Innovations in Process Management/Optimizing

Patient Management

Leslie S. Zun, MD, MBA, FAAEM

Chairman & ProfessorDepartment of Emergency Medicine

Chicago Medical School and Mount Sinai Hospital Chicago, Illinois

Leslie Zun, MD, FAAEM

ObjectivesObjectives• Primary Objective: Enhance pain

treatment in the emergency department• Secondary Objectives:

• Systematic pain assessment and pain treatment

• Rapid determination of the appropriate dose for the complaint

• Proper documentation and QI review of the process

• Proper patient education

Leslie Zun, MD, FAAEM

Why Optimize Patient Why Optimize Patient Management?Management?

• Ensure that patients who need pain medications get them• Minority patients• Pediatric patients

• Reduce errors in administration of pain medications

• Prevent inadequate dosing• Improve proper medication selection• Increase pain dosing schedules• Reduce variability in patient care

Leslie Zun, MD, FAAEM

What can be undertaken to improve What can be undertaken to improve patient pain treatment?patient pain treatment?

• Charting systems• Treatment guidelines for complaint• Establish criteria for administration

of pain medications based on pain scales

• Matching complaint, medication and frequency and dose

• Input into a quality improvement process

Leslie Zun, MD, FAAEM

How to automate the process?How to automate the process?

• Need for sophisticated electronic medical record • Artificial Intelligence

• Interface with physician order entry

• Pop up after certain time intervals

• Interface with pharmacy

Innovations in Process Management/Optimizing Patient Management Electronic Medical Record with Artificail Intelligence

Triage

Evaluation andTreatment

Disposition

Discharge Admit

Triage screen forpain assessment

and treatment

Order screen formedication and

dose

Disposition screenfor on-going pain

medication

Automationpoint #1

Automationpoint #2

Automationpoint #3

QI audits fortriage, treatmentand disposition

Pop-ups

Floor ordersscreen include

pain assessmentand medication

Outpatient charts withpain assessment and

medications

QI audits forinpatient care

QI audits foroutpatient care

Innovations in Process Management/Optimizing Patient Management Electronic Medical Record with Artificail Intelligence

Yes

QI audits

Pain

Scale

Doesthe

patienthavepain?

What isthe

patient'slevel ofpain?

What is thepatient's

complaint?

DataElements

ProcessTriage, Evaluate

and Treat,Discharge

Does thecomplaintmatch the

medication?

Dete

rm

ine

proper

dosage

Is the dose andadministrationappropriate?

Audit forpain

assessment

Audit forpain level

Audit for doseand

administration

Audit forconsistancy

Pain assessment

Pain medication

Pain dosing andadministration

Points for patienteducation

Compaint needspain assessment

Is the pain beingre-assessedperiodically?

Audit forpain re-

assessment

What is the patient's level of pain?Did you order pain medication for the

patient's condition?

Innovations in Process Management/Optimizing Patient Management Electronic Medical Record with Artificail Intelligence

Leslie Zun, MD, FAAEM

What is needed?What is needed?• Standardize pain assessment

• Numerical rating scale measures pain from 0–10 or 0–100 with endpoints of “no pain” and “worst pain ever”

• Agree on treatment guidelines

• Concurrent patient education

Leslie Zun, MD, FAAEM

What is needed?What is needed?Treatment GuidelinesTreatment Guidelines

• Guidelines for common pain conditions such as sickle cell, trauma, fractures, chest pain• Include complaint, pain medication, dose,

frequency and route

• Guidelines begin in triage and follow patient through the ED visit• Standing orders for nurses to give the pain

medication beginning in triage• OTC meds or narcotic agents

Leslie Zun, MD, FAAEM

What is needed? What is needed? Patient Education Patient Education

• Use computerized discharge instructions

• Let the patient control or modulate his\her own pain

• Prescribed standardized dosing

• Add adjuncts to the treatment plan

• Establish a set of follow-up times depending on the discharge diagnosis

Leslie Zun, MD, FAAEM

Establish criteria to start pain Establish criteria to start pain meds early in patient caremeds early in patient care

• Use pain assessments frequently to determine patient’s pain level

• Agreement to treat patients prior to the arrival of consultants or test results

• Need buy-in from the surgical services

• Dispel the myths concerning early pain treatment

Leslie Zun, MD, FAAEM

Dispel MythsDispel Myths

• Administration of analgesic in acute abdomen does not change physical exam.

• LoVeechio, F, Oster, N, Sturman, K, et al: the use of analgesics in patients with acute abdominal pain. J Emerge Med 1997; 15: 775-779.

• 53% of the surveyed surgeons stated pain meds precluded a patient from signing a valid informed consent.

• Graber, MA, Ely, JW, Clarke, S, Kurtz, AS, Weir, R: Informed consent and general surgeons’ attitudes toward the use of pain medication in acute abdomen. Am J Emerge Med 1999;17:113-116.

• Problems with this view_ Pain treatment does not necessarily cloud sensorium.

_ Withholding pain medication could be considered coercion.

_ Pain may in itself cloud a patient’s judgment.

Quality Improvement ProcessQuality Improvement ProcessQI audits

Doesthe

patienthavepain?

What isthe

patient'slevel ofpain?

DataElements

Does thecomplaintmatch the

medication?

Is the dose andadministrationappropriate?

Audit for painassessment

Audit forpain level

Audit for doseand

administration

Audit forconsistancy

Is the pain beingre-assessedperiodically?

Audit forpain re-

assessment

Leslie Zun, MD, FAAEM

Quality Improvement ProcessQuality Improvement Process• Set monitor criteria• Pain is assessed in triage• Pain treatment initiated in triage• Pain treatment must be continued

periodically in the treatment area• If no treatment, reason for non-compliance

with established protocol needs to be documented.

• Discharge instructions and medications must also be documented

Leslie Zun, MD, FAAEM

What does it take to make it work?What does it take to make it work?

• Computer systems with artificial intelligence

• Dedication to good patient care • Commitment to excellent customer

service• Involve all stakeholders in the

improvement process• Determine what can be automated• Implement systems that are user friendly

Questions?Questions?