Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: There is ongoing controversy regarding the appropriate use of narcotic analgesia for patients presenting frequently to the emergency department (ED) with subjective acute exacerbations of pain. "Are we treating pain or enabling addiction?”

Objectives: To determine whether the presence o f specific factors could be used to identify adults complaining of acute exacerbations of pain for suspected drug addiction, to estimate the percentage of drug addicted patients, to assess the physicians’ ability to detect drug addiction and to evaluate interrater reliability.

Methods: A Drug Abuse Screening Test (DAST-20) was administered to 76 ED patients who presented with acute exacerbations of pain and either multiple ED visits for similar pain complaints, specific narcotic requests, or “allergies to non-narcotics. The DAST-20 was also administered to 74 age-matched controls. Treating ED physicians rated their suspicion for drug addiction using a visual analog scale (VAS).

Results: The overall estimation of drug addiction based on the DAST-20 survey was 17.3% (26/150). Twenty-one percent (16/76) of the analgesia subjects and 13.5% (10/74) of the control subjects scored positive for drug addiction as measured by the DAST-20. Of the analgesia subjects with positive DAST-20 scores for drug addiction, 43.8% (7/16) had multiple ED visits, 43. 8% (7/16) requested specific narcotics and 6.3% (1/16) reported “allergies” to non-narcotics. There was no correlation between the VAS scores and the DAST-20 scores. There was a significant correlation between resident and attending VAS scores for their suspicion for drug addiction.

Conclusion: There exists a clinically significant drug addiction problem among ED patients presenting with acute exacerbations of pain and among low-acuity patients who do not present to the ED for pain management.

Patient satisfaction must be a priority in emergency departments (EDs). The care provided by residents forms much of the patient contact in academic EDs.

Objective: To determine if monetary incentives for emergency medicine (EM) residents improve patient satisfaction scores on a mailed survey.

Methods: The incentive program ran for nine months, 199-2000. Press-Ganey survey responses from ED patients in 456 hospitals; 124 form a peer group of larger, teaching hospitals. Questions relate to: 1) waiting time, 2) taking the problem seriously, 3) treatment information, 4) home care concerns, 5) doctor’s courtesy, and 6) concern with comfort. A 5-point Likert scale ranges from “very poor” (0 points) to “very good” (100) Raw score is the weighted mean, converted to a percentile vs. the peer group. Incentives were three-fold: a year-end event for the EM residents if 80th percentile results were achieved; individual incentives for educational materials of $50/resident (50th percentile), $100 (60th), $150 (70th), or $200 (80th); discount cards for the hospital’s espresso cart. These were distributed by 11 EM faculty (six cards/month) as rewards for outstanding interactions. Program cost was <$8,000, from patient-care revenue. Faculty had similar direct incentives, but nursing and staff incentives were ill defined and indirect.

Results: Raw scores ranged from 66.1 (waiting time) to 84.3 (doctor’s courtesy) (n=509 or ~7.2% of ED volume). Corresponding percentiles were 20th-43rd (mean=31st). We found no difference between the overall scores after the incentives, but three of the six questions showed improvement, with one, “doctors’ courtesy,” reaching 53rd percentile reward.

Conclusions: Incentives are a novel idea to improve patient satisfaction, but did not foster overall Press-Ganey score improvement. We did find a trend toward improvement for doctor patient interaction scores. Confounding variables, such as increasing patient census, could account for inability to demonstrate positive effect.