Credentials of Corresponding Author
MSN, APRN, FNP-BC, CEN, TNS
Name of Faculty Advisor
Vicki Bacidore DNP, APRN, ACNP-BC, CEN
Nature and scope of the project
The US is currently in the midst of a fatal opioid epidemic. More than 130 people die daily from an opioid overdose and approximately 2.4 million people currently suffer from opioid use disorder (OUD) and there was a 30 percent increase in opioid overdose related ED visits during the recent years. The opioid epidemic strongly impacts ED as patients with OUD, withdrawal and overdose frequently present to the ED with fatal or near death visits. ED serves as a major opportunity to identify, treat and refer patients for OUD treatment, care and recovery (CDC, 2020).
Currently, there is a lack of standardized screening, treatment and referral protocols or processes for the most EDs within this country resulting in greatly missed opportunities for overdose treatment leading to increased mortality. Addiction is a long lasting chronic disease. It is currently an ED standardized practice to treat chronic disease with high quality evidence based treatment interventions. Patients with OUD should also receive the equivalent standardized evidence based treatment as well, which is not the case at this time. Each and every OUD patients' ED visit provides a window of therapeutic opportunity for treating OUD patients to a complete recovery.
For OUD patients, ED is their primary source of healthcare and the only access to recovery. With the standardized evidence based OUD protocols, ED can become a launching pad for recovery instead of a haven for frequent overdose visits.
Evidence based screening tools, medication assisted treatment/medication for addiction treatment (MAT) with an early initiation of buprenorphine in the ED along with effective referral to treatment can reduce morbidity, mortality, ED recidivism, improve quality of life and health outcomes for these vulnerable patients.
Synthesis and analysis of supporting literature
The literature review was performed using PubMEd and CINNAHL.
There are rapidly emerging evidences of improved OUD treatment outcomes after early initiation of buprenorphine within the ED. Through randomized clinical trial of ED patients with OUD, there was significant reduction in overdose risk behaviors and opioid use in ED patients treated with buprenorphine. For these groups, there was also a significant increase in treatment engagement when buprenorphine was initiated in the ED before discharge (D'Onofrio et al., 2015) .
Developing evidence shows that the overdose education and naloxone distributions for these high risk OUD populations play a significant part in reducing the number of overdose fatalities. US Surgeon General fully supports providers to prescribe or dispense naloxone to high risk patients to increase the awareness, possession and use of naloxone. Buprenorphine is considered to be a safe and effective drug of choice for OUD treatment. Therefore, many literatures fully support for early initiation of buprenorphine and warm handoff referral to MAT clinic within the ED in order to improve patient outcome and increase their chance to a complete recovery.
Project implementation
For this evidence based quality improvement initiative, a single sample, non randomized cohort of participants will be included in the setting of an urban ED at the Mount Sinai Hospital in Chicago. Participants will include ED physicians, nurses, advanced practice registered nurses, physician assistants and patients meeting the inclusion criteria. The electronic health record (EHR) will be revised to include a NIDA quick screen questions, Clinical Opiate withdrawal scale (COWS), MAT protocol for within ED and for discharge and proper discharge referral for follow up MAT services. OUD education will be provided to ED providers with pre test and post test scores evaluating the educational module provided to them. ED OUD MAT protocol for within and after discharge will be developed and implemented as educated and planned.
All staff will be educated of the MAT protocol interventions (screening tools, MAT initiation, proper referral to MAT clinic, Naloxone kit, X-waiver if needed) before implementation of the protocol via educational module.
For every patients presenting to the ED, they will go through a simple OUD screening by triage nurse. This process will assist staff to recognize/screen patients with OUD, in need of MAT protocol activation.
Those patients screened for OUD+ will be screened for the risk of withdrawal (COWS screening), if clinically appropriate, ED nurses will notify providers for the need of MAT-buprenorphine initiation to reduce cravings/withdrawal symptoms, which will increase patients comfort and satisfaction.
At time of discharge, these patients will be referred to a proper MAT clinic and discharged with a Naloxone kit in their hand along with an appropriate discharge instructions/demonstration on how/when to use the kit. This process will be implemented by ED nurses.
Evaluation criteria
For the educational component of the protocol, a paired sample t test will indicate the differences between the pre and post test scores evaluating the effectiveness of the educational module for the staff.
For the ED OUD MAT protocol intervention evaluation, nonparametric descriptive statistics will be used to identify documented staff adherence to the protocol/interventions. Evaluation data will include if all ED patients were screened, MAT initiated for those clinically appropriate, and referred to MAT clinic at time of discharge, provided with naloxone kit with proper instruction/demonstration of its use at time of discharge were all followed.
Outcomes
Direct outcomes for this evidence based initiative are simple.
Currently there is no set standards or protocols for OUD patients and their treatment within this ED.
Goal/outcome is to create MAT protocol within the ED that will be consistently implemented to improve patient outcomes and reduce the number of overdose patients and their fatalities.
All nursing staff/providers will be educated on this new MAT protocol and interventions within. After education, nursing staff will screen all patients presenting to the ED for risk/presence of OUD.
When clinically applicable (COWS screening performed by nursing staff for withdrawal risk)), providers will order/nursing staff will initiate Buprenorphine (MAT) early as possible to reduce withdrawal symptoms and decrease cravings and increase chance for MAT clinic engagement/recovery.
At time of discharge nursing staff consistently will physically provide naloxone kit and/or naloxone prescription to those patients and provide a complete teaching on its use with an appropriate demonstration on its use if needed.
The ultimate outcome will be to increase treatment capacity within the ED, provide evidence based quality improvement to ED patients suffering from OUDs and to transition their care to outpatient setting in hopes of turning the tide against this epidemic affecting the health of the most vulnerable population within our community and break the cycle of this cyclic disease and improve quality of life for all. ED can initiate all of this by providing early MAT intervention based on high quality evidence.
Recommendations
While caring for patients with OUD may not be the primary focus of emergency medicine providers, it is an inevitable component of this setting. ED providers are on the front line of the opioid crisis. ED is often their initial and only access to treatment and recovery. Consistent opioid use disorder education and proper screening will identify patients otherwise might be undetected for this chronic disease. ED providers and nurses play a pivotal role in initiating MAT and referral for ongoing treatment within ED in order to improve outcomes for these patients, increase chance for patient recovery and significantly reduce overdose and mortality rates for these patients. Improving treatment plan for patients with OUDs within the ED using evidence based interventions during their most vulnerable state will enhance patient knowledge and promote safety which will alleviate the burden opioid crisis and properly allocate ED resources by reducing the number of accidental overdoses and deaths.
Recommendation is for ED to consistently utilize high quality evidence based treatment interventions as suggested above early within ED to reduce patient fatalities and overdose events through proper screening, MAT treatment and MAT referral/Naloxone Kit education to further recovery and eventually stop the viscous cycle of overdose.
Implementing Opioid Use Disorder Screening, Medication-Assisted Treatment and Referral in the Emergency Department: An Evidence-Based Quality Improvement Initiative