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Patient-centered care for chronic pain in the emergency department: A qualitative study Jayalakshmi Jambunathan PhD, MSN, BSN, MA (Assistant Dean; Professor & Director, Research & Evaluation) a,*, Sharon Chappy PhD, MSN, BSN (Dean) a,b, Jack (John) Siebers MSN, RN APNP (Advanced Practice Nurse Prescriber, Family Nurse Practitioner–Board Certified) a,c, Alishia Deda MSN, RN FNP (Family Nurse Practitioner– Board Certified) a,d a
College of Nursing, University of Wisconsin Oshkosh, 800 Algoma Blvd, Oshkosh, WI 54901, USA Concordia University, 12800 North Lake Shore Drive, Mequon, WI 53097, USA Affinity Health System, 3329, N. Richmond Street, Appleton, WI 54914, USA d Aurora BayCare Medical Center, 2845, Greenbrier Road, Green Bay, WI 54311, USA b c
A R T I C L E
I N F O
Article history: Received 30 January 2015 Received in revised form 16 May 2015 Accepted 18 May 2015 Keywords: Chronic pain Care planning Patient-centered care Emergency department Individualized plan of care Care transitions
A B S T R A C T
Pain is a common problem for which patients seek care in the emergency department, accounting for up to 42% of all ED visits. The purpose of this study was to explore qualitatively the reasons for use of the emergency department (ED) by those frequenting the ED for treatment of chronic pain. The settings for the study were two sites of a large U.S. Midwestern healthcare system. The sample comprised patients who used the ED four or more times in the 3-month time of data collection. From a total of 85 frequent users identified through retrospective chart reviews, a computer generated random sample of patients was selected to explore their reasons for use of ED for treatment of chronic pain. Content analysis was used to identify themes from the interviews. Four themes emerged from the qualitative data analysis: time of day, pain intensity, barriers to and reasons for using the emergency department for care, and lack of individualized plan of care. Reasons patients use the ED for chronic pain are numerous and complex. Leaders of healthcare organizations must address patient-centered care, with specific alternatives to the emergency department such as individualized care plans, and care transition interventions. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Pain is a common problem for which patients seek care in the emergency department (ED), accounting for up to 42% of all ED visits (Grover et al., 2012). Six of the seven chief complaints among a sample of frequent users in ED chart reviews were pain related (Milbrett and Halm, 2009). McLeod and Nelson (2013) found that people make decisions to present to the emergency department because of exacerbation of pain, inadequate coping strategies, or disease severity and desperation that is associated with stress and anxiety. Although pain is a common chief complaint among patients presenting to the emergency department, and nonopioid protocol is a viable alternative for reducing frequent pain-related ED visits (Svenson and Meyer, 2007), there are minimal interventions found in the literature to improve these patients’ care and management
* Corresponding author. College of Nursing, University of Wisconsin Oshkosh, 800 Algoma Blvd, Oshkosh, WI 54901, USA. Tel.: +920 424 1274; fax: 920-424-0123. E-mail address: [email protected] (J. Jambunathan).
with the goal of decreasing their ED use. Masterson and Wilson (2012) concluded that a proactive pain care management program that includes coordination of both primary care provider and a supportive medical staff can assist those patients who frequently use emergency department for chronic pain-related complaints. The authors found that ED visits by frequent users were reduced by 77% because of a pain care management program. The most common pain management interventions were narcotic restriction (65%), establishing a nonnarcotic treatment regimen (57%), and enacting a “1 pharmacy/1 provider” restriction (23%). The current study was undertaken when leaders at a regional healthcare center in the midwestern part of the United States identified a significant problem with patients frequenting the emergency department for chronic pain management. The financial burden imposed by as few as 9 patients frequenting the ED in a 3-month period was over 500,000 U.S. dollars, within this system. Hence, the purpose of this study was to explore the reasons for frequenting the emergency department by a random sample of patients for their treatment of chronic pain. Frequent ED use was defined as 4 or more ED visits in a 3-month time period.
http://dx.doi.org/10.1016/j.ienj.2015.05.005 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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2. Background/literature Current treatment regimens for chronic pain are clearly identified as unsatisfactory by participants in several studies (Andersen, 2012; Deyo et al., 2011; Sanderson et al., 2012; Todd et al., 2010). Patients with chronic pain expect a more lasting solution than the symptomatic treatment of acute pain exacerbations. 2.1. Pharmacological treatment Pharmacological options for the treatment of chronic pain are many, but opioids are most frequently prescribed in the treatment of chronic pain (both in single and multimodal approaches). Yet, opioids have shown to be largely ineffective in achieving adequate pain control, both in the primary care and emergency settings (Andersen, 2012; Deyo et al., 2011; Sanderson et al., 2012; Todd et al., 2010). Svenson and Meyer (2007) reported a significant drop in the number of pain-related visits to the emergency department after initiating a nonnarcotic protocol for frequent users presenting with chronic non-cancerous pain. A nonnarcotic protocol could help to decrease the number of ED visits (McLeod and Nelson, 2013) and encourage patients to refer back to their own physician to discuss a more appropriate rescue regime. 2.2. Care transitions There is a need for improvement in care transitions that might increase effectiveness of chronic pain care while decreasing ED visits and their associated costs. Currently, there are no specific national guidelines for communication regarding care transitions between the emergency department and other settings of care such as the patient’s primary care provider. However, Limpahan et al. (2013) have assisted in developing a set of care transition best practices to provide standards for evaluating and improving the method in which patients transition out of the emergency department. Specific suggestions include sending summary clinical information to downstream clinicians, and providing patients with effective written discharge instructions of when to seek follow-up care. 2.3. Care planning Although not pain related, Pugh et al. (2010) found that a multidisciplinary care plan (MDCP) to address nursing, social and behavioral issues, along with social worker involvement, staff acceptance, and education resulted in increased patient satisfaction in ED frequent users. The MDCPs guided the staff to provide consistent care and clear behavior guidelines for the most difficult patients that frequented the ED. Care planning is also a central focus of Spectrum Health Medical Group Center for Integrative Medicine, whose goal is to identify, accurately diagnose, and develop a care plan for each high frequency ED user (2011), as well as to assist these patients with integration into primary care or other outpatient medical settings. The economic burden that chronic pain imposes on society is calculated in hundreds of billions of dollars annually on treatment costs and lost productivity (Sanderson et al., 2012). Variations in treatment between providers, along with a blend of societal misconceptions, stigma and individual bias regarding medications may create a hostile environment to those seeking effective chronic pain treatment, and make it more challenging to manage frequent ED users (Monsivais, 2011). 3. Methods This study used an exploratory qualitative study design. Frequent ED users for treatment of chronic pain were identified by a
