary. If the patient declines, a physician will examine them in-person. The telehealth encounter takes place with the on-call Telehealth Physician, a board certified Emergency Medicine faculty member. Evaluation, diagnosis, treatment, and education are discussed at-length, with family members present if desired. Discharge instructions are printed directly at the end of the visit by the physician with any prescribed medications sent electronically to a pharmacy of the patient's choice.

So, why would someone physically go to an emergency department, only to be seen by a remote physician through a screen? Dr. Sharma responds in an Urgent Matters podcast:

When was the last time you actually went to the bank and went to the teller instead of the ATM to get cash? You don’t, you only go in when you need a certified check or something complicated.”

The data supports him. The ED Express Care Service has been in place since July 2016 is available at two of six EDs at New York Presbyterian: Weill Cornell - a Level 1 Trauma Center, and Lower Manhattan - a community hospital. Together these hospitals see an annual volume of over 140,000 visits. To date, over 4,000 patients have been through the ED Express Care Service with impressive results. Express Care Service has helped reduce wait times for low-acuity patients from 2.5 hours to an average 39 minutes from arrival to discharge. The project also helps to establish primary care appointments, and twenty percent of patients receive follow-up appointments via the in-house ED patient navigator program with a primary care physician or sub-specialist prior to discharge. From the first year of data, Express Care patients, compared to those receiving a traditional fast track evaluation, were younger (median age: 38 [IQR, 27-54] vs. 43 [31-58]; P<0.001) and more likely to be male (52% vs. 46%; P<0.001), Express Care patients had less acute illness as measured by triage severity score (ESI 4 or 5: 97% vs. 84%; P<0.001), and more likely being treated for wound check/suture removal and infectious illness. Express Care patients were less likely to have x-rays preformed as part of their ED evaluation (24% vs. 42%; P<0.001). Express Care patients were treated and released more quickly than fast track patients (median time door to discharge 39 minutes as compared to 120 minute). Express Care patients were less likely to return within 72 hours, and no Express Care patient returning within 72 hours required admission to the hospital. There was a trend to higher Press Ganey satisfaction among Express care patients as compared to fast track ED patients (median: 100 [87-100] vs. 89 [74-100]; P=0.15). Another analysis listed in their submission comparing older patients to younger patients in express care found that although Express Care patients trended younger than traditional ED pathway patients on average, patients 60 and older comprised 24% of the total Express Care population, indistinguishable from the percentage of people 60 and older in the conventional treatment fast track area. Among patients 60 years and over seen in Express Care, the average age was 72. There were no significant differences by age group with respect to 72 hour returns to the ED and a low likelihood for a change in treatment plan on return. In addition to eliciting patient feedback regarding satisfaction with the ED experience, the team surveyed participating physicians about their telemedicine background and experience with the program, with most physicians reporting a significant increase in comfort and positivity about telemedicine patient encounters.Future Direction

At the Urgent Matters meeting, Dr.’s Rahul Sharma, Peter Greenwald, and Hanson Hsu spoke on plans to expand the project by incorporating nursing homes consultation, telehealth kiosks in NYC pharmacies, and paramedic telemedicine visits for CHF patients. Dr. Greenwald also briefly mentioned the value of engaging with insurance companies to provide coverage for virtual urgent care as part of a benefits package. Dr. Ali Raja, Vice Chairman of the Department of Emergency Medicine at Massachusetts General Hospital was quoted in the Wall Street Journal saying, “Ten years from now, tele-emergency medicine will be the standard around the country. We’ll still have emergency departments for those patients who are critically ill, but I think we’re all headed in this direction.”

Personally, I would like to extend my congratulations to the ED Express Care team for their innovative, patient-centered, and value-driven work. Make sure to look out for an upcoming webinar with the New York Presbyterian/Weill Cornell Medical Center team (subscribe here).

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Ameer Khalek is a MPH student at the GWU Milken Institute School of Public Health

Greg Jasani 

November 8, 2017

At 1:42 pm on August 12th, 2017, a speeding car rammed into a group of protestors who had gathered in Charlottesville, Virginia, resulting in many injuries.  In the ensuing hours, the University of Virginia Health System (UVAHS) would be called upon to provide care to all of the victims of the day’s violence.  A recent article in ACEPNow, authored by some of the physicians there that day, details how UVAHS handled the sudden influx of critically injured patients. Their response to the day’s events, and the decisions made in the days before, provides an excellent example of how to provide critical care and coordination during a mass casualty event (MCE).

The emergency department at UVAHS had one advantage that many EDs facing a MCE do not; they had prior warning.  The white supremacist rally, and expected counter rally, had been scheduled in advance.  Due to this, the ED was able to take proactive steps to better prepare themselves for the anticipated surge in volume.    The ED reviewed and updated their emergency notification procedures as well as each member’s roles in the medical care team.  They also created two additional shifts around the event to increase the number of providers.  Other departments that expected to be impacted by the protests (ie anesthesia and critical care) also underwent similar preparations.

Outside of the ED, the UVA hospital also took active steps to prepare for the increased surge.  One of the areas that the hospital took active steps to optimize was capacity.  The hospital leadership decided to limit non-urgent procedures 48 hours before the protests.  Additionally, transfers into the hospital were also curtailed.  These actions freed up significant inpatient space that allowed patients to move out of the ED faster.  Also, additional patient care areas were created; the hospital lobby was converted into a triage area for the ED and an invasive radiology recovery area adjacent to the ED was used as an admissions holding area.

The ED also worked closely with community EMS, firefighter, and law enforcement personnel.  In addition to reviewing and updating their operating procedures, UVAHS took the additional step of creating a command center to better coordinate everyone’s response to the event.  The command center had an incident commander as well as general staff positions (ie, clinical operations, logistics, plans, public information, and communications), each responsible for their specific area of UVAHS function.  The command center closely monitored events at the protests through radio, real-time video monitoring, and even social media.  Thus, within three minutes of the car hitting the protestors, the command center was alerted and began coordinating the response.

Ten patients had to be admitted (to either the OR or critical care areas) and nine were treated and discharged by the ED.  One woman, Heather Heyer, sadly died from her injuries in the ED.  Yet perhaps the most astonishing thing about that day’s events was how little it impacted the operation of the UVA ED.  While caring for the victims of the day’s violence, the ED continued to treat non-event patients with no real disruption of service.  Additionally, within two hours of initial notification of the MCE, the ED returned to normal operations.

Unfortunately, violence came to Charlottesville and the ED had to provide urgent care to many seriously injured patients.  Yet the ED managed to respond swiftly and likely kept the death rate from going higher than it did.  While the skill and courage of the ED providers definitely deserve praise, it was the thorough planning and coordination that allowed the health system to react appropriately and operate smoothly during that time of high stress.  This incident shows that, as much as possible, health systems should take pro-active steps to prepare themselves when it’s likely that a MCE will come to their community.

References

Brady W, Berry T, Ginsburg J, Iftikhar S, Izadpanah K, Lindbeck G, Sutherland S, O’Connor R.  UVAHS Emergency Team Helps Victims in Charlottesville Tragedy.  ACEPNow [Internet]. 2017 Oct 15.  Available from: http://www.acepnow.com/article/uvahs-emergency-team-helps-victims-charlottesville-protest-tragedy/

 


Greg Jasani is a fourth year medical student at the GW School of Medicine & Health Sciences