The potential impact of alternatives to opioids (ALTO) protocol on opioid reduction in the community emergency department
DOI:
https://doi.org/10.5055/jom.0895Keywords:
pain management, opioid reduction, emergency departmentAbstract
Objective:To investigate the potential impact of implementing alternatives to opioids (ALTOs) protocol in a community emergency department (ED) in North Texas. We hypothesize that the ALTO protocol is associated with decreased opioid utilization without affecting patient satisfaction to pain control and ED flow.
Design:A retrospective, single-center, cohort study.
Setting:An urban ED.
Participants:Adult patients (age >18 years old) who received pain medications in ED during the study timeframe were included. A total of 34,251 patients were included for final analysis.
Intervention:Patients receiving pain medication after the implementation of the ALTO protocol during March to August 2019 and patients during the same period from the prior year were identified as the post-protocol group and preprotocol group, respectively.
Main outcome measures:The primary outcome was the change in ED opioid administration. Secondary outcomes included patient satisfaction to pain control, left without being seen (LWOBS), door-to-doctor time, and turnaround time.
Results:The total opioid administration rate decreased by 59.6 percent after the implementation of the ALTO protocol. The percentage of patients that LWOBS (p = 0.003) and the average door-to-doctor time (p < 0.001) were significantly decreased in the post-protocol group. There was no significant difference in patient satisfaction to pain control (p = 0.192) and average turnaround time (p = 0.209).
Conclusions:Implementation of an ALTO protocol was associated with a significant reduction of opioid administration without a negative impact on patient satisfaction regarding pain control and ED flow.
References
Rech MA, Griggs C, Lovett S, et al.: Acute pain management in the emergency department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med. 2022; 58: 57-65. DOI: 10.1016/j.ajem.2022.05.022.
Goldstick JE, Guy GP, Losby JL, et al.: Changes in initial opioid prescribing practices after the 2016 release of the CDC guideline for prescribing opioids for chronic pain. JAMA Netw Open. 2021; 4(7): e2116860. DOI: 10.1001/jamanetworkopen.2021.16860.
Coffin PO, Martinez RS, Wylie B, et al.: Primary care management of long-term opioid therapy. Ann Med. 2022; 54(1): 2450-2468. DOI: 10.1080/07853890.2022.2121417.
Barnett ML, Olenski AR, Jena AB: Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017; 376(7): 663-673. DOI: 10.1056/NEJMsa1610524.
Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain–United States, 2016. JAMA. 2016; 315(15): 1624-1645. DOI: 10.1001/jama.2016.1464.
Werb D, Scheim AI, Soipe A, et al.: Health harms of non-medical prescription opioid use: A systematic review. Drug Alcohol Rev. 2022; 41(4): 941-952. DOI: 10.1111/dar.13441.
US Department of Health and Human Services: 2018 annual surveillance report of drug-related risks and outcomes—United States. Surveillance special report. Available at https://www.cdc.gov/drugoverdose/pdf/pubs/2018cdc-drug-surveillance-report.pdf. Accessed January 12, 2024.
Hedegaard H, Miniño AM, Warner M: Drug overdose deaths in the United States, 1999-2019. NCHS Data Brief. 2020; 394: 1-8.
Wilson N, Kariisa M, Seth P, et al.: Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep. 2020; 69(11): 290-297. DOI: 10.15585/mmwr.mm6911a4.
Sutherland TN, Wunsch H, Pinto R, et al.: Association of the 2016 US Centers for Disease Control and Prevention opioid prescribing guideline with changes in opioid dispensing after surgery. JAMA Netw Open. 2021; 4(6): e2111826. DOI: 10.1001/jamanetworkopen.2021.11826.
Yang BK, Storr CL, Trinkoff AM, et al.: National opioid prescribing trends in emergency departments by provider type: 2005-2015. Am J Emerg Med. 2019; 37(8): 1439-1445. DOI: 10.1016/j.ajem.2018.10.041.
Patanwala AE: When less is more: Opioid use in the emergency department. Am J Health Syst Pharm. 2019; 76(22): 1812- 1813. DOI: 10.1093/ajhp/zxz194.
Motov S, Strayer R, Hayes B, et al.: AAEM white paper on acute pain management in the emergency department. American Academy of Emergency Medicine (AAEM). Available at https://www.aaem.org/resources/statements/position/whitepaper-on-acute-pain-management-in-the-emergency-department. Accessed December 11, 2022.
LaPietra AMS, Motov S, Rosenberg M: Alternatives to opioids for acute pain management in the emergency department: Part I. Emergency medicine reports. Available at https://www.reliasmedia.com/articles/138799-alternatives-to-opioids-foracute-pain-management-in-the-emergency-department-part-i. Accessed August 30, 2021.
Papa L, Maguire L, Bender M, et al.: Patient controlled analgesia for the management of acute pain in the emergency department: A systematic review. Am J Emerg Med. 2022; 51: 228-238. DOI: 10.1016/j.ajem.2021.10.042.