retrospective record review [to formulate a demographic database] for qualitative interviews. Prior to data collection, the study was approved by the Institutional Review Boards (IRBs) for the Protection of Human Participants at the Midwestern University in the United States to which the authors are affiliated, and the regional healthcare system in which the patients sought care. The settings for this project were two separate institutions (Agency A and Agency B) that are part of a large U.S. Midwestern healthcare system. Staff at Agencies A and B compiled a de-identified list of patients who visited the emergency department 4 or more times in the 3-month period immediately prior to data collection. Restrospecitve chart reviews were done to extract data elements including patient age, gender, day of the week and time of day in which the visit occurred, patient’s payment source, and chief complaint including primary and secondary diagnoses for each visit. Based on the numbers of frequent users, the researchers used a computer generated random sample of 20 participants for the qualitative interviews. Data were collected in a confidential, aggregated manner. As part of usual care, nursing staff make follow-up phone calls to all patients seen in the emergency department. When staff members contacted patients identified as frequent ED users, in addition to asking the usual care questions, staff read a script asking if the patient’s name and phone number could be disclosed to researchers for this project. For those patients who agreed, names and phone numbers were forwarded to the researchers. One researcher contacted the patient to explain the qualitative interview associated with this project and asked if the patient would agree to an interivew. If they agreed, the interview was either conducted at the time of initial contact, or an agreeable time was arranged. Researchers read the informed consent document and recorded the patient’s agreement to participate. Interviews were conducted using an interview guide to assure consistency among researchers. The interview guide was developed based on the literature review and input from experts in qualitative research (sample questions can be found in Table 1). Interviews were tape-recorded and transcribed verbatim by a professional transcriptionist. Transcripts were used for data analysis, which consisted of each team member independently reading
Table 1 Interview guide. 1. Can you explain how long you have been dealing with chronic pain? 2. Can you describe the last chronic pain experience that led you to the use of the emergency department (ED)? 3. To what extent do you feel that treatment in the ED helps you with your recurring chronic pain problem? 4. When you were treated in the ED, were you given directions to follow up with a family doctor or a pain specialist for your pain? Did you follow up as directed? Why or why not? 5. Can you explain any barriers to following up with other healthcare providers after your ED visit? 6. Since you have used the ED several times recently to get care for your chronic pain, can you explain why you used the ED rather than contacting your family doctor or primary care provider? 7. Overall, what would you change about how you receive treatment of your chronic pain if you were able to do so? 8. What other resources are available to you, aside from visiting the ED when dealing with your chronic pain? Have you used any of those resources? Why or why not? 9. One of the best practices for treating chronic pain is that consistent care is provided among all healthcare providers that a person sees. Do you have a formal individualized care plan in place that providers use when they treat your chronic pain? a. If yes, what is your perception of the effectiveness of that care plan? b. If no, would you be willing to be referred by an ED nursing staff to one of Ministry’s social worker who can assist in setting you up with a consistent healthcare provider and an individualized care plan? Patient confidentiality will be maintained by using the ED nursing staff who are knowledgeable about the patient. 10. Is there anything else you would like to add?
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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and reviewing the transcripts looking for common themes. Content analysis (Krippendorff, 2005) was conducted to define the units based on commonality in the interview data, followed by a thematic analysis to describe patient perceptions. After independent analysis, the group came together to discuss commonalities and develop the final themes that emerged from the data.
ticipant P5 reported using the ED because “I wasn’t able to get into the pain specialist or, you know, it was after business hours” and followed up with “they close at 4, so, if it’s after 4, I have to go into the emergency room.”
4. Data/results
Of the 13 participants, 10 (77%) specifically noted the intensity of chronic pain as a major factor leading to presentation in the emergency department. Of those not explicitly describing increased severity, they noted associated symptoms or conditions that accompanied severe pain. Participant P6 stated “I need to go right away. . .I was sick of throwing up”. Common descriptions of pain intensity leading to ED visits included “hard to get out of the house” due to pain and “most of the time I wait a really long time before I call, so I try to tolerate the pain as long as I can.” Increases in chronic pain intensity due to socioeconomic factors such as employment status, stress, and education were reported. Participant P2 stated “I’m a single mom and I work 40+ hours a week. . .”. For several participants, waiting until “after work” to seek care in the emergency department for increased pain intensity made sense, since they did not want to contribute further to often already-strained job attendance records. Several participants described being unable to get their pain under control with the medications they had available to them leading to interruptions in functioning, coping, and rest. Participant P2 noted: “I was laying on my living room floor, flat on my back, with a towel underneath my head. It was the only way I could get comfortable, and it was still nauseating. . . I couldn’t even drive myself to the ED”, while participant P10 said: “I do try to alleviate the pain so I can sleep it off, let it run its course, whatever. But when I break through all of the pain medicine and everything I have and it’s not helping, that’s when I have to go in.” Treatment in the emergency department is often seen as a short term help to regain control. When pain intensity led to an ED visit, participants generally described their treatment there as “just throwing a Bandaid on it.” Participant P5 noted, “My pain medication was just not working and I ended up having to go in and receive a little extra boost on the medication to get the pain to where I was comfortable again.” Participant P4 added, “I’m not looking for a fix. A little increase in the pain medication sometimes, that’s the only thing that helps.” Even among participants with existing pain medication contracts, ED visits to regain control during episodes of increased pain intensity are reported in the hope of getting something to relieve their pain. Participants noted that seeking treatment in the emergency department for increased chronic pain intensity may be for the purpose of short term assistance only. Participant P12 noted she got a “quick fix” for the problem when visiting the ED, but that ED care is “definitely not there to help you long term.”
Retrospective chart reviews showed a total of 85 frequent users at both agencies in the 3-month time of data collection. Of the twenty computer generated random sample of participants from the list of frequent users, 13 agreed to participate (P1 to P13), four were not available despite phone calls per IRB protocol, and three declined to participate. A demographic profile of the 13 participants can be found in Table 2. Participants ranged in age from 22 to 67 and reported having chronic pain from 3 years to 27 years, with participant P7 reporting having pain for his “whole life.” The four themes that emerged included: time of day, pain intensity, barriers to and reasons for using the ED for care, and lack of individualized plan of care. These themes are described below with quotes from the participants to support each theme. 4.1. Time of day A major factor influencing participants’ decision to seek treatment in the emergency department rather than their primary care providers was the time of day in which they felt they needed management of their chronic pain. For example, participant P2 claimed the time his pain was the worst was “usually at night” while participant P3 stated she tended to use the ED because “usually, it’s after hours or the middle of the night”. Participant P10 commented “I would say most times I ever have to go in usually was the evening, and that is a lot of the time when my pain is the worst.” She elaborated with “it was probably about 9:00 at night and it kept getting worse, and I couldn’t sleep. And then finally, like, 1:00 in the morning rolls around, and I couldn’t get comfortable.” The increasing intensity of her pain resulted in a family member bringing her to the ED in the early morning hours. Participants reported that if their pain exacerbations were not as severe during the office hours of their primary care providers, they did not turn to them for treatment. This is demonstrated by participant P10 who claimed “after hours or on weekends I have to resort to going to an ER to receive treatment for my migraines.” Participant P9 explained: “. . .well, like, time of day, like in the middle of the night, or you know, a weekend, and it’s something that was an emergency situation that I needed to deal with right away.” Par-
Table 2 Demographic profile of frequent users in the emergency department.
