Increasing Naloxone Prescribing in the Emergency Department Through Education and Electronic Medical Record Work-Aids

Abstract

Background: Emergency department (ED) visits for opioid overdose continue to rise. Evidence-based harm reduction strategies for opioid use disorder (OUD), such as providing home naloxone, can save lives, but ED implementation remains challenging.

Methods: The researchers aimed to increase prescribing of naloxone to ED patients with OUD and opioid overdose by employing a model for improvement methodology, a multidisciplinary team, and high-reliability interventions. Monthly naloxone prescribing rates among discharged ED patients with opioid overdose and OUD-related diagnoses were tracked over time. Interventions included focused ED staff education on OUD and naloxone, and creation of electronic medical record (EMR)-based work-aids, including a naloxone Best Practice Advisory (BPA) and order set. Autoregressive interrupted time series was used to model the impact of these interventions on naloxone prescribing rates. The impact of education on ED staff confidence and perceived barriers to prescribing naloxone was measured using a published survey instrument.

Results: After adjusting for education events and temporal trends, ED naloxone BPA and order set implementation was associated with a significant immediate 21.1% increase in naloxone prescribing rates, which was sustained for one year. This corresponded to increased average monthly prescribing rates from 1.5% before any intervention to 28.7% afterward. ED staff education had no measurable impact on prescribing rates but was associated with increased nursing perceived importance and increased provider confidence in prescribing naloxone.

Conclusions: A significant increase in naloxone prescribing rates was achieved after implementation of high-reliability EMR work-aids and staff education. Similar interventions may be key to wider ED staff engagement in harm reduction for patients with OUD.

Figure 1:

Key Driver Diagram. ED: Emergency Department, DUH: Duke University Hospital; EMR: Electronic medical record; BPA: Best practice advisory.

Figure 2:

P-chart showing the monthly proportion of emergency department patients with opioid use disorder or opioid overdose who received a naloxone prescription from January 2017 to March 2020. CL = centerline; UCL = upper control limit; OUD: opioid use disorder; BPA: best practice advisory; RCT: randomized controlled trial.

Figure 3:

Pareto analysis graph of reasons for failure to receive a naloxone prescription (n = 60, chart review timeframe = July-August 2019). ED: Emergency Department.