1. Pain in the ED: meeting the needs of frequent presenters at John Hunter Hospital
Fiona Hodson & Dr Ines Arenal De La Piedad & Angela Fischer Hunter New England (HNE) Health
Background
The cost of persistent pain in Australia is estimated at $34.3 billion, 20% for health care1. The John Hunter Hospital (JHH) Emergency Department (ED) Executive and the Hunter Integrated Pain Service (HIPS), identified a need to better manage patients who frequently present with complaints of persistent pain outside of the acute system as evidence shows that this may not be the best approach.
In 2007, a review of 8 patients at JHH with persistent abdominal pain showed these patients had high end needs and consumed large amounts of resources. They had multiple hospital admissions with prolonged stays, extensive and duplicated investigations, large numbers of invasive surgeries, and a tendency toward deterioration rather than improvement in their pain, health and function over time2. An integrated model of care had previously been shown to be effective reducing presentations to ED by 29%, hospital admissions by 38% saving 177 bed days3. It was agreed that this model could be expanded and strengthened.
The existing model of care was broadened to include care coordination, early identification, clinical pathways and management plans to a range of patients presenting frequently to the JHH ED with pain.
Findings
Figure 2. Process Map for Patients with Persistent Pain in the JHH ED
2009 John Hunter Emergency Department
(iPM ED Data)
Figure 3. Flow chart of frequent presenters with pain to the JHH with the sample of 11 patients reviewed for the project evaluation
Other Findings:
Clinical management of frequent presenters with pain is inefficient and confusing for patients, staff and carers. This at times led to conflict and hostility within and between treating teams, patients, their families and hospital staff.
Solutions (cont)
Solution 3.1: Nursing staff training with regard to new processes
Solution 3.2: Medical officer and all healthcare staff training with regard to new processes
Solution 3.3: Patient education with regard to new processes and management plans
Education
Solution 4.1: Refined organisational processes in the ED
Solution 4.2: Electronic storage of management plans and pathways
Solution 4.3: Yearly review of management plans and flags
Models of Care
Solution 5.1: Communication plan for all stakeholders updated regularly
Solution 5.2: Care coordination role to enhance communication between the ED, patient ,GP and other relevant care providers
Solution 5.3: Develop ED electronic discharge and referral capability eg) GP, mental health and HIPS
Communication
511 patients were frequent presenters presenting 3 or more times for a total of 2,370 presentations
14,704 patients made 30,736 presentations with pain or a pain related condition
Sample: 42 patients aged 16-64yrs presented 3 or more times for 326 presentations (6.3/week) within 16 target ICD Codes of:
Headache; Migraine; Tension headache; Pain in joint; Pain in limb; Muscle pain; Low back pain; Backache; Chest wall pain; Chest pain; Epigastric pain; Abdominal pain; Chronic and intractable pain; Generalised pain; Chronic pancreatitis; Acute cholecyctitis.
John Hunter Hospital Emergency Department in 2009
PMP (Patient Management Plan) Group
11 patients presented 3 or more times for 119 presentations (2.3/week). These patients were identified as chronic and complex with escalating persistent pain needs and had management plans put in place in 2009.
No PMP Group
31 presented 3 or more times for 207 presentations (4.0/week) & were not identified as frequent presenters.
Aim
This project aimed to improve the acute care management of patients with chronic pain, and to decrease ED presentations, inpatient bed days and unnecessary investigations in the Emergency Department.
Objectives
Reduce ED length of stay and ED presentations in the defined cohort.
Reduce avoidable acute hospital inpatient admissions and occupied bed days of defined cohort.
Development of a new model of care that is transferable across other chronic and complex care conditions.
Outcome and Evaluation April 2011
Qualitative data included four patient experience interviews and a staff survey
Quantitative data was collected from an audit of electronic medical records to compare presentations, admissions and occupied bed days between 2009 and 2010 for the 11 patients with Patient Management Plans (PMP’s) in place from 2009 to the 31 patients without PMP’s (see Figure 3). Compliance with PMP’s and investigations in ED for patients with PMP’s was also reviewed.
Key Outcomes:
Of 16 strategies that make up the model, 10 (62.5%) were fully implemented and sustained, 1 was partially implemented and sustained, 1 was not implemented and 4 were either fully or partially implemented but not sustained.