4.3. Barriers to and reasons for using the ED
Gender Age Times of day
Total visits Plan to ED of care
PCP
F M F M F F F M M M M F
50 22 34 62 46 27 31 51 31 67 45 25
6 5 6 6 4 4 5 4 5 5 6 8
No No No May be No Yes No No Kind of Yes No No
Yes Yes No Yes Yes Yes No No Yes Yes Yes Yes
F
34
8
No
Yes
1431, 1921, 1256, 1858, 1348, 2146 1922, 0456, 1405, 0805, 1202 1758, 1025, 0831, 1801, 1000, 1734 1659, 2117, 1219, 1541, 1206, 2029 1622, 2147, 2137, 1753 1234, 1628, 1927, 1351 1128, 1956, 1247, 1123, 0915 1952, 1935, 1542, 1852 0606, 2212, 2206, 1224, 2038 2257, 2220, 0447, 0148, 2158 2307, 2003, 0009, 1937, 0954, 2154 1757, 1109, 1044, 1459, 1745, 1448, 1146, 1608 1135, 2114, 1513, 1511, 0005, 2346, 1250, 1720
4.2. Pain intensity
Participants reported various barriers when using the emergency department, including being judged by those with whom they came into contact. Participant P11 said: “I did get accused of trying to get pain medication. . .nobody would listen to me, you know” and was further told, “you’re an addict, or you’re just crazy. . .”. This participant reported that she wished that ED providers would take “that extra little effort to really get to know the person before they judge them. . .” Participant P10 reported being treated negatively when she went to the ED for care, noting “. . .some of the doctors in there [ED], I don’t know if they have a God-complex or what, but they think whatever. . .they don’t have to listen to the order, they don’t have to follow procedure, it’s their ER, they’ll do what they want. And those doctors try to say this is all we can give you, this is what we give you, even
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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if it’s something I’m allergic to. . .it seems they label you a drug seeker before you walk into the entrance.” Several participants reported reasons for using the emergency department rather than using a primary care physician or pain speciatlist, including lack of money or insurance so the emergency department became the only place in which they could receive care. Participants also reported they could not secure reliable transportation to a primary care provider’s office. Other responses included primary care provider was “very hard to get in to see. . .I try to contact my care provider first. And then if I can’t get a hold of them I go to the ED,” and “Usually I can get into the ED quick; quicker than I can get into my family doctor as it is typically a week or two to secure an appointment with the family doctor.” An example of another reason for using the ED for chronic pain management was when participants reported that staff in the primary care clinics, including physicians, actually told them to go to the emergency department rather than be seen in the clinic. Participant P5 reported: “I mean, you call a doctor, and they’ll be like, we already saw you for this, you know, I can’t help you any more. . .” Other participants echoed similar comments noting, “ I usually do call my family physician first and then she tells me to go in [to the ED] because pain medications don’t help. It usually takes the injection or something to help calm it down, and then I have to rest.” Hence, some participants reported wanting to seek care with a primary care provider, but were turned away for various reasons. 4.4. Lack of individualized plan of care The majority of participants (n = 9; 69%) reported that they did not have a care plan or were “unsure” if they had one or “didn’t even know what it is.” When asked if she had an individualized plan of care, participant P13 stated, “Not as far as a regular doctor. I know my pain clinic has the actual way to follow up. So that’s basically it. When I go to my regular doctor, they are like, well, follow up with the pain clinic.” When participants were asked if they would be willing to meet with a social worker within the healthcare system regardless of whether or not they had an individualized plan of care, seven (54%) reported in the affirmative. Participant P13 noted, “Whatever makes the pain go away. You can always go for extra help and they can always suggest something that someone has overlooked. I’m game for anything.” 5. Discussion Visiting the emergency department for increasing pain intensity is consistent with findings by McLeod and Nelson (2013). Participants in this study often put off seeking treatment for their pain for various reasons (work, trying to deal with it on their own, lack of transportation, lack of money) until it got so severe that they could no longer cope with it. For some, when pain exacerbations happened during regular business hours, they were “encouraged” to go to the ED anyway by primary care providers who noted there was nothing they could do for them in the office. So even if participants tried to use less costly resources to treat their pain, they were turned away. Some participants reported that an important reason to use the emergency department was related to time of day (weekends, night hours); 33 of the 72 visits (46%) occurred between 0800 and 1700, a time when most primary care and walk-in clinics are typically open. Participants reported needing a little “extra” to treat their pain when it got severe, and were aware that the only place in which they could get that extra treatment was in the emergency department. Some participants had opioid agreements in place (agreements with primary care providers which should be honored if possible in treating any acute pain exacerbations), yet they still went to the
emergency department, knowing that they would likely not be provided opioids there. Opioid agreements lead to cost savings related to an increase in patient adherence and the rationalization of the care provided and serve as an effective tool for communicating the plan of care to the ED provider. As part of the patient’s agreement, the option to have a nonopiod protocol for ED visits could be discussed (Svenson and Meyer, 2007); however, this should be an individual determination between the provider and the patient at the time of ED presentation, since there is limited research to suggest that such agreements are effective. The opioid agreement could be just one part of individualized, patient-centered care. Since the Institute of Medicine published Crossing the Quality Chasm (2001) calling for patient-centered care, much emphasis has been placed on involving patients and their families in care decisions. A multidisciplinary plan of care can enhance patient care, decrease frustration and improve patient and staff satisfaction (Pugh et al., 2010). In this study, only four participants reported having a plan of care and even those four could not necessarily explain their plan of care which indicates they were not involved in developing their plan of care. Each patient who presents with exacerbations of chronic pain needs to be thoroughly assessed; however, having an individualized plan of care may assist providers to treat patients consistently and with evidence-based recommendations, which often includes multi-modal drug therapy that does not include opioids (McLeod and Nelson, 2013). Reasons for using the ED for the study participants included transportation, hours of operation, and the availability of parenteral medications that may not be delivered in primary care offices. The emergency department is clearly available 24/7, whereas primary care clinics do not offer that flexibility. Several participants noted that they could not take time off from work to visit a primary care provider. Barriers to using the emergency department included perception of disrespect and even disgust that some participants reported. However, these perceptions were not enough to dissuade a person from seeking relief from the pain. One key aspect of implementing such a plan of care is having electronic records that are accessible wherever the patient presents. Addressing the root causes of patients’ frequenting the emergency department for treatment of chronic pain, and treating each patient in a highly individualized and holistic manner using appropriate resources, can have significant personal and financial impact for both the patient and the treating institution. The best practice recommendations discussed by Limpahan et al. (2013) may provide appropriate evidence to incorporate individualized care planning so as to ensure an effective transition of care for patients seeking treatment for chronic pain. Limpahan et al. (2013) outline eight best practices for “cross setting clinician-to-clinician communication, and also incorporate elements of patient activation, including obtaining contact information for patients’ outpatient clinicians, sending summary clinical information to downstream clinicians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions” (p.1300).
