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Opioid analgesics are FDA-approved prescription medications that can provide pain control for moderate to severe pain when appropriately prescribed; however, inappropriate prescribing can lead to opioid abuse, diversion, and deadly overdoses.1

According to the Centers for Disease Control and Prevention (CDC), the number of drug overdose deaths was four times higher in 2018 than in 1999 despite a recent decrease and, of those 67,367 deaths in 2018, nearly 70 percent involved an opioid and 14 percent involved prescription opioids. As stated by the CDC, “the best ways to prevent opioid overdose deaths are to improve opioid prescribing, reduce exposure to opioids, prevent misuse, and treat opioid use disorder.”2

Benefits of Electronic Prescribing of Controlled Substances

Electronic prescribing of controlled substances (EPCS) allows physicians to transmit controlled substance prescriptions securely to their patient’s pharmacy. The use of EPCS reduces prescription fraud and diversion by removing the risk of prescription forgery and alterations. It also decreases prescribing errors that are often caused by illegible handwriting and use of unapproved abbreviations. And, because the electronic prescription data flows into state prescription drug monitoring program (PDMP) databases, EPCS can help provide physicians with insight into a patient’s controlled substance prescription history, thus helping to identify “doctor shopping” behaviors and opioid overuse.3

Current Usage and Future Requirements

EPCS is now legal in all fifty states, yet it is not widely adopted. Less than 60 percent of all United States prescribers are currently EPCS-enabled, despite having 96 percent of US retail pharmacies capable of receiving electronic controlled substance prescriptions.4 However, individual state and federal regulations will soon change that.

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, passed by Congress in 2018 to help combat the opioid crisis, requires EPCS for all controlled substances prescriptions covered under a Medicare Part D prescription drug plan or Medicare Advantage Prescription Drug (MA-PD) Plan, beginning January 1, 2021.5 Recently, Centers for Medicare & Medicaid Services (CMS) announced that they will delay enforcement until January 1, 2022.6 Despite the delay in enforcement, many states are continuing to pass their own EPCS-required mandates to help address the opioid crisis. Twelve states have already required the use of EPCS prior to December 31, 2020 and an additional 15 states will begin requiring EPCS this year.7

How Your Facility Can Make an Impact in Your Community

MEDHOST EPCS solution is DEA-compliant, Surescripts-certified, and is available in both MEDHOST Emergency Department Information System (EDIS) and MEDHOST Enterprise Electronic Health Records (EHR). To learn more about how MEDHOST can help your facility reduce opioid prescription fraud, improve patient safety, enhance physician workflow, and meet EPCS state and federal requirements, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.

References:

1Preuss, C.V., Kalava, A., & King, K.C. (2020). Prescription of Controlled Substances: Benefits and Risks. StatPearls [Internet]. Retrieved from here.

2Centers for Disease Control and Prevention (CDC).  (2020, March 19). Opioid Overdose. Retrieved from https://www.cdc.gov/drugoverdose/index.html

3The Office of the National Coordinator for Health Information Technology (ONC). (2019, December 18). Health IT Playbook: Opioid Epidemic & Health IT. Retrieved from https://www.healthit.gov/playbook/opioid-epidemic-and-health-it/

4Surescripts. (2020, December). Electronic Prescribing for Controlled Substances. Retrieved from https://surescripts.com/EPCS/

5Center for Medicare & Medicaid Services. (2020). Medicare Program: Electronic Prescribing of Controlled Substances; Request for Information (RFI). Federal Register 85:150 p. 47151-47157. Codified at 42 CFR §423. Retrieved from https://www.govinfo.gov/content/pkg/FR-2020-08-04/pdf/2020-16897.pdf  

6Center for Medicare & Medicaid Services. (2020). Medicare Program; CY 2021 Payment Policies Under the Physician Fee Scheduled and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/ Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID–19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID–19. Federal Register 85:248 p. 84472-85377. Codified at 42 CFR §400, 410, 414, 415, 423, 424, and 425. Retrieved from https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf

7Imprivata. (n.d). Federal and State Regulations. Retrieved from https://www.imprivata.com/federal-and-state-regulations. Accessed January 3, 2021.

