Emergency Triage System for Back Pain

Transcription

1 Emergency Triage System for Back Pain Andrew J. Haig, M.D. Haig et al., Consulting The University of Michigan Physical Medicine and Rehabilitation

2 Haig Disclosures Haig et al., Consulting helps hospitals, healthcare systems and policymakers in spine care The Center for Healthcare Research & Transformation funded the FastBack project

3 Stuff I hear from the ED: We need the bed, but I m still waiting for MRI Surgery consult Malingering, drug seeking, bounce-backing weasel! Time off work? for a rock concert, or what? then I get screwed if something IS going on. She s my neighbor All I could do was give some muscle relaxants.

4 Stuff I don t hear in the ED: Sure wish I could make that lumbago conference in Pittsburgh next week. Physical therapy hmm Kaltenborg? Greenman? No, it s radicular, lets do McKenzie. I ve got to run time for my multidisciplinary rehab team meeting. We ll follow up on your depression and OxyContin refills in one month.

5 Back pain in the ED 3.1% of all visits Usually not an emergency ED docs: Too many tests Too many drugs Miss the psychosocial boat Three times as deviant (!) as Occ docs Waterman 2012, Siebert 1998, Elam 1995, Reinus 1998, Webster 2005

6 People have tried Keep them out of the ED? Not. Physical therapy in the ED? Only partially helpful (Lau 2008) Jorgensen: The emergency department s mandate is immediate symptom relief, not follow-up care and coordination of health care resources. (Jorgensen 2007)

7 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 86% Medical School Rotations in Neurology ED Specialists Medical School Training in PM&R 27% Medical School Rotations in Neurosurgery 55% Medical School Rotations in Ortho surg 18% Medical School Rotations in PM&R 7% Medical School Rotations in Rheum Yes Residency Training 80% 70% 60% 50% 40% 30% 66% 70% Yes 20% 10% 0% Residency Rotation in Neuro 7% Residency Rotation inneurosurg Residency Rotation in OrthoSurg 5% 7% Residency Rotation in PMR Residency Rotation in Rhuematology Haig unpublished 2012

8 60% ED Specialists Exposure to PT During Training 50% 40% 30% 52% Yes 20% 10% 16% 20% 20% 23% 0% No Formal Exposure Single Lecture series of lectures observation in PT clinic 2% Formal hands on training clinical edu Haig unpublished 2012

9 What we found in the ED (Kohns submitted TSJ 2015)

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14 Why did they order tests?

15 Why did they order drugs?

16 How can we change all that?

17 Where d it come from? My experience with the E.D. in Neenah, Wisconsin Funded by the Center for Healthcare Research and Transformation Executed by Haig et al., Consulting Involving St. Joes, Mercy Port Huron and UM Only outcome data from UM

18 The research project Done June 1st 6 months Survey docs Check 200 records Survey docs Check 200 records Survey docs Check 200 records See what works! Do everything* we can to improve care in the ED

19 *Everything we can Teach a protocol Get Physical Therapy involved Get Physiatry involved Remind, encourage, update

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21 Physical Therapy PT is the most effective short term treatment FastBack eliminates barriers to ED referrals: Specific limited protocol, 4 visits You have to sign off, but PM&R will back up Problems in therapy? PM&R will help End of therapy? PT will triage However: PT alone is NOT appropriate for chronic pain. Send to PM&R, as FastBack PT will reject chronic pain patients. Insurer issues continue, but BCBSM, BCN, Priority, Medicare, medicaid basically covered How? Fax form to XXX-XXXX

22 Physiatry Who goes to PM&R? Chronic pain. (You don t do face lifts. You don t do chronic pain, either.) Sciatica: (It s NOT a surgical emergency, but it can use expert help.) Yellow flags, wants opiates, coping badly Anyone else you have a serious worry about. How? Faxed form to XXX-XXXX

23 In the ED: Intake worker identifies a person with backache. That person fills out a patient questionnaire You fill out a physical exam form You fill out Diagnosis and Orders Worksheet You write your orders You prepare your abbreviated record

24 Back Pain History: Red Flags: Highly sensitive for dangerous causes Cancer Age >50 Male with diffuse osteoporosis or compression fracture Cancer history Insidious onset Worse at night Infection Recent infection or surgery Diabetes, Steroids, immune disorders, IV drugs Constitutional symptoms Neurological risk Progressive neurological deficit New bowel or bladder dysfunction Saddle anesthesia Caused by significant trauma

25 Back Pain History Yellow Flags: Highly sensitive for future disability Previous episodes Previous musculoskeletal complaints Rate pain severe Psychiatric history Alcohol or drug abuse Smoker Maladaptive pain beliefs Legal issues or compensation Physically demanding job Doesn t believe will be working in 6 months Doesn t get along with co-worker/supervisor Emotional trauma in childhood

26 Back Pain Exam Red flags: Maybe bad disease? Sick patient Crazy patient Fever Can t localize pain to a specific structure More than one nerve root: Root strength reflex L234 knee extend, hip flex Patella L5 toe up, hip int.rotate Hamstring S1 toe rise x5 Achilles S234 anal sphincter Bulbocavernosus

27 Back Pain Exam Yellow Flags: Non-organic pain Waddell Signs: 1. Excessive pain behavior 2. Pain on superficial palpation 3. Positive Straight Leg Raise, but negative when distracted 4. Ratchety/inconsistent strength exam 5. Pain on sham stress to spine

28 Decision making Red Flags: None means no diagnostic tests Positive means maybe a test if they can t wait for FastBack PM&R consult. X-ray and sedimentation rate almost always sufficient. Yellow Flags: None means likely to get better no matter what. Positive means caution about: time off work opiates Follow-up FastBack PM&R or someone within 3-4 days.

29 ER Disposition: Minor back pain Teach that it s not dangerous, keep active, Ibuprofen, Ice, no tests. Moderate back pain Above plus FastBack Physical Therapy Significant pain, confusing pain, radicular pain, difficult behavior, multiple yellow flags FastBack PM&R consult Clearly dangerous pain: Order tests, consults, or admission as required. Chronic stable pain: Teach that there is no ED treatment. Do not treat. Do not send to PT. Refer to FastBack PM&R.

30 FastBack results (Haig AJPMR pending 2015) Bounce backs decreased 10% to 2% Opiate prescriptions 40% to 28% Valium from 19% to 12%, MRI scans from 11.5% to 8.5% But CT scans increase, both NS PT referrals went from 0 to 23 PM&R referrals from REAL dangerous disease 3% to 6.5%

31 Putting it together FastBack brings the help you need: Gives them better treatment Gets them out faster Gets them back to work faster Helps prevent bounce-backs Cuts overall costs FastBack s goal is to build YOU what you need. Feedback on FastBack? andyhaig@umich.edu

32 Questions?