5.1. Implications for emergency nurses The majority of participants in this study said they would be willing to meet with a social worker to develop a plan of care. This individualized plan could include an opioid agreement. A multidisciplinary plan of care could include treatment recommendations for breakthrough pain that may bring patients to the emergency setting and would help to take the guesswork out of the ED provider’s hands and facilitate communication between multiple providers. Emergency department nurses can advocate for an intensive case management program (Grover et al., 2012) comprising a multidisciplinary team of physicians, nurses, social services, and
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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the increasingly financially capitated and fragmented healthcare environment (Coleman and Williams, 2007). Based on the results of this study, leaders in the EDs in both agencies have set up a committee to address chronic pain patients. They have hired a social worker with a behavioral health background to assist the patients in dealing with chronic pain and emergency department physicians with non-opioid treatments. The ED nurses have started writing and using a pain care plan, with the help of the ED Physician. Also, the agencies are piloting a process in conjunction with the social worker and legal/risk RN to develop individualized patient plans of care that are signed by the patient. 6. Limitations Limitations include using participants from two facilities affiliated with the same U.S. Midwestern healthcare system. The 13 participants interviewed may not be typical of other patients with chronic pain, and so transferability of the findings to other populations should be done with careful consideration. Additionally, findings may be limited due to recall bias and lack of response. Fig. 1. A model for patient-centered care in ED.
specialists in pain management and behavioral health, all of whom can help decrease frequency of emergency department use. Community resources such as low cost transportation and clinics with extended hours, or even extending services within the emergency department itself, such as providing immediate social work support or providing 24/7 access to a registered nurse could assist frequent users in accessing more appropriate resources for treating their chronic pain. Healthcare providers may need to be educated on dealing ethically and respectfully with patients of all types, since some participants gave very clear accounts of disrespectful treatment by those whom they encountered in the emergency department. Emergency department nurses can advocate for a model of patient-centered care (Fig. 1) incorporating several elements from our study. Patient-centered care means not only incorporating current clinical practice guidelines for chronic pain, but also individualized, culturally appropriate assessment. In the traditional medical model, patients may first experience the need to establish credibility and acceptance with each different provider they see (Monsivais, 2011). A key element of care transitions includes follow up within 1–2 weeks after hospital discharge, as this is widely recognized as a period at risk for adverse events (Misky et al., 2010). It is clear from this study that patients discharged from the emergency department for treatment of chronic pain need assistance transitioning to more appropriate primary care resources. Given that two-thirds of emergency visits occur after business hours (weekdays 9 am–5 pm), identifying primary care sites available after business hours is one strategy for improving appropriate access to healthcare services (Centers for Medicare and Medicaid Services, 2014). If primary care clinics are to be definitive centers for care transitions in the management of patients with chronic pain, then providers must possess the desire and skills commensurate with care of these challenging patients, who seldom develop optimal outcomes. Patient-centered care must include skill development for staff, patients, and their family caregivers related to transitions between care centers (Parry et al., 2009). Clearly, the reasons for patients using the ED for chronic pain are numerous and complex. Future research could explore the effectiveness of individualized plans of care when implemented for those with chronic pain. Developing care transition interventions is also required to allow widespread adoption and sustainability in
7. Conclusions Developing a solution to eliminating the emergency department as a primary source of treatment for patients suffering from chronic pain has proven to be a rather difficult task. Patients in this particular group often have multiple issues and personal factors that prevent them from being able to use primary care services appropriately which often necessitates they use the emergency department to obtain the care they need or desire. It is paramount that healthcare organizations address the issue and develop a plan that provides these patients with specific alternatives to the emergency department such as individualized care plans, or they will continue to use its services to obtain chronic pain treatment and management, resulting in continued financial burdens that this imposes. However, it is also imperative that various other models for outcomes on pain, patient and facility burden are tested and implemented. References Andersen, T.E., 2012. Does attachment insecurity affect the outcomes of multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and use of opioids. Social Science and Medicine. 77, 1461–1468. Centers for Medicare and Medicaid Services, 2014. Reducing nonurgent use of emergency departments and improving appropriate care in appropriate settings. Baltimore, MD: 21244-1850. Coleman, E.A., Williams, M.V., 2007. Executing high-quality care transitions: a call to do it right. Journal of Hospital Medicine. 2, 287–290. Deyo, R.A., Smith, D.H.M., Johnson, E.S., Donovan, M., Tillotson, C.J., Yang, X., et al., 2011. Opioids for back pain patients: primary care prescribing patterns and use of services. Journal of the American Board of Family Medicine. 24, 717–727. Grover, C.A., Close, R., Wiele, E., Villarreal, K., Goldman, L., 2012. Quantifying drugseeking behavior: a case control study. The Journal of Emergency Medicine. 42, 15–21. IOM (Institute of Medicine), 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, D.C. Krippendorff, K., 2005. Content Analysis: An Introduction to Its Methodology. Sage Publications, Thousand Oaks, CA. Limpahan, L.P., Baier, R.R., Gravenstein, S., Liebmann, O., Gardner, R.L., 2013. Closing the loop: best practice for cross-setting communication at ED discharge. The American Journal of Emergency Medicine 31, 1297–1301. Masterson, B., Wilson, M., 2012. Pain care management in the emergency department: a retrospective study to examine one program’s effectiveness. Journal of Emergency Nursing. 38, 429–434. McLeod, D., Nelson, K., 2013. The role of the emergency department in the acute management of chronic or recurrent pain. Australasian Emergency Nursing Journal 16, 30–36. Milbrett, P., Halm, M., 2009. Characteristics and predictors of frequent utilization of emergency services. Journal of Emergency Nursing. 13, 191–198. Misky, G.J., Wald, H.L., Coleman, E.A., 2010. Post hospital transitions: examining the effects of timing of primary care provider follow-up. Journal of Hospital Medicine. 5, 392–397.