Human trafficking, believed to be the third-largest criminal activity in the world, is a form of modern-day slavery where people are bought, sold, and smuggled, often beaten, starved, and forced to work as prostitutes with little or no pay.1

It is a human rights violation that severely impacts millions of people worldwide. Emergency nurses have a unique opportunity to recognize victims of human trafficking and intervene. A recent study revealed that of 173 U.S. victims surveyed, 68 percent had presented to a healthcare provider at least once while being trafficked, most frequently to an emergency department provider.2

Determining the magnitude of human trafficking has proved challenging for law enforcement, policy makers, and trafficking advocates due to the covert nature of the crime and the prevalence of hidden populations.3 The United States government estimates approximately 17,500 people are trafficked nationwide.4 Researchers found that 87.8 percent of surveyed trafficking survivors were seen by a healthcare professional during captivity and went undisclosed, resulting in a missed lifesaving opportunity.5 63 percent of those surveyed were specifically examined in an emergency department.5

Healthcare access for these victims is limited and most will only have one opportunity to be examined by healthcare professionals. At present, the research is limited concerning the effectiveness of training for the emergency department staff on identification and treatment of human trafficking victims. 6 Additionally, limited availability of emergency department-specific screening tools and limited established reporting requirements, together with the barriers to patients disclosing their involvement in trafficking, make it difficult to identify these patients and provide the proper care and advocacy.

Unfortunately, these victims rarely identify themselves, and the failure to recognize victims reduces the opportunity to provide resources to such victims. Only 40.7 percent of the emergency departments specifically screened adults for human trafficking, with most ED clinical staff using one or more safety questions as their screening tools.7 Of the 59.3% of the emergency departments that did not screen adults specifically for human trafficking, several screened only children; some focused on domestic violence or abuse/neglect screening; others asked questions about safety in general but clarified that it was not specific to screening for human trafficking; and some offered no information on any actions taken in the emergency department related to human-trafficking screening.8

Typically, these victims report a high incidence of health issues such as physical abuse, sexually transmitted infections, undernourishment, and psychological trauma. When a victim seeks medical attention, this presents healthcare staff a rare opportunity to recognize victims. Hence, healthcare facilities, especially emergency departments, become the venue for identifying victims of human trafficking, providing a prospective safe haven for victims. To combat human trafficking, healthcare workers need to be trained on how to identify and approach such victims and understand what actions to take once a victim is identified.

At the health facility, screening begins at the registration desk, where the staff can look for signs of trafficking. Signs may include the patient has no insurance, guardianship information, and personal identification, the patient offers to pay with cash, or the patient may be with another individual who answers all the questions for the patient.7  If registration personnel are successful in identifying a possible victim, or if the screening for human trafficking indicates abuse, the emergency nurse can take further actions to provide help and resources.

Other red flags that may help identify victims of human trafficking include: The patient is unaware of his/her location, the patient exhibits fear, anxiety, depression, and avoids eye contract, and the patient is reluctant to explain his/her injuries.7   In addition, emergency department nurses need to know the common signs that victims of human trafficking present with to the emergency department.  The most common signs of trafficking are bruises, broken bones, scars, pelvic inflammatory disease, urinary tract infections, multiple abortions or pregnancies, sexually transmitted infections, malnutrition, feelings of helplessness, shame, humiliation, and confusion.9 As victims may be fearful of the trafficker accompanying them, sometimes a silent visual notification tool can be implemented to notify staff of abuse or unsafe living situations. After that visual tool has been identified, the team members should be alerted immediately, and the patient can be escorted to a designated safe area until further steps can be taken.

If human trafficking, exploitation, or slavery is suspected, an advocate, such as a social worker or case management, should be contacted to assess the victim’s needs and educate the patient about his/her rights.  If the victim is an adult, law enforcement should be contacted only after obtaining patient consent. If consent is not obtained, the patient should be given the number to the National Human Trafficking Hotline to memorize and resources should be provided. If the victim is a minor, law enforcement should be contacted to report suspected abuse.

Increasing the understanding, knowledge, and skills of ED staff and providers is essential for accurate identification of such victims so resources can be provided.  MEDHOST Emergency Department Information System (EDIS) allows for screening tools to be built per your needs, as well as charting choices that can be created to help your facility identify victims of human trafficking. To learn more about how MEDHOST EDIS can help run your hospital more efficiently with customizable tools, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.

 

1 U.S. Department of Justice. (2019). Human trafficking/involuntary servitude. Federal Bureau of Investigation. Retrieved from https://www.fbi.gov/investigate/civil-rights/human-trafficking

2 Breuer, G. J. & Daiber, D. (2019). Human trafficking awareness in the emergency care setting. Journal of Emergency Nursing, 45(1), 67-77. https://doi.org/10.1016/j.jen.2018.11.011

3 Hachey, L.M., & Phillippi, J.C. (2017). Identification and management of human trafficking victims in the emergency department. Advanced Emergency Nursing Journal, 39(1), 31-51. https://doi.org/10.1097/tme.0000000000000138

