A Novel Triage Protocol to Increase Evidence-Based Treatment for Opioid Use Disorder
Margaret Lowenstein, MD, MSHP
Jeanmarie Perrone, MD
Zachary Meisel, MD, MPH
Rinad Beidas, PhD
Kyle Kampman, MD
Christopher Edwards, MD, FACEP
CDC Injury Control Research Centers – Penn Injury Science Center
Thousands of patients with opioid use disorder (OUD) visit Penn Medicine’s emergency departments (EDs) annually. These visits present a critical opportunity to link patients to evidence-based interventions, such as medication-assisted treatment (MAT).
ED-initiated buprenorphine, a form of MAT that stabilizes opioid withdrawal and reduces cravings, has been shown to double rates of treatment engagement at 30 days compared to referral alone and lower mortality rates.
Building upon previous work conducted by our team showing that automation in the electronic health record (EHR) alone wasn’t sufficient for identifying OUD patients, we used a participatory design approach to develop a new triage protocol to identify and deliver evidence-based treatment interventions for OUD patients in the ED.
The intervention introduced an EHR bundle with a 1-question screener for nurses to enact, triggering a triage protocol that defaulted to two order sets. The first was an OUD induction order set, which provided decision support tools for buprenorphine induction, and the second was an OUD discharge smart set, which included similar prepopulated orders for buprenorphine, a default prescription for naloxone, and referrals for linkage to outpatient care such as Penn Medicine’s peer recovery specialist program.
When piloting the protocol, we observed increases in both ED administration and discharge prescribing of buprenorphine as well as naloxone prescriptions at discharge. We also saw an increase in withdrawal assessment compared to control hospitals, a rise in the use of the OUD induction order set, and substantial use of the OUD discharge smart set.
By the end of the study, the rate of OUD patients in the ED receiving buprenorphine climbed from just 3 percent to 23 percent. Based on these findings, Penn Medicine implemented the triage protocol at the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, and Pennsylvania Hospital.
After launching the new protocol in these hospitals, we saw the rates of patients with OUD who were identified and assessed for withdrawal climb from 26 to 48 percent, prescriptions for buprenorphine rise by five percentage points, and prescriptions for naloxone increase by 12 percentage points. In comparison, data from two hospitals that didn’t implement the protocol showed no significant changes in any of these measures.
This intervention, now proven to increase identification and improve initiation of evidence-based treatment for OUD patients, is easy to implement and can be used by any hospital hoping to nudge their patients toward better OUD care.