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Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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Patient-centered care for chronic pain in the emergency department: A qualitative study Jayalakshmi Jambunathan PhD, MSN, BSN, MA (Assistant Dean; Professor & Director, Research & Evaluation) a,*, Sharon Chappy PhD, MSN, BSN (Dean) a,b, Jack (John) Siebers MSN, RN APNP (Advanced Practice Nurse Prescriber, Family Nurse Practitioner–Board Certified) a,c, Alishia Deda MSN, RN FNP (Family Nurse Practitioner– Board Certified) a,d a
College of Nursing, University of Wisconsin Oshkosh, 800 Algoma Blvd, Oshkosh, WI 54901, USA Concordia University, 12800 North Lake Shore Drive, Mequon, WI 53097, USA Affinity Health System, 3329, N. Richmond Street, Appleton, WI 54914, USA d Aurora BayCare Medical Center, 2845, Greenbrier Road, Green Bay, WI 54311, USA b c
A R T I C L E
I N F O
Article history: Received 30 January 2015 Received in revised form 16 May 2015 Accepted 18 May 2015 Keywords: Chronic pain Care planning Patient-centered care Emergency department Individualized plan of care Care transitions
A B S T R A C T
Pain is a common problem for which patients seek care in the emergency department, accounting for up to 42% of all ED visits. The purpose of this study was to explore qualitatively the reasons for use of the emergency department (ED) by those frequenting the ED for treatment of chronic pain. The settings for the study were two sites of a large U.S. Midwestern healthcare system. The sample comprised patients who used the ED four or more times in the 3-month time of data collection. From a total of 85 frequent users identified through retrospective chart reviews, a computer generated random sample of patients was selected to explore their reasons for use of ED for treatment of chronic pain. Content analysis was used to identify themes from the interviews. Four themes emerged from the qualitative data analysis: time of day, pain intensity, barriers to and reasons for using the emergency department for care, and lack of individualized plan of care. Reasons patients use the ED for chronic pain are numerous and complex. Leaders of healthcare organizations must address patient-centered care, with specific alternatives to the emergency department such as individualized care plans, and care transition interventions. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Pain is a common problem for which patients seek care in the emergency department (ED), accounting for up to 42% of all ED visits (Grover et al., 2012). Six of the seven chief complaints among a sample of frequent users in ED chart reviews were pain related (Milbrett and Halm, 2009). McLeod and Nelson (2013) found that people make decisions to present to the emergency department because of exacerbation of pain, inadequate coping strategies, or disease severity and desperation that is associated with stress and anxiety. Although pain is a common chief complaint among patients presenting to the emergency department, and nonopioid protocol is a viable alternative for reducing frequent pain-related ED visits (Svenson and Meyer, 2007), there are minimal interventions found in the literature to improve these patients’ care and management
* Corresponding author. College of Nursing, University of Wisconsin Oshkosh, 800 Algoma Blvd, Oshkosh, WI 54901, USA. Tel.: +920 424 1274; fax: 920-424-0123. E-mail address: [email protected] (J. Jambunathan).
with the goal of decreasing their ED use. Masterson and Wilson (2012) concluded that a proactive pain care management program that includes coordination of both primary care provider and a supportive medical staff can assist those patients who frequently use emergency department for chronic pain-related complaints. The authors found that ED visits by frequent users were reduced by 77% because of a pain care management program. The most common pain management interventions were narcotic restriction (65%), establishing a nonnarcotic treatment regimen (57%), and enacting a “1 pharmacy/1 provider” restriction (23%). The current study was undertaken when leaders at a regional healthcare center in the midwestern part of the United States identified a significant problem with patients frequenting the emergency department for chronic pain management. The financial burden imposed by as few as 9 patients frequenting the ED in a 3-month period was over 500,000 U.S. dollars, within this system. Hence, the purpose of this study was to explore the reasons for frequenting the emergency department by a random sample of patients for their treatment of chronic pain. Frequent ED use was defined as 4 or more ED visits in a 3-month time period.
http://dx.doi.org/10.1016/j.ienj.2015.05.005 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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2. Background/literature Current treatment regimens for chronic pain are clearly identified as unsatisfactory by participants in several studies (Andersen, 2012; Deyo et al., 2011; Sanderson et al., 2012; Todd et al., 2010). Patients with chronic pain expect a more lasting solution than the symptomatic treatment of acute pain exacerbations. 2.1. Pharmacological treatment Pharmacological options for the treatment of chronic pain are many, but opioids are most frequently prescribed in the treatment of chronic pain (both in single and multimodal approaches). Yet, opioids have shown to be largely ineffective in achieving adequate pain control, both in the primary care and emergency settings (Andersen, 2012; Deyo et al., 2011; Sanderson et al., 2012; Todd et al., 2010). Svenson and Meyer (2007) reported a significant drop in the number of pain-related visits to the emergency department after initiating a nonnarcotic protocol for frequent users presenting with chronic non-cancerous pain. A nonnarcotic protocol could help to decrease the number of ED visits (McLeod and Nelson, 2013) and encourage patients to refer back to their own physician to discuss a more appropriate rescue regime. 2.2. Care transitions There is a need for improvement in care transitions that might increase effectiveness of chronic pain care while decreasing ED visits and their associated costs. Currently, there are no specific national guidelines for communication regarding care transitions between the emergency department and other settings of care such as the patient’s primary care provider. However, Limpahan et al. (2013) have assisted in developing a set of care transition best practices to provide standards for evaluating and improving the method in which patients transition out of the emergency department. Specific suggestions include sending summary clinical information to downstream clinicians, and providing patients with effective written discharge instructions of when to seek follow-up care. 2.3. Care planning Although not pain related, Pugh et al. (2010) found that a multidisciplinary care plan (MDCP) to address nursing, social and behavioral issues, along with social worker involvement, staff acceptance, and education resulted in increased patient satisfaction in ED frequent users. The MDCPs guided the staff to provide consistent care and clear behavior guidelines for the most difficult patients that frequented the ED. Care planning is also a central focus of Spectrum Health Medical Group Center for Integrative Medicine, whose goal is to identify, accurately diagnose, and develop a care plan for each high frequency ED user (2011), as well as to assist these patients with integration into primary care or other outpatient medical settings. The economic burden that chronic pain imposes on society is calculated in hundreds of billions of dollars annually on treatment costs and lost productivity (Sanderson et al., 2012). Variations in treatment between providers, along with a blend of societal misconceptions, stigma and individual bias regarding medications may create a hostile environment to those seeking effective chronic pain treatment, and make it more challenging to manage frequent ED users (Monsivais, 2011). 3. Methods This study used an exploratory qualitative study design. Frequent ED users for treatment of chronic pain were identified by a