4 Ahn, R., Alpert, E. J., Purcell, G., Konstantopoulos, W. M., McGahan, A., Cafferty, E., … Burke, T. F. (2013). Human trafficking: Review of educational resources for health professionals. American Journal of Preventive Medicine, 44(3), 283–289. https://doi.org/10.1016/j.amepre.2012.10.025

5 Lederer, L. J., & Wetzel, C. A. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals of Health Law, 23(1), 61–91.

6 Donahue, S., Schwien, M., & LaVallee, D. (2019). Educating emergency department staff on the identification and treatment of human trafficking victims. Journal of Emergency Nursing, 45(1), 16-23. https://doi.org/10.1016/j.jen.2018.03.021

7 Egyud, A., Stephens, K., Swanson-Bierman, B., DiCuccio, M., & Whiteman, K. (2017). Implementation of human trafficking education and treatment algorithm in the emergency department. Journal of Emergency Nursing, 43(6), 526-531. https://doi.org/10.1016/j.jen.2017.01.008

8 Dols, J. D., Beckmann-Mendez, D., McDow, J., Walker, K., & Moon, M. D. (2019). Human trafficking victim identification, assessment, and intervention strategies in South Texas emergency departments. Journal of Emergency Nursing, 45(6), 622-633. https://doi.org/10.1016/j.jen.2019.07.002

9 Lamb-Susca, L. & Clements, P.T. (2018). Intersection of human trafficking in an urban emergency department. Journal of Emergency Nursing, 44(6), 563-569. https://doi.org/10.1016/j.jen.2018.06.001  

 

The U. S. Department of Health and Human Services (HHS) and numerous national organizations and task forces have established guidelines recommending screening for intimate partner violence (IPV).

Clinical practice and risk management experts indicate that best practice would be to include screening in emergency department protocols. Under the Affordable Care Act, these services are generally covered in new health plans without requiring a co-payment, co-insurance, or deductible.1

In the United States, over 43.6 million women and 37.7 million men have experienced physical violence, sexual violence, stalking, or psychological aggression by an intimate partner.2 About one in four women and one in ten men have experienced and reported some form of intimate partner violence.2  IPV affects all people regardless of gender, age, race, socioeconomic status, religion, or sexual orientation. Survivors of IPV can experience long-lasting effects including mental health issues, depression, and post-traumatic stress disorder (PTSD) symptoms.2

Nurses working in the emergency department (ED) can play a crucial role in the identification and management of IPV. EDs should be fully equipped and ready to identify and triage such cases since they are often the first point of contact for victims. Universal screening for IPV must be conducted consistently to increase identification and management of victims and ensure resources and referrals are provided.3

Most EDs have mandated protocols for IPV screening and intervention, but not all clinicians have received specialized training to respond to victims of various types of violence. Examination and clinical management of these patients are very complex, requiring documentation that is subject to increased scrutiny by the justice system. Clinicians, especially in the emergency room setting, must be ready for such victims while continuing to manage the rest of the department.

Screening for IPV should be conducted in a private place without visitors present. The screening questions should be asked using a respectful and nonjudgmental tone of voice.4 If the screening reveals any signs of abuse, the provider should be promptly notified so a secondary screening can occur, immediate safety concerns are addressed, and treatment protocols are followed. Patients should be offered the opportunity to contact law enforcement and should be given a referral to a domestic violence agency.

Victims cannot be accurately identified consistently without proper IPV screening tools. It is important for your emergency department EHR vendor to provide you with tools to improve IPV screening. MEDHOST Emergency Department Information System (EDIS) has a plug-in builder that allows for screening tools to be built per your needs, as well as charting choices that can be created to help your facility identify victims of IPV.

To learn more about how MEDHOST EDIS can help run your hospital more efficiently with customizable plug-ins and other tools, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.

 

References

  1. Coverage of Recommended Preventative Services Under 26 C.F.R. 54.9815-2713, 29 C.F.R. 2590.715-2713, and 45 C.F.R. 147.130. 80 Fed. Reg. 41317 (2015). https://www.federalregister.gov/documents/2015/07/14/2015-17076/coverage-of-certain-preventive-services-under-the-affordable-care-act
  2. Smith, S.G., Zhang, X., Basile, K.C., Merrick, M.T., Wang, J., Kresnow, M., & Chen, J. (2018). The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 Data brief – Updated release. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf
  1. Karnitschnig, L. & Bowker, S. (2020). Intimate partner violence screening in the emergency department: A quality improvement project. Journal of Emergency Nursing, 46(3), 345-353.  https://doi.org/10.1016/j.jen.2020.02.008
  1. Choo, E. & Houry, D. (2014). Managing intimate partner violence in the emergency department. Annals of Emergency Medicine, 65(4), 447-451. https://doi.org/10.1016/j.annemergmed.2014.11.004