DorlandHealth

How an ED Countered Overuse

Three years ago Dr. Salvatore Vertaramo came up with an idea. As with most emergency departments, we had developed our own list of “frequent flyers.” Dr. Vertaramo, an ED physician, noticed there were in fact two lists of frequent flyers. The first were those who were very ill and frequented the ED related to their illness—for instance, those with congestive heart failure or cancer.

The second group frequented the ED for pain control. Realizing that an ED is not the most appropriate place for anyone to obtain pain control, Dr. Vertaramo came up with a plan to give this group a contract to lessen their narcotic use. Starting off by trying to convince fellow doctors and those in administration that this plan could work, he was met initially with a dose of skepticism. Even if the plan were effective, was it ethical? Was it even legal?

Dr. Vertaramo enlisted the help of our clinical information department to run a list of everyone who had visited the ED at least 10 times in the past year. He scoured every name and checked to see why they had come to the ED. He compared what medications had been administered both in the ED and by prescription for discharge. Equipped with this information, he took it to administration, where they decided that he could trial his idea for six months and see how it worked—provided it was greenlighted by our legal department, our patient advocates, and corporate compliance. The team identified the process for a contract, a referral list of pain and addiction centers, and options for chronic pain management. All contracts were individualized to target specific patients and their problems.

In November 2005, Dr. Vertaramo sent our first pain contract letter to a patient. The contract stated that this patient had visited the ED at least 10 times for pain control in the last 12 months and that, although he could come back to the ED whenever he felt the need, he would not be given narcotics unless the doctor felt it was irrefutably warranted. If, say, there was the case of a broken leg or a myocardial infarction. Dr. Vertaramo sat down and explained the intricacies of the contract, including the list of facilities. Lo and behold, the patient signed.

Since that time these contracts have been an integral part of our program. Although not every doctor buys into the program and some continue to dole out narcotics, the overarching impact it has made in our pain population is astounding. Every six months, Dr. Vertaramo goes through the old and the new list and deletes and adds people as he feels appropriate. He has added other types of frequenters to the list, like those who have forged prescriptions or those who have overdosed. Altogether we have had 151 patients on our contract list, 62 of whom we have been able to remove as a consequence of decreased visits. Out of the 89 names on our current pain contract list, 20 individuals had no visits in 2008 while another 31 had two or less. Are we naive enough to think we cured all these people? Of course not. Some have likely gone on to other hospitals and other doctor’s offices. But we believe that at least a few have gotten into pain management or participated in addiction counseling.

Now we are taking it a step further by referring the patients on our list who have insurance to case management. Some insurance companies have initiated a corrective managed care program to assist patients in getting the help they need.

While our program is relatively small in scale, the bottom line speaks loudest. Since its initiation in 2005, the program has saved thousands of dollars in ED care. These 89 people accounted for at least 890 visits over the span of one year. At an estimated $500 per visit, the savings have been huge. With the overcrowding of EDs in today’s health care arena, we have identified how a chronic pain issue can be addressed in the appropriate environment, allowing the ED to focus on truly emergent issues.

Linda Ferara, RN, is a case specialist in the ED at Shore Health System in Easton, Md.
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