retrospective record review [to formulate a demographic database] for qualitative interviews. Prior to data collection, the study was approved by the Institutional Review Boards (IRBs) for the Protection of Human Participants at the Midwestern University in the United States to which the authors are affiliated, and the regional healthcare system in which the patients sought care. The settings for this project were two separate institutions (Agency A and Agency B) that are part of a large U.S. Midwestern healthcare system. Staff at Agencies A and B compiled a de-identified list of patients who visited the emergency department 4 or more times in the 3-month period immediately prior to data collection. Restrospecitve chart reviews were done to extract data elements including patient age, gender, day of the week and time of day in which the visit occurred, patient’s payment source, and chief complaint including primary and secondary diagnoses for each visit. Based on the numbers of frequent users, the researchers used a computer generated random sample of 20 participants for the qualitative interviews. Data were collected in a confidential, aggregated manner. As part of usual care, nursing staff make follow-up phone calls to all patients seen in the emergency department. When staff members contacted patients identified as frequent ED users, in addition to asking the usual care questions, staff read a script asking if the patient’s name and phone number could be disclosed to researchers for this project. For those patients who agreed, names and phone numbers were forwarded to the researchers. One researcher contacted the patient to explain the qualitative interview associated with this project and asked if the patient would agree to an interivew. If they agreed, the interview was either conducted at the time of initial contact, or an agreeable time was arranged. Researchers read the informed consent document and recorded the patient’s agreement to participate. Interviews were conducted using an interview guide to assure consistency among researchers. The interview guide was developed based on the literature review and input from experts in qualitative research (sample questions can be found in Table 1). Interviews were tape-recorded and transcribed verbatim by a professional transcriptionist. Transcripts were used for data analysis, which consisted of each team member independently reading
Table 1 Interview guide. 1. Can you explain how long you have been dealing with chronic pain? 2. Can you describe the last chronic pain experience that led you to the use of the emergency department (ED)? 3. To what extent do you feel that treatment in the ED helps you with your recurring chronic pain problem? 4. When you were treated in the ED, were you given directions to follow up with a family doctor or a pain specialist for your pain? Did you follow up as directed? Why or why not? 5. Can you explain any barriers to following up with other healthcare providers after your ED visit? 6. Since you have used the ED several times recently to get care for your chronic pain, can you explain why you used the ED rather than contacting your family doctor or primary care provider? 7. Overall, what would you change about how you receive treatment of your chronic pain if you were able to do so? 8. What other resources are available to you, aside from visiting the ED when dealing with your chronic pain? Have you used any of those resources? Why or why not? 9. One of the best practices for treating chronic pain is that consistent care is provided among all healthcare providers that a person sees. Do you have a formal individualized care plan in place that providers use when they treat your chronic pain? a. If yes, what is your perception of the effectiveness of that care plan? b. If no, would you be willing to be referred by an ED nursing staff to one of Ministry’s social worker who can assist in setting you up with a consistent healthcare provider and an individualized care plan? Patient confidentiality will be maintained by using the ED nursing staff who are knowledgeable about the patient. 10. Is there anything else you would like to add?
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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and reviewing the transcripts looking for common themes. Content analysis (Krippendorff, 2005) was conducted to define the units based on commonality in the interview data, followed by a thematic analysis to describe patient perceptions. After independent analysis, the group came together to discuss commonalities and develop the final themes that emerged from the data.
ticipant P5 reported using the ED because “I wasn’t able to get into the pain specialist or, you know, it was after business hours” and followed up with “they close at 4, so, if it’s after 4, I have to go into the emergency room.”
4. Data/results
Of the 13 participants, 10 (77%) specifically noted the intensity of chronic pain as a major factor leading to presentation in the emergency department. Of those not explicitly describing increased severity, they noted associated symptoms or conditions that accompanied severe pain. Participant P6 stated “I need to go right away. . .I was sick of throwing up”. Common descriptions of pain intensity leading to ED visits included “hard to get out of the house” due to pain and “most of the time I wait a really long time before I call, so I try to tolerate the pain as long as I can.” Increases in chronic pain intensity due to socioeconomic factors such as employment status, stress, and education were reported. Participant P2 stated “I’m a single mom and I work 40+ hours a week. . .”. For several participants, waiting until “after work” to seek care in the emergency department for increased pain intensity made sense, since they did not want to contribute further to often already-strained job attendance records. Several participants described being unable to get their pain under control with the medications they had available to them leading to interruptions in functioning, coping, and rest. Participant P2 noted: “I was laying on my living room floor, flat on my back, with a towel underneath my head. It was the only way I could get comfortable, and it was still nauseating. . . I couldn’t even drive myself to the ED”, while participant P10 said: “I do try to alleviate the pain so I can sleep it off, let it run its course, whatever. But when I break through all of the pain medicine and everything I have and it’s not helping, that’s when I have to go in.” Treatment in the emergency department is often seen as a short term help to regain control. When pain intensity led to an ED visit, participants generally described their treatment there as “just throwing a Bandaid on it.” Participant P5 noted, “My pain medication was just not working and I ended up having to go in and receive a little extra boost on the medication to get the pain to where I was comfortable again.” Participant P4 added, “I’m not looking for a fix. A little increase in the pain medication sometimes, that’s the only thing that helps.” Even among participants with existing pain medication contracts, ED visits to regain control during episodes of increased pain intensity are reported in the hope of getting something to relieve their pain. Participants noted that seeking treatment in the emergency department for increased chronic pain intensity may be for the purpose of short term assistance only. Participant P12 noted she got a “quick fix” for the problem when visiting the ED, but that ED care is “definitely not there to help you long term.”
Retrospective chart reviews showed a total of 85 frequent users at both agencies in the 3-month time of data collection. Of the twenty computer generated random sample of participants from the list of frequent users, 13 agreed to participate (P1 to P13), four were not available despite phone calls per IRB protocol, and three declined to participate. A demographic profile of the 13 participants can be found in Table 2. Participants ranged in age from 22 to 67 and reported having chronic pain from 3 years to 27 years, with participant P7 reporting having pain for his “whole life.” The four themes that emerged included: time of day, pain intensity, barriers to and reasons for using the ED for care, and lack of individualized plan of care. These themes are described below with quotes from the participants to support each theme. 4.1. Time of day A major factor influencing participants’ decision to seek treatment in the emergency department rather than their primary care providers was the time of day in which they felt they needed management of their chronic pain. For example, participant P2 claimed the time his pain was the worst was “usually at night” while participant P3 stated she tended to use the ED because “usually, it’s after hours or the middle of the night”. Participant P10 commented “I would say most times I ever have to go in usually was the evening, and that is a lot of the time when my pain is the worst.” She elaborated with “it was probably about 9:00 at night and it kept getting worse, and I couldn’t sleep. And then finally, like, 1:00 in the morning rolls around, and I couldn’t get comfortable.” The increasing intensity of her pain resulted in a family member bringing her to the ED in the early morning hours. Participants reported that if their pain exacerbations were not as severe during the office hours of their primary care providers, they did not turn to them for treatment. This is demonstrated by participant P10 who claimed “after hours or on weekends I have to resort to going to an ER to receive treatment for my migraines.” Participant P9 explained: “. . .well, like, time of day, like in the middle of the night, or you know, a weekend, and it’s something that was an emergency situation that I needed to deal with right away.” Par-
Table 2 Demographic profile of frequent users in the emergency department.
