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A Pain Management Plan to Address Drug-Seeking in the Emergency Department
An Interview with Bat Masterson, RN

Bat Masterson, RN is the Emergency Department case manager at the Kootenai Medical Center in Coeur d’Alene, Idaho. He began his nursing career in the Navy and has worked as a staff nurse in the ICU and ED for much of his career. He was the ED Clinical Instructor until he was hired into the new position of ED Case Manager in 2006.  

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Questions

1: What were the problems at the Kootenai Medical Center that led to the creation of your position in the ED and the request that you develop a pain care management program?

2: Who was on the team that you assembled and what were your goals?

3: What strategies did you undertake to accomplish these goals?

4: You have described that a key component in the program was to refer patients to a primary care provider. How did you accomplish this?

5: What were the results of the efforts of the Emergency Department pain care management program?

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Evelyn Corsini, MSW:

What were the problems at the Kootenai Medical Center that led to the creation of your position in the ED and the request that you develop a pain care management program?

Bat Masterson, RN: Kootenai Medical Center (KMC) is a 246-bed acute care hospital. Drug-seeking behavior, doctor shopping, and prescription scams are all concerns for emergency medicine clinicians as they treat legitimate pain without enabling these behaviors. When I began my role as case manager in 2006 I identified reducing repetitive visits for patients with pain as my primary task. At that time the ED saw 48,949 patients per year, and 36 percent of these visits were for pain or pain-related complaints. Physicians were spending 19.5 hours of their 56 hour/week with these patients, and there were some inappropriate admissions. Our goal was to make this work more time and cost-efficient.

At the same time I felt that our physicians and nurses were developing apathy toward this type of patient, and I felt I was beginning to see signs of "labeling". Most importantly, the patient’s issues/complaints were not being addressed appropriately and there was very limited follow up care. This led to a “revolving door” for the ED.

EC: Who was on the team that you assembled and what were your goals?

BM: The team consisted of the Emergency Department physicians, nurses, department director, social worker and case manager. As the program developed we added a psychiatrist/addiction specialist, occupational health physician, palliative care physician, physiatrist, and a representative of the hospital administration. Our team identified these goals:

  1. Manage patients with chronic pain or pain related complaints through coordination of care with the patient’s primary physician and the Emergency Department.

  2. Support the treatment goals of the primary physician without encumbering the Emergency Department.

  3. Use non-narcotic pain relief, whenever possible, and as a standard of care for the treatment of headaches.

  4. Provide the best care for the patient for the condition they have that day.

EC: What strategies did you undertake to accomplish these goals?

BM: We felt that improving the communication between the primary care providers in the community and the emergency staff with the goal of coordination was imperative. All pain patients were seen by an ED case manager, assessment done, and the care plan discussed with the patient and the ED physician. Patients were placed on a monitor status and reviewed periodically for visit history at the ED and the primary care physician’s office. The case manager intervened to assist in managing and coordinating care through the primary care provider’s office.

We invited primary care physicians to the bimonthly interdisciplinary meeting where each patient in the program is evaluated and plans of care are created. We wanted to avoid having patients denied narcotics in the ED from seeking them from other health care providers, switching the burden from one facility to another.

We also linked communication with electronic health records with most major health care facilities within a 150-mile radius. Computerized prompts alerted staff members in any participating emergency department that the patient was enrolled in a pain care management program, and detailed the individual’s plan of care, such as restriction of narcotic, non-narcotic treatment protocols, use of one retail pharmacy and one provider, and involvement with chemical dependency programs. Emergency physicians gained access to Idaho’s prescription monitoring system, which along with the electronic medical records was absolutely essential.

EC: You have described that a key component in the program was to refer patients to a primary care provider. How did you accomplish this?

BM: KMC has an agreement with ALL physicians on staff that if they have privileges at KMC they must agree to see patients in follow up to an ED visit, regardless of the patient’s ability to pay at the time of service or not. The case managers made the appointments for the patients initially, but then we had the patients take a more active role in the care management by making their own appointments.

EC: What were the results of the efforts of the Emergency Department pain care management program?

BM: In 2009, we found that the ED visits for the study pool had been reduced by 77 percent, from 3,689 visits in the year before the program to 852 in the year after. Since more than 70% of the enrolled patients had no insurance coverage or plans that did not cover the cost of the visit, we estimated that the savings to the hospital that year were $7.5 million.

We also found that the percentage of those in the program with a primary care provider rose from 42 percent to 89 percent, and this also led to an increased number of referrals to the pain care management program coming from the primary care providers themselves. Other tangible rewards have been the reduced burdens of time, costs, and employee stress on the ED staff. There was a marked improvement in Nursing and Patient satisfaction scores as well. We hope that reducing available opioids in the community has also had an effect on addiction rates and crime.

 

  Last Update
4/23/2014
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