Duncan RW, Smith KL, Maguire M, et al.: Alternatives to opioids for pain management in the emergency department decreases opioid usage and maintains patient satisfaction. Am J Emerg Med. 2019; 37(1): 38-44. DOI: 10.1016/j.ajem.2018.04.043.
Hughes JA, Brown NJ, Chiu J, et al.: The relationship between time to analgesic administration and emergency department length of stay: A retrospective review. J Adv Nurs. 2020; 76(1): 183-190. DOI: 10.1111/jan.14216.
Stader D, Wald H, Rossi MacKay D, et al.: Alternatives to opioid protocols in Colorado Emergency Departments reduce opioid use without changing reported pain. JACEP Open. 2020; 1(6): 1493-1499. DOI: 10.1002/emp2.12263.
Sharp AL, Shen E, Wu YL, et al.: Satisfaction with care after reducing opioids for chronic pain. Am J Manag Care. 2018; 24(6): e196-e199.
Hallway A, Vu J, Lee J, et al.: Patient satisfaction and pain control using an opioid-sparing postoperative pathway. J Am Coll Surg. 2019; 229(3): 316-322. DOI: 10.1016/j.jamcollsurg.2019.04.020.
Preuss CV, Kalava A, King KC: Prescription of Controlled Substances: Benefits and Risks. Treasure Island, FL: StatPearls, 2022.
Hwang U, Richardson L, Livote E, et al.: Emergency department crowding and decreased quality of pain care. Acad Emerg Med. 2008; 15(12): 1248-1255. DOI: 10.1111/j.1553-2712.2008.00267.x.
Hwang U, Richardson LD, Sonuyi TO, et al.: The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc. 2006; 54(2): 270-275. DOI: 10.1111/j.1532-5415.2005.00587.x.
Ouyang H, Wang J, Sun Z, et al.: The impact of emergency department crowding on admission decisions and patient outcomes. Am J Emerg Med. 2022; 51: 163-168. DOI: 10.1016/j.ajem.2021.10.049.
Pines JM, Hollander JE: Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008; 51(1): 1-5. DOI: 10.1016/j.annemergmed.2007.07.008.
Gardner RL, Sarkar U, Maselli JH, et al.: Factors associated with longer ED lengths of stay. Am J Emerg Med. 2007; 25(6): 643-650. DOI: 10.1016/j.ajem.2006.11.037.
El Sayed MJ, El-Eid GR, Saliba M, et al.: Improving emergency department door to doctor time and process reliability: A successful implementation of lean methodology. Medicine. 2015; 94(42): e1679. DOI: 10.1097/md.0000000000001679.
Mixon M, Dietrich S, Floren M, et al.: Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services. Am J Emerg Med. 2021; 44: 291-295. DOI: 10.1016/j.ajem.2020.04.008.
Jaffe TA, Goldstein JN, Yun BJ, et al.: Impact of emergency department crowding on delays in acute stroke care. West J Emerg Med. 2020; 21(4): 892-899. DOI: 10.5811/westjem.2020.5.45873.
Pryce A, Unwin M, Kinsman L, et al.: Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow. Int Emerg Nurs. 2021; 54: 100956. DOI: 10.1016/j.ienj.2020.100956.
van der Linden MCC, van Ufford H, van der Linden NN: The impact of a multimodal intervention on emergency department crowding and patient flow. Int J Emerg Med. 2019; 12(1): 21. DOI: 10.1186/s12245-019-0238-7.
Anderson SW, Bhattacharjee S, Patanwala AE: Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States. Am J Emerg Med. 2020; 38(9): 1802-1806. DOI: 10.1016/j.ajem.2020.06.002.
Hitti E, Hadid D, Tamim H, et al.: Left without being seen in a hybrid point of service collection model emergency department. Am J Emerg Med. 2020; 38(3): 497-502. DOI: 10.1016/j.ajem.2019.05.034.
Nguyen BN, Barta RJ, Stewart CE, et al.: Ketorolac for patients undergoing implant-based breast reconstruction: Impact on hospital length of stay and postoperative narcotic use. Aesthet Surg J. 2020; 40(2): 174-179. DOI: 10.1093/asj/sjz179.
Storrow AB, Zhou C, Gaddis G, et al.: Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: A simulation model. Acad Emerg Med. 2008; 15(11): 1130-1135. DOI: 10.1111/j.1553-2712.2008.00181.x.
Gorski JK, Arnold TS, Usiak H, et al.: Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department. Am J Emerg Med. 2021; 48: 73-78. DOI: 10.1016/j.ajem.2021.04.005.
Rathlev NK, Visintainer P, Schmidt J, et al.: Patient characteristics and clinical process predictors of patients leaving without being seen from the emergency department. West J Emerg Med. 2020; 21(5): 1218-1226. DOI: 10.5811/westjem.2020.6.47084.
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