BCMS Medical Record Fall 2020 - 40

Student Summer Research Projects
continued from page 39

Impact of Expedited Referral
to Treatment on Emergency
Department Utilization/
Recidivism Amongst Patients
with Opiate, Benzodiazepine,
and Alcohol Addiction
Joaquim Diego Santos, The Pennsylvania State University;
Alexis Schoener, The Pennsylvania State University;
McKenna Brower, Syracuse University; Adam Sigal, MD;
Traci S. Deaner, MSN, RN; Megan Reed; Monisha Bindra,
DO; Charles Barbera, MD
INTRODUCTION: Substance abuse disorder (SUD) affects
people from all walks of life and all age groups. Illnesses
involving controlled substances and drugs, that include, but are
not limited to, heroin, marijuana, benzodiazepines, cocaine,
methamphetamines, K2, and alcohol, can be common, recurrent,
and serious. Fortunately, SUD is treatable, and many people do
recover.1 Individuals with complications related to substance abuse
regularly access emergency care in the Emergency Department
(ED). However, out of 19.9 million adults who needed addiction
treatment, only 2.1 million (or 10.8%) receive addiction treatment.
Costs associated with SUD exceed $400 billion per year, but this
amount could be dramatically decreased by closing the treatment
gap and providing direct treatment referrals to patients with SUD.2
The Pennsylvania Department of Drug and Alcohol has recently
implemented the Warm Hand Off (WHO) protocol in numerous
hospitals across the Commonwealth. This protocol "ensure[s] a
seamless transition for opioid overdose survivors from emergency
medical care to specialty substance use disorder treatment, thus
improving the prospect of recovery."3 WHO first began at Reading
Hospital in Fall 2015 as an on-call service, but has since developed
into a full service program with 24/7 coverage by a Certified
Recovery Specialist (CRS). Once a WHO Consult is placed by a
healthcare provider, a CRS meets with patients face- to-face and
makes a direct referral to substance abuse inpatient or outpatient
treatment.
This study aims to measure the impact of expedited referral to drug
detoxification and rehabilitation for patients identified with SUD
and to describe the compliance of patients through the subsequent
steps of the process.
METHODS: 5,280 patient charts for this study were chosen based
on visits to the ED for any substance abuse disorder-related issue,
with the index visit being the first visit after October 1, 2015
(the start of the WHO program at Reading Hospital). Using a
retrospective chart review, a descriptive outcomes study will examine
the effectiveness of a SUD referral by comparing patients who

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accepted WHO versus patients who declined WHO on several
measures of ED utilization before the first WHO referral and within
72 hours, 30 days, 60 days, and 1 year of the first WHO referral.
Primary outcomes include the total number of all-cause ED visits,
non-fatal overdoses, fatal overdoses, and all-cause mortality.
RESULTS: Preliminary results show 1,673 patient charts that have
a documented substance abuse disorder-related issue. Overall, 45
patients displayed housing insecurity (2.69%), 800 patients cited
unemployment (47.82%), and 105 patients did not have health
insurance (6.28%). The most common substances abused included
alcohol (35%) and THC (23%).
In terms of all-cause ED utilization after the first WHO referral,
which included substance abuse, mental health, medical-surgical,
and trauma, 142 patients accepted WHO vs. 59 patients declining
WHO, if offered. Out of the 142 patients who accepted WHO, nine
patients returned to the ED within 72 hours, 26 patients returned to
the ED within 30 days, five patients returned to the ED within 60
days, and 77 patients returned to the ED within a year. Out of the
59 patients who declined WHO, four patients returned to the ED
within 72 hours, four patients returned to the ED within 30 days,
two patients returned to the ED within 60 days, and 23 patients
returned to the ED within a year.
When evaluating non-fatal overdoses and patients who accepted
WHO, one patient returned to the ED within 30 days, one patient
returned to the ED within 60 days, and four patients returned to the
ED within a year. There were zero patients that declined WHO and
returned to the ED due to a non-fatal overdose.
Out of patients who accepted WHO, there have been zero all-cause
deaths, while there have been three all- cause deaths in patients who
declined WHO. Moreover, there have been zero fatal overdoses
recorded so far. Additionally, 247 patients (14.76%) accepted either
inpatient or outpatient treatment after seeing a CRS, Addiction
Medicine, and/or Psychiatric Emergency Services.
Conclusion: Although the study is still being conducted, preliminary
conclusions show that the WHO Program effectively provides direct
referrals to patients with SUD that would benefit from treatment.
Although the data currently shows no reduction in all-cause ED
utilization and non-fatal overdoses in patients accepting WHO, there
is a reduction in all-cause mortality. Moreover, the WHO Program
has seen no cases of fatal overdoses so far.
In practice, an ED visit provides the opportunity for physicians to
actively engage with patients in discussion and reflection to provide
motivation for treatment acceptance and a change in behaviors. Most
patients who have been offered and accepted WHO presented to
the ED primarily to request detox. In almost all cases, patients who
requested detox and spoke with a CRS, Addiction Medicine, and/
or Psychiatric Emergency Services were referred to treatment, but
some patients were referred to treatment without any consultation
outside of the ED. This practice explains the findings of 142 patients
accepting WHO, but 247 patients receiving treatment. By providing
a direct referral to treatment, costs and medical complications
associated with SUD can be decreased. Furthermore, ED admissions,
unintentional injuries, motor vehicle accidents, interpersonal
violence, and intentional/unintentional overdoses decrease as well.2
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BCMS Medical Record Fall 2020

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