4.3. Barriers to and reasons for using the ED
Gender Age Times of day
Total visits Plan to ED of care
PCP
F M F M F F F M M M M F
50 22 34 62 46 27 31 51 31 67 45 25
6 5 6 6 4 4 5 4 5 5 6 8
No No No May be No Yes No No Kind of Yes No No
Yes Yes No Yes Yes Yes No No Yes Yes Yes Yes
F
34
8
No
Yes
1431, 1921, 1256, 1858, 1348, 2146 1922, 0456, 1405, 0805, 1202 1758, 1025, 0831, 1801, 1000, 1734 1659, 2117, 1219, 1541, 1206, 2029 1622, 2147, 2137, 1753 1234, 1628, 1927, 1351 1128, 1956, 1247, 1123, 0915 1952, 1935, 1542, 1852 0606, 2212, 2206, 1224, 2038 2257, 2220, 0447, 0148, 2158 2307, 2003, 0009, 1937, 0954, 2154 1757, 1109, 1044, 1459, 1745, 1448, 1146, 1608 1135, 2114, 1513, 1511, 0005, 2346, 1250, 1720
4.2. Pain intensity
Participants reported various barriers when using the emergency department, including being judged by those with whom they came into contact. Participant P11 said: “I did get accused of trying to get pain medication. . .nobody would listen to me, you know” and was further told, “you’re an addict, or you’re just crazy. . .”. This participant reported that she wished that ED providers would take “that extra little effort to really get to know the person before they judge them. . .” Participant P10 reported being treated negatively when she went to the ED for care, noting “. . .some of the doctors in there [ED], I don’t know if they have a God-complex or what, but they think whatever. . .they don’t have to listen to the order, they don’t have to follow procedure, it’s their ER, they’ll do what they want. And those doctors try to say this is all we can give you, this is what we give you, even
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if it’s something I’m allergic to. . .it seems they label you a drug seeker before you walk into the entrance.” Several participants reported reasons for using the emergency department rather than using a primary care physician or pain speciatlist, including lack of money or insurance so the emergency department became the only place in which they could receive care. Participants also reported they could not secure reliable transportation to a primary care provider’s office. Other responses included primary care provider was “very hard to get in to see. . .I try to contact my care provider first. And then if I can’t get a hold of them I go to the ED,” and “Usually I can get into the ED quick; quicker than I can get into my family doctor as it is typically a week or two to secure an appointment with the family doctor.” An example of another reason for using the ED for chronic pain management was when participants reported that staff in the primary care clinics, including physicians, actually told them to go to the emergency department rather than be seen in the clinic. Participant P5 reported: “I mean, you call a doctor, and they’ll be like, we already saw you for this, you know, I can’t help you any more. . .” Other participants echoed similar comments noting, “ I usually do call my family physician first and then she tells me to go in [to the ED] because pain medications don’t help. It usually takes the injection or something to help calm it down, and then I have to rest.” Hence, some participants reported wanting to seek care with a primary care provider, but were turned away for various reasons. 4.4. Lack of individualized plan of care The majority of participants (n = 9; 69%) reported that they did not have a care plan or were “unsure” if they had one or “didn’t even know what it is.” When asked if she had an individualized plan of care, participant P13 stated, “Not as far as a regular doctor. I know my pain clinic has the actual way to follow up. So that’s basically it. When I go to my regular doctor, they are like, well, follow up with the pain clinic.” When participants were asked if they would be willing to meet with a social worker within the healthcare system regardless of whether or not they had an individualized plan of care, seven (54%) reported in the affirmative. Participant P13 noted, “Whatever makes the pain go away. You can always go for extra help and they can always suggest something that someone has overlooked. I’m game for anything.” 5. Discussion Visiting the emergency department for increasing pain intensity is consistent with findings by McLeod and Nelson (2013). Participants in this study often put off seeking treatment for their pain for various reasons (work, trying to deal with it on their own, lack of transportation, lack of money) until it got so severe that they could no longer cope with it. For some, when pain exacerbations happened during regular business hours, they were “encouraged” to go to the ED anyway by primary care providers who noted there was nothing they could do for them in the office. So even if participants tried to use less costly resources to treat their pain, they were turned away. Some participants reported that an important reason to use the emergency department was related to time of day (weekends, night hours); 33 of the 72 visits (46%) occurred between 0800 and 1700, a time when most primary care and walk-in clinics are typically open. Participants reported needing a little “extra” to treat their pain when it got severe, and were aware that the only place in which they could get that extra treatment was in the emergency department. Some participants had opioid agreements in place (agreements with primary care providers which should be honored if possible in treating any acute pain exacerbations), yet they still went to the
emergency department, knowing that they would likely not be provided opioids there. Opioid agreements lead to cost savings related to an increase in patient adherence and the rationalization of the care provided and serve as an effective tool for communicating the plan of care to the ED provider. As part of the patient’s agreement, the option to have a nonopiod protocol for ED visits could be discussed (Svenson and Meyer, 2007); however, this should be an individual determination between the provider and the patient at the time of ED presentation, since there is limited research to suggest that such agreements are effective. The opioid agreement could be just one part of individualized, patient-centered care. Since the Institute of Medicine published Crossing the Quality Chasm (2001) calling for patient-centered care, much emphasis has been placed on involving patients and their families in care decisions. A multidisciplinary plan of care can enhance patient care, decrease frustration and improve patient and staff satisfaction (Pugh et al., 2010). In this study, only four participants reported having a plan of care and even those four could not necessarily explain their plan of care which indicates they were not involved in developing their plan of care. Each patient who presents with exacerbations of chronic pain needs to be thoroughly assessed; however, having an individualized plan of care may assist providers to treat patients consistently and with evidence-based recommendations, which often includes multi-modal drug therapy that does not include opioids (McLeod and Nelson, 2013). Reasons for using the ED for the study participants included transportation, hours of operation, and the availability of parenteral medications that may not be delivered in primary care offices. The emergency department is clearly available 24/7, whereas primary care clinics do not offer that flexibility. Several participants noted that they could not take time off from work to visit a primary care provider. Barriers to using the emergency department included perception of disrespect and even disgust that some participants reported. However, these perceptions were not enough to dissuade a person from seeking relief from the pain. One key aspect of implementing such a plan of care is having electronic records that are accessible wherever the patient presents. Addressing the root causes of patients’ frequenting the emergency department for treatment of chronic pain, and treating each patient in a highly individualized and holistic manner using appropriate resources, can have significant personal and financial impact for both the patient and the treating institution. The best practice recommendations discussed by Limpahan et al. (2013) may provide appropriate evidence to incorporate individualized care planning so as to ensure an effective transition of care for patients seeking treatment for chronic pain. Limpahan et al. (2013) outline eight best practices for “cross setting clinician-to-clinician communication, and also incorporate elements of patient activation, including obtaining contact information for patients’ outpatient clinicians, sending summary clinical information to downstream clinicians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions” (p.1300).
