A Rapid Review of evidence for management of patients that frequently attend Emergency Departments with Chronic Pain.

Purpose

Frequent attenders (FA) (defined as individuals that attend more than 5 times per annum) of ED have been reported to account for 13% of the total cohort. A common reason for presentation is chronic pain. Guidelines recommended that Frequent Attenders are identified, that case management may assist with involving other services and that multidisciplinary case conferences may aid patient engagement.

  • To critique evidence for case management of patients that frequently attend ED with chronic pain.
  • To utilise the evidence to support an innovative rapid access pathway to a pain rehabilitation service.
Frequent attenders (FA)
(defined as individuals that attend more than 5 times per annum) of ED have been reported to account for 13% of the total cohort. A common reason for presentation is chronic pain.
Learning point 1.
The real world complexity of clinical practice is that physical and psychological co-morbidities associated with persistent pain may be present and there may be multifactorial reasons for presenting to health services.
Learning point 2.
Medication restriction is also effective, however access to non-pharmacological approaches is recommended as best practice.
Learning point 3.
To the author’s knowledge, a review of literature to evaluate interventions for people living with persistent pain who attend ED frequently has not been conducted.

Approach

A rapid review approach was used whereby a Systematic Review methodology is streamlined and used to inform healthcare decisions. The levels of evidence criteria were assigned to papers included in this review which were based on Oxford Centre for Evidence Based Medicine standards. A PRISMA diagram detailed number of articles yielded in the initial search.

A Population, Intervention, Comparator, Outcome and Study design methodology was utilised. Inclusion criteria were: studies in English, adult subjects with persistent pain and reduction in Emergency Department attendance was an outcome. Studies including homelessness or substance abuse were excluded.

Outcomes

Eleven studies were included in the review.

Interventions were classified into the following categories -

  • Multidisciplinary Review
  • Referrals to primary care, pain services, mental health, psychological support, physiotherapy, social workers
  • Behavioural care +/- addiction care package
  • Case management including advice on medical, behavioural and social issues
  • Medication restriction, care plans in notes
  • Chronic pain care plan or pain management programme

Grade A and B evidence for reducing frequent attendance was for a multidisciplinary team to offer a care package, including referral to specialists in both chronic pain and mental health. Grade C evidence suggests that multidisciplinary, prescription restriction or a pain management programme were effective in reducing ED FA.

There is low to moderate evidence to suggest that MDT case management and treatment with specialists in pain management and mental health is effective in reducing frequent Emergency Department attendance for persistent pain.

Implications

Future research should focus on -

  • More adequately defining the interventions and dose response relationship.
  • Calculating a rate ratio to aid policy makers and clinicians in decision making.

Top three learning points

  1. The real world complexity of clinical practice is that physical and psychological co-morbidities associated with persistent pain may be present and there may be multifactorial reasons for presenting to health services.
  2. Medication restriction is also effective, however access to non-pharmacological approaches is recommended as best practice.
  3. To the author’s knowledge, a review of literature to evaluate interventions for people living with persistent pain who attend ED frequently has not been conducted.

Fund acknowledgements

The review was conducted as part of a Clinical Innovations in Healthcare Module funded by Health Education England. 

Additional notes

This work was presented at Physiotherapy UK 2019

Please see the attached Innovations poster below. 

 

For further information about this work please contact Leila Heelas  

 

 

 

References:

Heelas, L, Emergency Department: Frequent Attendance due to Persistent Pain: A Rapid Review, Pain and Rehabilitation Journal (2020) In Press. 

Royal College of Emergency Medicine. Frequent Attenders in the Emergency Department (2017). Available from: https://www.rcem.ac.uk/docs/RCEM%20Guidance/Guideline%20-%20Frequent%20Attenders%20in%20the%20ED%20(Aug%202017).pdf

Moe, J. et al. Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A Systematic Review. Acad. Emerg. Med. 24, 40–52 (2017).

Flores-Mateo, G., Violan-Fors, C., Carrillo-Santisteve, P., Peiró, S. & Argimon, J. M. Effectiveness of organizational interventions to reduce emergency department utilization: A systematic review. PLoS One 7, 1–7 (2012).

Soril, L. J. J., Leggett, L. E., Lorenzetti, D. L., Noseworthy, T. W. & Clement, F. M. Reducing frequent visits to the emergency department: A systematic review of interventions. PLoS One 10, 1–18 (2015).