Patients in our medical management initiative were suggested by physicians, nurses, and pharmacists working in the ED and referred to the committee. These patients were reviewed by a multidisciplinary team made up of physicians (hospital medicine and emergency medicine), nurses, pharmacists (ED pharmacist and pain pharmacist), social work and behavioral health, and legal representation. Every patient that was referred was reviewed by the multidisciplinary committee. Most patients referred were entered into the program after all patient details were reviewed. There was also tracking of number of visits, number of CT scans ordered for the same patient complaint, and number of opioid prescriptions written. The committee met quarterly with additional meetings as needed to review new patients.
Utilizing chart review for the most frequent complaints, a plan was developed to address the patient’s care. These plans utilized non-opioid alternatives to address the patient’s pain. If patients were dissatisfied with their medical management plan, they were told to return at 9 AM on the next business day to discuss the plan with the ED pharmacist. Once a plan was finalized for a patient, an easily identifiable icon was attached to their electronic medical record. The medical provider would open the icon and could easily identify the detailed plan for the patient’s care. Every effort was made to encourage advanced practice providers and physicians to follow the treatment plan in order to provide continuity in the care of the patient. Patients were allowed and encouraged to discuss their plan; however, no changes were allowed or negotiated during an ED visit. The committee reviewed plans on an ongoing basis to keep them updated, and any changes were updated in the electronic medical record.
All patients included in the intervention were listed in a spreadsheet, and clinicians reviewed the EMR for the following data elements: (1) demographic characteristics: age, gender, race/ethnicity, residence type, and insurance; (2) clinical: patient’s chief complaint, past medical history, substance abuse history, primary care provider, and pain management provider; and (3) number of ED visits: pre plan and post plan and number of admissions: pre plan and post plan. The time frame was the same for both pre and post, which was 1 year.
Measures were summarized using categories, such as age were grouped as follows: 0 to 17, 18 to 24, 25 to 34, 35 to 44, 45 to 54, and 55 to 64. Patients could have more than one chief complaint; thus, complaints were coded into groups of headache/migraine, chest pain, abdominal pain, back/neck pain, musculoskeletal/extremity pain, and other pain. Patients could have more than one condition or disease for their past medical history, and the following was extracted: depression, anxiety, bipolar, pain, hypertension, diabetes, chronic obstructive pulmonary disease, coronary artery disease, headache/migraine, back pain, and abdominal pain. Substance history was coded for patients that reported tobacco, alcohol, opioids, and illicit drugs. The change in number of visits/admissions was calculated by post plan minus pre plan (negative number was a decrease in post visits/admission compared to pre).
The measures were summarized to describe the patients, and two types of statistical tests were used to determine whether post visits were significantly reduced compared to pre. To determine the difference between pre and post plan for the number of visits/admissions, the Wilcoxon signed-rank test was used. Additionally, number of visits/admissions was categorized into groups, and the McNemar test was used to determine differences between pre and post plan proportions. A p-value of less than 0.05 was considered significant.