An interesting policy

Published

An intersting policy. Anybody think this is a bad idea?

http://www.ohiocountyhospital.com/och.nsf/View/EmergencyDepartmentUseofNarcoticsandSedatives

MEDICAL STAFF POLICY

SUBJECT:

Emergency Department Use of Narcotics and Sedatives

Ohio County Hospital (OCH) has adopted a policy relating to the writing of narcotic and sedative medication prescriptions by the Emergency Department physicians. Because OCH is increasingly concerned about the abuse of narcotics in our society, this hospital discourages use of narcotics except when absolutely necessary.

The following policies and practices are for patients seen in the OCH Emergency Department who, after a medical screening exam, are found not to have an emergency medical condition:



      • Prescriptions for narcotic and sedative medications that have been lost or expired will not be refilled. It is the patient's responsibility to maintain active prescriptions with his or her primary care physician, specialty physician, or pain control clinic that have regularly prescribed these medications. Patients who have chronic pain will now only receive non-narcotic pain medications as temporary treatment.

        Patients who have frequent or multiple visits to the Emergency Department seeking relief from painful conditions will be considered to have chronic pain syndromes. Painful conditions include (but are not limited to) migraine headaches, back pain, pelvic or ovarian pain, dental pain, kidney stones, and fibromyalgia. In these cases, non-narcotic pain medication should be prescribed.

        ER Physicians are expected to work with any patient in trying to arrange appropriate follow-up care, but continuation of narcotics through the Emergency Department will not be done.

    In the event of an acute problem for which the Emergency Physician feels it is appropriate that a patient be given a narcotic or sedating medication (either by injection or by mouth), the Hospital requires that a driver for that patient be physically present in the patient's room before administering the medication.

    If a narcotic prescription is given for care of an acute painful condition, this prescription will be only for a small number of pills to last until the patient can follow-up with his or her primary doctor or specialist. Any patient returning to the Emergency Department for refills of said prescription will be given a non-narcotic prescription. Follow-up with a primary care physician or specialist for definitive and continued care must be the approach the patient takes.

    For any questions regarding the policy, you may call 270-298-7411 ext. 452.

Specializes in ER, Home Health.

I can see both sides to this story. First we all know their are the FF out their that are just seeking narcotic meds. Second, I suffer from chronic/Acute migraines. I used to have to run to the ER for a shot of demerol or morphine or whatever they wanted to give me. I didnt have other options. You ask why? My neuro didnt give me "rescue meds", the GP was scared to write narcs etc. etc. I have finally met up with a Neuro and Pain mgmt DR that allows me to inject Toradol along with multiple other medications. I think this is partly due to my education. Being able to tell the DRs how bad it is, plan so I dont have to go to ER, etc.

The ER I just left pretty well had an unspoken rule that Toradol was the drug of choice. For the scripts they wrote Tramadol.

I think it depends on the complaint, the condition, the patient, the nurses' assessment and the DR to come to a desirable medication that will decrease the patients pain level at the ER.

Specializes in ER.

I moved from an ER that gave narcotics to every dental pain to one that gives antibiotics and instructions for heat and ibuprofen. We have about 10% of the dental pains we had in Maine. Migraines have been cut by about 2/3 too, and every migraine I've dealt with has gone home pain free in about an hour. So that will tell you how changing narcotics policies will do for your ER. One could argue that AT LEAST half of the patients at hospital #1 were there for the narcotics.

Specializes in Hospice.

I think it's a fabulous idea. There needs to be some serious limit-setting with frequent fliers who are abusing the ED.

Kidney stones and sickle cell crisis are acute issues that shouldn't have a pt returning every few days or weeks. If they are, then they need to be steered to a pcp ... and it can't be the ED's fault when they don't have one.

As other posters have pointed out, the ED is not the place for chronic pain issues, or managing chronic conditions.

The tricky bit is figuring out reasonable "flags" or indicators for ED abuse and mechanisms for filtering out folks who might have a real emergency cooking so they don't fall through the cracks.

As it is now, everyone who complains of pain who isn't writhing on the floor is likely to be labelled a seeker ... dangerous for patient, the public and providers.

Maybe if EDs had real support dealing with seekers, providers wouldn't get so burned out and cynical everytime they hear a pts pain is 12/10.

Active addicts are some of the most difficult people to deal with. But the ED isn't the place for it. When they find out that the friendly neighborhood ED isn't the soft touch it used to be, they'll move on. Maybe to rehab, maybe to other drug sources ... but they'll stop clogging the ED and give the system a chance to work the way it's supposed to.

Now, if we can only pull something similar off to filter out the VIPs, we'd be in business.

:up: I think this is a wonderful idea. What concerns do you have?

Sounds good to me. I am interested whether any experienced ER nurses think it is a bad idea, and what they consider a better idea.

