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.
My last job was as a case manager in the level one trauma center where I worked in various capacities for 10 years. Our job was to find PCPs for pts, get the chronic pain patients pain addressed, steer non-ER pts to the appropriate place.
We presented at several conferences in 2004/2005 (in IL) and actually saw a 62% reduction in FF visits.
This is a good idea. I would assume that once FF's find out that said hospital is implementing this system, they will scratch that hospital off of their list. Having a driver present in the room is a good idea as well, but what about a homeless person? Our ER provides cab rides to some patients, but the monthly bill on this is outrages. This system has also been abused just like patients calling 911 to catch an ambulance to the ED to get their prescriptions refilled. Happened twice in one hour the other day. Pain management is a tough issue to debate since it is subjective, but ED's certainly should take advantage of resources to catch and discourage abuse. Physicians should also refuse to prescribe narcotics to these same patients. They should refer them to pain management clinics. This is an ED, not a doctors office.
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.
From a liability point of view the guy that presents with chest pain for the 10th time that month/100th time that year should be treated as if we'd never seen him before BUT
From a patient care point of view the guy coming in for the 1st time with the same complaint is more likely to have pathology. Patient #1 having been worked up umpteen times in the past. We all know it.
So this is the point where you have to decide, what are you going to treat, the chart, or the patient?
Luckily, excellent charting will mask the fact that #1 came in 5 min earlier, but got the stretcher instead of the trauma bed, and actually got EKG'ed after #2. The docs will immediately go to trauma bedside, and will review #1's EKG and clear it, probably from the other guy's bedside. They'll be concentrating on #2.
IMHO that is how it should be. You HAVE to take history into account, no matter what that history is. Why ask for old charts, or go through a history with the patient, if you aren't going to use it. Of course you treat the patient, you rule out the life threatening issues, but if I have to triage resources the patient's history gets taken into account. diabetics get a fast track to cardiac workups, and people with a negative angiogram in the last year get more emphasis on non cardiac problems. I'd go so far as to say it would be dangerous and incompetence to do otherwise.
If you're talking about unlimited resources and staff though, I take it all back.
This policy is truely a work of art! I immediately called my NM and made her check it out! Anyone poo-pooing this policy has never worked in an ED, that's easy to see. And I think that it is unfair that people are suggesting that highly qualified ED nurses have such poor assessment skills that we can not easily tell a seriously ill person from a drug seeker.
Sickle cell patients who come in in crisis are always admitted (because they are very sick-duh) and given high dose narcotics and a lot of fluids (which usually helps their pain more than anything), and have the underlying cause treated.
Kidney stones too-there are definitive diagnostic tests that quickly tell us if you are fibbing or not.
Migranes don't get any narcs, just fluids, toradol (if a nice doc is working), and a referral to a pcp/neuro if no underlying symptoms of a bigger problem are seen, and then you would only get a CT. Migranes are NOT an emergency!!
Chest pain doesn't get you anything more than maybe a one time dose of morphine (only if EKG is abnormal), but if you want a little rush from nitro, well then come to my ED.
We've been over this and over this on this site! Pain is usually not an emergency, and chronic pain is never an emergency. If you get drunk, fall down, and get an SAH, you have an emergency. If you crash your car and your leg has broken and is poking through the bone, you are emergently injured. If you are having a CVA, MI, or you stop breathing, or your heart ceases to beat, you have an emergency.
Otherwise, if you have a headache, earache, sore throat, back pain, fibromyalgia, etc... go to your doctor's office or the free clinic!!!
And remember this- if you take 75 or more mg of methadone everyday for your back pain/headache/fibromyalgia everyday-when you fall down and break your skull/body-we are not going to be able to control your pain during your stay this time (when you have a real reason to hurt) unless we entubate you and sedate you-and we are not going to do that.
After my shift was over this morning my back hurt so bad that I was walking a little funny, which made my feet get sore. And after working a 12 hour shift with only one potty break and a small drink of water, I got a headache from not eating for 16 hours, which made me nauseated, and my kidneys felt like I had been kicked by a mule. But I didn't even take a tylenol, I just went to bed and rested, and I feel ready and able to do it all again for another 12 hours.
I am so glad that that my ED gets it. We may not have a specific policy spelling it out, but they get it. Until you have walked a mile in our shoes...
This policy is truely a work of art! I immediately called my NM and made her check it out! Anyone poo-pooing this policy has never worked in an ED, that's easy to see. And I think that it is unfair that people are suggesting that highly qualified ED nurses have such poor assessment skills that we can not easily tell a seriously ill person from a drug seeker.
Sickle cell patients who come in in crisis are always admitted (because they are very sick-duh) and given high dose narcotics and a lot of fluids (which usually helps their pain more than anything), and have the underlying cause treated.
Kidney stones too-there are definitive diagnostic tests that quickly tell us if you are fibbing or not.
Migranes don't get any narcs, just fluids, toradol (if a nice doc is working), and a referral to a pcp/neuro if no underlying symptoms of a bigger problem are seen, and then you would only get a CT. Migranes are NOT an emergency!!