5.1. Implications for emergency nurses The majority of participants in this study said they would be willing to meet with a social worker to develop a plan of care. This individualized plan could include an opioid agreement. A multidisciplinary plan of care could include treatment recommendations for breakthrough pain that may bring patients to the emergency setting and would help to take the guesswork out of the ED provider’s hands and facilitate communication between multiple providers. Emergency department nurses can advocate for an intensive case management program (Grover et al., 2012) comprising a multidisciplinary team of physicians, nurses, social services, and
Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
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the increasingly financially capitated and fragmented healthcare environment (Coleman and Williams, 2007). Based on the results of this study, leaders in the EDs in both agencies have set up a committee to address chronic pain patients. They have hired a social worker with a behavioral health background to assist the patients in dealing with chronic pain and emergency department physicians with non-opioid treatments. The ED nurses have started writing and using a pain care plan, with the help of the ED Physician. Also, the agencies are piloting a process in conjunction with the social worker and legal/risk RN to develop individualized patient plans of care that are signed by the patient. 6. Limitations Limitations include using participants from two facilities affiliated with the same U.S. Midwestern healthcare system. The 13 participants interviewed may not be typical of other patients with chronic pain, and so transferability of the findings to other populations should be done with careful consideration. Additionally, findings may be limited due to recall bias and lack of response. Fig. 1. A model for patient-centered care in ED.
specialists in pain management and behavioral health, all of whom can help decrease frequency of emergency department use. Community resources such as low cost transportation and clinics with extended hours, or even extending services within the emergency department itself, such as providing immediate social work support or providing 24/7 access to a registered nurse could assist frequent users in accessing more appropriate resources for treating their chronic pain. Healthcare providers may need to be educated on dealing ethically and respectfully with patients of all types, since some participants gave very clear accounts of disrespectful treatment by those whom they encountered in the emergency department. Emergency department nurses can advocate for a model of patient-centered care (Fig. 1) incorporating several elements from our study. Patient-centered care means not only incorporating current clinical practice guidelines for chronic pain, but also individualized, culturally appropriate assessment. In the traditional medical model, patients may first experience the need to establish credibility and acceptance with each different provider they see (Monsivais, 2011). A key element of care transitions includes follow up within 1–2 weeks after hospital discharge, as this is widely recognized as a period at risk for adverse events (Misky et al., 2010). It is clear from this study that patients discharged from the emergency department for treatment of chronic pain need assistance transitioning to more appropriate primary care resources. Given that two-thirds of emergency visits occur after business hours (weekdays 9 am–5 pm), identifying primary care sites available after business hours is one strategy for improving appropriate access to healthcare services (Centers for Medicare and Medicaid Services, 2014). If primary care clinics are to be definitive centers for care transitions in the management of patients with chronic pain, then providers must possess the desire and skills commensurate with care of these challenging patients, who seldom develop optimal outcomes. Patient-centered care must include skill development for staff, patients, and their family caregivers related to transitions between care centers (Parry et al., 2009). Clearly, the reasons for patients using the ED for chronic pain are numerous and complex. Future research could explore the effectiveness of individualized plans of care when implemented for those with chronic pain. Developing care transition interventions is also required to allow widespread adoption and sustainability in
7. Conclusions Developing a solution to eliminating the emergency department as a primary source of treatment for patients suffering from chronic pain has proven to be a rather difficult task. Patients in this particular group often have multiple issues and personal factors that prevent them from being able to use primary care services appropriately which often necessitates they use the emergency department to obtain the care they need or desire. It is paramount that healthcare organizations address the issue and develop a plan that provides these patients with specific alternatives to the emergency department such as individualized care plans, or they will continue to use its services to obtain chronic pain treatment and management, resulting in continued financial burdens that this imposes. However, it is also imperative that various other models for outcomes on pain, patient and facility burden are tested and implemented. References Andersen, T.E., 2012. Does attachment insecurity affect the outcomes of multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and use of opioids. Social Science and Medicine. 77, 1461–1468. Centers for Medicare and Medicaid Services, 2014. Reducing nonurgent use of emergency departments and improving appropriate care in appropriate settings. Baltimore, MD: 21244-1850. Coleman, E.A., Williams, M.V., 2007. Executing high-quality care transitions: a call to do it right. Journal of Hospital Medicine. 2, 287–290. Deyo, R.A., Smith, D.H.M., Johnson, E.S., Donovan, M., Tillotson, C.J., Yang, X., et al., 2011. Opioids for back pain patients: primary care prescribing patterns and use of services. Journal of the American Board of Family Medicine. 24, 717–727. Grover, C.A., Close, R., Wiele, E., Villarreal, K., Goldman, L., 2012. Quantifying drugseeking behavior: a case control study. The Journal of Emergency Medicine. 42, 15–21. IOM (Institute of Medicine), 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, D.C. Krippendorff, K., 2005. Content Analysis: An Introduction to Its Methodology. Sage Publications, Thousand Oaks, CA. Limpahan, L.P., Baier, R.R., Gravenstein, S., Liebmann, O., Gardner, R.L., 2013. Closing the loop: best practice for cross-setting communication at ED discharge. The American Journal of Emergency Medicine 31, 1297–1301. Masterson, B., Wilson, M., 2012. Pain care management in the emergency department: a retrospective study to examine one program’s effectiveness. Journal of Emergency Nursing. 38, 429–434. McLeod, D., Nelson, K., 2013. The role of the emergency department in the acute management of chronic or recurrent pain. Australasian Emergency Nursing Journal 16, 30–36. Milbrett, P., Halm, M., 2009. Characteristics and predictors of frequent utilization of emergency services. Journal of Emergency Nursing. 13, 191–198. Misky, G.J., Wald, H.L., Coleman, E.A., 2010. Post hospital transitions: examining the effects of timing of primary care provider follow-up. Journal of Hospital Medicine. 5, 392–397.
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Please cite this article in press as: Jayalakshmi Jambunathan, Sharon Chappy, Jack (John) Siebers, Alishia Deda, Patient-centered care for chronic pain in the emergency department: A qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.05.005
