Tough Love - A New ED Pain Management Model

Valentine's Day is Thursday.

The US emergency room has become infirmary, dispensary, primary care clinic, birth control provider, prison health office, pediatrician, counselor, pharmacy, meal ticket, and yes, there is a life-threatening emergent condition or trauma every so often just to spice things up.

Emergency care professionals in the blogosphere tell us it's becoming near impossible to show patients the TLC they want - issues of legitimate need and, alternately, misuse abound. Crowding in the ED is crowding out timely quality care.

The prescription? Time for some tough love in emergency rooms.

I'm not going to rehash multiple episodes of drug-seeking behavior or abuse of the system's resources in EDs detailed by medbloggers, such as the good docs over at M.D.O.D.

If you want tragically interesting examples of misuse, read entries by EMTs like Emergency Em (calling 911 and then asking the ambulance crew to take you to the ER for a flu shot? seriously?)

We're all spending a lot of time writing about the unbelievable excess use & abuse of the US emergency care system.

One could even argue we've become "frequent flyers" in the blogosphere - reporting anonymously on repeat patients, are we too becoming addicted to getting our chronic cathartic fix without seeking appropriate preventative care, i.e. trying to mend the broken model?

I'd like to propose a new method for ED pain management care and in-house referrals. Code name: tough love.

Here's how it could work:

• Each and every time ER staff rules out other complications, emergent conditions, etc., and is able to isolate pain management as a primary issue, the ER doc transfers the patient to the pain management or "chronic pain" section of the ED (similar to a Fast Track or Urgent Care setup, with dedicated staff and physical space concurrent to the ED - don't be tempted to put this team in the basement to deter prospective patients).

• There, the patient is seen by a specialist, a pain management doc/NP who begins treatment by gathering a comprehensive H&P and interview.
  

• If (and only if) the pain mgmt ED team determines that narcotics are appropriate, they will be administered onsite or prescribed according to the team's best-practice treatment and goals. Let the pain specialists make the decisions for these patients. Let them see the repeat patients who present with chronic pain and/or pain management issues.
  

• In the pain management docs black bag is a list of treatment centers, including dental clinics, county/municipal health departments, etc. Prescriptions for treatment may be doled out in place of narcotics as the team determines necessary. Patients in noncompliance with a previous treatment program referral may find they will not receive narcotic refills via this ED until they are in compliance with a program the pain management team recommends.

Here's what you need:

• First, you must have a pain management doc on staff. All the time.

• Second, your ED physicians must be willing to appropriately and efficiently hand off patients with pain management issues as primary complaints. You have to track systemic bottlenecks that block flow, including those to the new department.
  

• Third, your administration will have to have, ahem, certain anatomical parts of steel. They have to be able to sell this idea to the Board, the medical team, the support staff, the community, the 'consumer', the media, and bare-everything medbloggers.
  

• Fourth, the pain management ED team will quite often see people with 'legitimate' chronic pain issues (migraines, cancer care, etc). The pain management skills of the team must be surmounted only by their high level of empathy. In other words, hire caregivers with people skills.
  

• Oh, and the lawyers will have to go over the program design with a fine-toothed comb. I'm sure the Joint Commission will want a look-see as well.

• And of course if a pain mgmt. patient develops an emergent issue during treatment, they can be quickly transferred to an ER bed (based on triage) for appropriate care.
  

Who knows if this tough-love program could actually work? The answer is simple: we won't know unless someone tries it.

Maybe it's time we stop blogging about caregivers showing more compassion and customers who take advantage. To some extent, that will happen no matter what we do to address the issue at a systemic level.

Let's show patients a little love by connecting prospective need and a service line that has the opportunity to help those living with chronic pain.

Let's design a system that allows ED personnel to get back to doing what they do best: assessing and treating emergent injuries and illnesses.

And let's build a safeguard into the system so those who abuse the 'open door' ED with drug-seeking behaviors are referred to appropriate care - including treatment and rehab centers.

In other words, let's do something about the situation, one ED at a time.

Of course, this is only a stopgap solution - we still have to fix primary care.

Roll up your sleeves, folks.