Implementation of the ACI back pain model in ED

Back pain is a leading cause for presentation to the emergency department (ED) in Australia.¹ Opioid medicines are not recommended in guidelines for most cases of back pain.² However in Australian EDs, about 70% of patients with back pain receive an opioid medicine.³

Reducing the use of opioid analgesics

Our aim was to reduce the use of opioid analgesics from 70% to 60% of patients with back pain presenting to the emergency departments of Sydney Local Health District and Dubbo Base Hospital within four months. We also aimed to reduce the use of lumbar imaging and hospital admissions. In this trial, we tested a multifaceted strategy (i.e., clinician education, education resources, and audit and feedback) to implement the ACI model of care for acute low back pain in EDs. Our strategy significantly reduced use of opioid analgesics to manage back pain and improved clinicians knowledge and attitudes towards back pain care. In addition, patient outcomes were not inferior after implementing the new model of care e.g. satisfaction with care was similar.

A multifaceted implementation strategy

The implementation of the ACI model of care for acute low back pain in the ED was clinician targeted. The clinicians included medical officers, nursing staff and physiotherapists that work in EDs. The multifaceted implementation strategy included five main components:⁵

• Education seminars: structured training from experienced rheumatologists and physiotherapists that focused on skills for assessing, managing, educating and referring patients according to the ACI model of care for acute low back pain.
• Educational materials: a hard copy of the ACI model of care, a website and decision support tools for appropriate use of analgesic medicines were distributed to the clinicians. Posters highlighting key messages about benefits and harms of opioid medicines were displayed throughout the EDs and patient handouts were provided so that clinicians could use them to educate patients more easily.
• Provision of non-opioid pain management strategies: a consensus-based list of non-opioid pain medicines was created by the directors of each ED and local rheumatologists. Superficial heat wraps were made more accessible to the emergency clinicians as a guideline-based alternative to opioid medicines.
• Fast-track referral to outpatient services: ED clinicians were educated on referral pathway options to outpatient services such as specialist back clinics and outpatient physiotherapy follow-up.
• Audit and feedback: ED clinicians were provided with structured real-time audit and feedback data on department-level opioid use rates through monthly email newsletters and real-time dashboard developed in Qlik Sense.

Significant reduction of opioids administered

Administration of opioid analgesics was measured using data extracted from each hospital's electronic medical record system, both in the control phase of usual care and the intervention phase. Our results showed that after active implementation of the ACI model of care for acute low back pain using our multifaceted strategy, the percentage of patients with back pain receiving any opioid analgesic in the emergency department reduced from 62.8% to 50.5%.⁶ This meant that 12.3% less patients were given an opioid medicine for their back pain in the ED and instead received evidence-based treatments.

In one hospital, we observed a significant reduction of 24% in the percentage of patients with back pain administered opioids withing the ED. This site was highly engaged with the trial with nearly all emergency clinical staff attending the educational sessions. The reduction in opioid use did not compromise patient health outcomes (i.e., pain, physical function) and satisfaction with care.

After our intervention, emergency clinicians significantly improved their knowledge and attitudes towards back pain care, as measured by validated questionnaires. In a follow-up study, we found that our implementation strategy of the ACI model of care for acute low back pain produced sustained reduction in opioid use over a 30-month period. Our intervention did not result in significant changes in the use of lumbar imaging or hospitalisation rates.

References

1. Emergency department care 2021-22 data tables. Australian Institute of Health and Welfare- Emergency department care. Available: https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care
2. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J 2018;27:2791–803
3. Ferreira GE, Machado GC, Abdel Shaheed C, et al. Management of low back pain in Australian emergency departments. BMJ Qual Saf 2019;28:826–34
4. NSW Agency for Clinical Innovation. Management of people with acute low back pain: Model of Care. Chatswood 2016
5. Machado GC, Richards B, Needs C, et al. Implementation of an evidence-based model of care for low back pain in emergency departments: protocol for the Sydney health partners emergency department (SHaPED) trial. BMJ Open 2018;8:e019052
6. Coombs DM, Machado GC, Richards B, et al. Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial. BMJ Quality & Safety 2021;30(10):825–35