94% compliance with PMP’s
48% reduction in occupied bed days
92% reduction in CT scans and ultrasounds (13 to 1)
Patients without PMP’s had increased length of stay
Four patients expedited up the surgical waiting list
Patients fast tracked to the Pain Service
Three patients stopped presenting to EDs within HNE
Three of 42 patients were identified as frequent callers of the ambulance service and 6 were enrolled in the HNE Connecting Care program.
100% positive feedback from staff and patients for coordinated care processes between Ambulance, GP’s, ED, inpatient teams and Pain Service
Potential savings of 450 bed days and $300,000 in 12 months at JHH, based on the finding that 35 patients were identified as frequent presenters within the current scope over a four month period. This equates to an additional 105 patients/year to the original 77 identified. The savings estimation is based on an average LOS of 5.2 days, a 48% reduction in bed days at $847/day and a care coordinator at $80,000.
Strong support for role of Persistent Pain ED Coordinator. This role was found to raise awareness, educate staff, facilitate the identification of new patients and provide a central point of contact for patient care between Ambulance, General Practitioners, ED and the Pain Service.
Scope
Male and Female aged 16 to 64 years of age with 3 or more JHH ED presentations over a 12 month period: 1/01/ /12/09)
Presenting problem of pain or a pain related complaint and a discharge diagnosis of 16 specified pain related ICD10 codes
Data from hospital Patient Identification System (iPM), at JHH ED and surrounding public hospital ED’s such as Calvary Mater, Belmont and Maitland hospitals to determine other patient presentation patterns
Excluded from the scope:
Children and young people <16 years of age
People aged 65 years and older
People presenting with needs in the sub categories of trauma, mental health, ophthalmology, ENT, obstetrics and gynaecology and respiratory
Solutions
Stakeholders where engaged through working parties, focus groups and face to face interviews to develop a list of appropriate and workable solutions for the model of care.
Figure 4 : Five Key Elements of the Solutions
Method
The project used NSW Health Centre for Healthcare Redesign4 methodology (Figure 1).This included, chart audits, staff, patient, carer and clinician interviews, tag alongs and a highly structured process mapping approach. A wide range of stakeholders were engaged at varied clinical including GP’s and the NSW Ambulance Service to identify key issues and find root. The diagnostic phase was between April and May 2010.
Figure 1. Centre for Healthcare Redesign methodology
Key issues identified were:
Acute system treats each ED visit for people with persistent pain as a new presentation
Excessive steps in process with no clear pathway (Figure 2)
Conflict, hostility between teams, patients, families and staff
Integration between Ambulance, acute care and chronic disease programs.
Future Scope:
Share plans with Ambulance Service.
Electronic access to Management Plans.
Potential savings in bed days could pay for co-ordinator role.
Care coordination role linked to Connecting Care Program.
Spreading model has potential to save thousands of bed days
Broaden scope to include other chronic and complex patients frequently presenting to ED and the paediatric population.
Solutions: Implemented in over 3-6months
Solution 1.1: Weekly iPM report
Solution 1.2: Frequent presenter with pain alert on iPM
Solution 1.3: Stamping of triage sheet to alert medical officer of management plan
Solution 1.4: iPM alert linked to a flag on the electronic whiteboard
Identification
References:
Access Economics (2007). The high price of pain: the economic impact of persistent pain in Australia. MBF Foundation in collaboration with University of Sydney Pain Management Research Institute.
Lantry, G. (2007), “Persistent (Chronic) Abdominal pain: designing a new model of care in the acute care setting”, (Hunter New England Health) Unpublished
Hodson, Fiona (2009). Evaluation of the Persistent Abdominal Pain. Presentation to the Hunter New England Health Innovation Support Advisory Committee. May (Unpublished)
NSW Health Services Performance Improvement Branch (2011); Centre for Healthcare Redesign – Project Management Program Information 2011; /performance/pdf/chr_course_info_for_parti.pdf (04/05/11)
Solution 2.1: Appropriate and current management plans
Solution 2.2: Rapid assessments and fast tracking according to ED “red flags” guideline for persistent pain
Solution 2.3: Persistent pain clinical pathways
Organisational processes
Acknowledgements:
Hunter New England Health Innovation Support Unit
Hunter New England Area Executive Team
JHH Emergency Department
Hunter Integrated Pain Service
Michael Sager, Project Officer
Angela Fischer, Evaluation Project officer
Contact Details:
Project Officer: Fiona Hodson, CNC Hunter
Integrated Pain Service, HNE Health