Chest pain doesn't get you anything more than maybe a one time dose of morphine (only if EKG is abnormal), but if you want a little rush from nitro, well then come to my ED.
We've been over this and over this on this site! Pain is usually not an emergency, and chronic pain is never an emergency. If you get drunk, fall down, and get an SAH, you have an emergency. If you crash your car and your leg has broken and is poking through the bone, you are emergently injured. If you are having a CVA, MI, or you stop breathing, or your heart ceases to beat, you have an emergency.
Otherwise, if you have a headache, earache, sore throat, back pain, fibromyalgia, etc... go to your doctor's office or the free clinic!!!
And remember this- if you take 75 or more mg of methadone everyday for your back pain/headache/fibromyalgia everyday-when you fall down and break your skull/body-we are not going to be able to control your pain during your stay this time (when you have a real reason to hurt) unless we entubate you and sedate you-and we are not going to do that.
After my shift was over this morning my back hurt so bad that I was walking a little funny, which made my feet get sore. And after working a 12 hour shift with only one potty break and a small drink of water, I got a headache from not eating for 16 hours, which made me nauseated, and my kidneys felt like I had been kicked by a mule. But I didn't even take a tylenol, I just went to bed and rested, and I feel ready and able to do it all again for another 12 hours.
I am so glad that that my ED gets it. We may not have a specific policy spelling it out, but they get it. Until you have walked a mile in our shoes...
except for the bold part i am mostly with you.....you appear to be ASSuming that that person on methadone is an addict.....not nec so...methadone is a good pain med, and cheaper than most.....and yes you could add meds on top of the daily dose, that is only covering their original pain.
I agree-but methadone has it's place. It can be very effective in pain control and with addiction, but in my experience it is often abused. Methadone should not be being used by many of the people who I see that use it. It should not be used to treat common back pain and other less severe causes of pain- but if people choose to use this, and in high doses, they cannot expect to be pain free during real times of need, there resp. and hemodynamic status will become compromised if they expect us to effectively control their pain. And even as I say this I know that this is not always the case. You would not believe the amount of conscious sedation procedures that we do where we have young, very skinny drug addicts that we cannot knock out with high dose fent, versed, diprivan, etc, and they usually are satting fine on 100% face mask-but they are still awake and are feeling that I&D or reduction, CT insertion etc.
I agree-but methadone has it's place. It can be very effective in pain control and with addiction, but in my experience it is often abused. Methadone should not be being used by many of the people who I see that use it. It should not be used to treat common back pain and other less severe causes of pain- but if people choose to use this, and in high doses, they cannot expect to be pain free during real times of need, there resp. and hemodynamic status will become compromised if they expect us to effectively control their pain. And even as I say this I know that this is not always the case. You would not believe the amount of conscious sedation procedures that we do where we have young, very skinny drug addicts that we cannot knock out with high dose fent, versed, diprivan, etc, and they usually are satting fine on 100% face mask-but they are still awake and are feeling that I&D or reduction, CT insertion etc.
depends what you mean by "common" back pain.....and dose is the key....you may be seeing more methadone, d/t to its cost......and it is in and of itself a longer acting med....one reason it is hard to use...and dangerous for the under educated; both prescriber and user
What would make it absolutely perfect if they would add
If you are awake alert oriented x 3 and cannot provide confirmable identification NO NARCS
cant tell you how many time i saw pt A on monday night at one hospital, and the same darn pt at another hospital for the same darn complaint on tuesday, only this time using a different name.
not to really change the subject
have any of you noticed how the fliers all come in together and when the er is SWAMPED and the only way to get them out is to treat and street. when the nurses and the docs dont have the time nor the energy to argue. just give em what they want and get em out.
do they call each other? do they stake out the er waiting rooms to see who is the busiest?
I am not an ED nurse, but I am a psych CNS who has had jobs that included doing the psych and drug evals in the ED, and I think this is a great policy. If nothing else, once word gets around the community the drug-seeking FFs will stop showing up at your facility and will be someone else's problem.
In a less cynical vein :), we all know that (as others have already posted here) EDs do a lousy job of managing people's chronic conditions -- people with chronic conditions and chronic pain are much better served by being hooked up with outpatient physicians and pain mgmt services that can manage them on an ongoing basis.
This is a horrible policy in regards to people who don't have medical insurance. If someone doesn't qualify for MA and has pain, there might not be a way for them to be followed by a primary care physician unless they live in an area where free/sliding-fee care is available to them.
I'm just not a fan of blanket policies, per se. I like this as a recommendation, but take it as it comes case-by-case, you know?
traumaRUs, MSN, APRN
87 Articles; 21,287 Posts
My last job was as a case manager in the level one trauma center where I worked in various capacities for 10 years. Our job was to find PCPs for pts, get the chronic pain patients pain addressed, steer non-ER pts to the appropriate place.
We presented at several conferences in 2004/2005 (in IL) and actually saw a 62% reduction in FF visits.