Also: Hearing somebody say (or seeing somebody write): "Pain is what the patient says it is." is kind of like watching somebody slip on a banana peel. You can see it coming from a mile away, but it's still funny.

What a waste of time to pull the pts MRs. I guess that hospital is going to do that for every person that comes into the ER with abdominal pain... headaches....... I dont think that is good pt care, but what do I know im still a student

You will learn the value of understanding a pt's hx in any care setting. It is really important.

Ok so maybe I am still soft, and think that everyone who says they are in severe pain, are really. Maybe I will grow out of this.!!

Just curious: If you don't think it is possible that a drug addict might lie to get drugs, what might they lie about?

Specializes in ER.

The Doctor's have had the power of the prescription pad all along....

Specializes in Geriatrics, Home Health.
I hear you on the sickle cell scenario. But patients with chronic conditions are poorly served by ERs - it is a different branch of medicine altogether. This policy may actually do the most compassionate thing for these patients by redirecting them back to their primary care and/or specialist providers where their long-term treatment, including plans for exacerbations, can be provided.

What if their primary care provider isn't available? I'm from Boston, which has a huge shortage of PCPs, and it's extremely rare for any doctor to see patients after 5 or on weekends. I spent 2 years as an ER volunteer, and a lot of patients came in for non-urgent care because the only alternative was waiting 3 weeks for an appointment with their PCP (3 weeks seemed to be the standard wait time unless you were actively coding). I don't like drug-seekers either, but it doesn't seem very compassionate to keep someone in crippling pain for 3 weeks.

Specializes in Hospice.
The Doctor's have had the power of the prescription pad all along....

And hospitals have the power of Press-Gainey. Many ED docs' come under heavy pressure to keep those scores up. I've even heard of compensation being tied to the PG score, though I could have heard wrong.

Besides, an active addict can make it real hard to say no. Before you even get the chance to say no, they are signed in (clerical time), triaged (triange nurse time), worked up (lab, radiology, nurse, doc time ... plus scads of money) ... all for negative findings, usually. Then you have to deal with the yelling, threats and acting out.

Please note the policy applies to known frequent fliers ... visiting from out of state or acute issues like kidney stones and sickle cell crisis tend not to result in the same pattern of visits as a ff seeking drugs. From my reading, the screening process is similar to the one existing in some states to track narcotic prescriptions filled at different pharmacies ... it picks up patterns of frequent scripts being filled at different pharmacies by the same person.

Relief of pain is a major provider responsibility, it's true. Until we develop a scan that can confirm pain, we have to depend on the report of the patient to assess it. But it isn't the function of the ED to manage chronic pain issues. They aren't trained for it and they don't do it very well ... that problem belongs to PCPs and pain management docs.

As far as addicted patients seeking drugs, the first goal of the provider should be to avoid enabling the addiction.

Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.

This is a great effort - to actually have it spelled out in policy form so there is guidance and people know what to do. Also to see admin support for this by putting it in force! This is a step in the right direction!

I would encourage the original author of this post to consider writing this up and submitting to ENA for publication as I believe this is definitely an article of interest for Emergency Nurses and managers!...(if not, I just might do it myself!)

Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
What a waste of time to pull the pts MRs. I guess that hospital is going to do that for every person that comes into the ER with abdominal pain... headaches....... I dont think that is good pt care, but what do I know im still a student

With an electronic health record (EHR) this can be done in seconds!

Matter of fact, I typically review ALL my patients for prior visits before even seeing the patient as part of my history gathering.

Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.

I think the key phrase to all of this discussion is "chronic" which means, ongoing-over time, persistent.

this is kind of like hypertension; chronic, ongoing, over time --- in the ED we don't manage HTN from a primary care perspective; we rather treat the exacerbations, which we call "hypertensive urgencies" and then get the pt back to baseline.

How many times have you d/c'd a pt home with an elevated BP? Many times I'm sure. But you did bring it down or make sure it wasn't a critical elevation for that individual patient.

I think that's what we do for the chronic pain pt's sometimes is just treat the acute situation and refer them back to the community for the managemnt of their chronic baseline.

Remember this too; every "FF", "turkey" or "toad" will eventually DIE someday from something; and odds are it will be before their average life expectancy as I suppose they have some other health risk factors which may cause an untimely death. Therefore, for us ED folks, the one thing we must ALWAYS do is to assess our patients like it's the first time, AND the same as we would assess any other patient that presents the same. The sad truth is, that if you show deference to patients based on complaints/history etc, then you open yourself up for not providing the same standard of care unequivocally. Once that happens, regardless of any "bad" outcomes, you entertain a liability from that point forward.

We must be firm, but cautious.

Having institutional guidelines (IE: policies) help us in our jobs to ensure that we consistently, across individuals, perform our jobs to a similar standard and thus minimize (note I did not say negate) our liability.

good post and good thread.

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