271 Implementation of an Opioid Detoxification Management Pathway Reduces Emergency Department Length of Stay

Abstract

Increasingly more patients are presenting to emergency departments (EDs) requesting detoxification from opioids. Traditional recommendations for ED management have focused on referral to substance use treatment facilities. Further, the demand for detoxification services has far outpaced supply, leaving providers with limited options for these patients. We set out to standardize, streamline, and improve the care of patients presenting to our ED seeking opioid detoxification. We implemented a management pathway and measured the effects of this intervention. We conducted a before and after study of the effect of our management pathway on ED length of stay, use of resources (social worker consultation, laboratory tests obtained), and prescribing. Adults requesting detoxification from opioids were eligible. Patients were excluded if they were: less than 18 years old; known to be pregnant; had a psychiatric emergency (endorsed suicidality, homicidality, or psychosis); were concomitantly dependent on benzodiazepines, alcohol, or barbiturates; or had a coincident medical illness requiring additional care. Our intervention included: medication recommendations (a clonidine taper, promethazine, and dicyclomine) and revised discharge instructions with community resources information. The primary outcome was ED length of stay. The pathway was implemented on October 25, 2016. To study the effects of the intervention, charts with any ED diagnosis ICD-10 code of “opioid- related disorders” were reviewed for exclusion criteria, first by ICD-10 code, then by chart review. Charts were reviewed for ED length of stay, sex, ICD-10 diagnosis, insurer, exclusion criteria, preferred drug of abuse, disposition, social work consultation obtained, laboratory tests obtained, prescriptions written, and return visits. The difference in length of stay in the pre-intervention and post-intervention groups was compared using the Wilcoxon Rank-Sum test. Categorical data were compared using the Fischer Exact test. From August 1, 2016 to January 31, 2017, 112 patients presented to the ED who met criteria, 59 in the pre-intervention period and 53 in the intervention period. The pre-and post-intervention groups were similar with respect to age, sex, and drug of choice. Median length of stay in the pre-intervention group was 301 (IQR 184.5-458) minutes as compared to 151 (IQR 93-237) minutes after the intervention (p=0.003). Patients in the post-intervention period were less likely to have a social work consultation (83.1% vs. 34.0%, p<0.001) or have laboratory tests obtained (76.4% vs. 34.0%, p<0.001), and were more likely to have been prescribed a medication for withdrawal symptoms (27.1% vs. 56.6%, p=0.002). Implementation of an ED management pathway for patients requesting opioid detoxification consisting of standardized medications and follow-up information for outpatient programs was associated with a decrease in both ED length of stay and utilization of resources, and an increased proportion of patients prescribed medications for symptom relief.Tabled 1Outcomes before and after implementation of management pathwayCharacteristicPre-intervention (n=59)Post-Intervention (n=53)P-valueCount (%)Social work consult49 (83.1)18 (34.0)<0.001Labs obtained None14 (23.7)35 (66.0)<0.001 Urine32 (54.2)12 (22.6) Blood13 (22.0)6 (11.3)Prescribed at least one medication for withdrawal symptoms16 (27.1)30 (56.6)0.002Medications prescribed Clonidine12 (20.3)25 (47.2)0.005 Anti-emetic16 (27.1)28 (52.8)0.007 Anti-diarrheal2 (3.5)18 (34.0)0.000Median (IQR)ED length of stay (minutes)301 (185-458)151 (93-237)0.003 Open table in a new tab