Monday, December 10, 2018

Acupuncturists Working in the Emergency Department at the Aurora Health System of Wisconsin: A Success Story

key phrases:  interview, acupuncture programs, acupuncture for acute pain, acupuncture in the ER, examples of incorporating acupuncture into healthcare systems and hospitals

Who:  John Burns, DPT, MSOM, Manager of Acupuncture at Aurora Health Care, Milwaukee, Wisconsin

Organization:  Advocate Aurora Health Care
Location:  Milwaukee, Wisconsin and surrounding suburbs
What:  Providing services in 11 oncology clinics, 7 OP clinics, 1 ED, 2 IP
website:  www.aurorahealthcare.org/services/integrative-medicine/acupuncture

Dr. Burns with his poster at the AIHM conference. #AIHM18
photo credit Megan Gale

Quick Outline

  1. Introduction
  2. The Study
  3. The Program
  4. References


Introduction
Wouldn’t it be great, as a patient, to have access in your local emergency room (ER) to non-pharm therapy option for relief of your strong pain, nausea, or GI symptoms, especially if you have adverse reactions to some medications?  Wouldn’t it be useful, as a provider in the Emergency Department (ED), if you had the ability to refer to a non-pharm therapy within your ED to help ease common ED presenting symptoms of pain, anxiety, stress, and nausea?

I met John Burns, DPT, MSOM, at the Academy of Integrative Health and Medicine (AIHM) conference #AIHM18 in San Diego in September where he was presenting his ED work at Advocate Aurora Health Care of Milwaukee, Wisconsin, in a poster session.  His study looked at the practicality of offering acupuncture services in the ED of a Wisconsin hospital. And, with enthusiasm, I watched him receive first place in the poster session for his team’s work!

Background
Dr. Burns has a doctorate degree in physical therapy and a master of science degree in oriental medicine from Midwest College of Oriental Medicine, Racine, Wisconsin.  For the past 4 years Dr. Burns has been the manager of the acupuncture services program at Aurora Health Care, Sinai Hospital.  During a lunch break at the AIHM conference, I interviewed Dr. Burns about his ED study from the poster, and about the Aurora Acupuncture program.

Part 2:  The Study
More about the AIHM Research Poster Submission
Site of the study presented in the poster:  Emergency Department, Aurora West Allis Medical Center, West Allis, WI. 

What was Dr. Burns’ inspiration for the project? 
With a smile, Dr. Burns notes it was the research study on acupuncture into the ED setting of the Allina Health system of Minnesota by Adam Reinstein and Jeff Dusek that inspired him. The Allina ED study was published in 2017 in the peer-reviewed scientific journal, Pain Medicine[1].

Poster Title
“Utilization of Acupuncture Services in the Emergency Department Setting:  A Quality Improvement Study” by John Burns, DPT, MSOM, Jessica J.F. Kram, MPH, Vashir Xiong, MSOM, Jeanne Stark Casadont, MSOM, Tiffany Mullen DO, Nancy Conway, MS, Dennis Baumgardner, MD
 
Dr. John Burns awarded first place of the
 AIHM 2018 posters.
photo credit Megan Gale
Background and Reason for this ED Pilot
Patients often present to the emergency department (ED) for pain.  Acupuncture may decrease acute pain experienced by patients seeking ED services.  Acupuncture is an evidence-based, non-pharmacologic option for pain relief and pain management[2].

Goal of the Pilot
Dr. Burns notes: “the major purpose was to determine acceptability of acupuncture in the ED as either adjunctive or optional care for patients.”  The study was the first to assess the impact of acupuncture in the ED for pain management in the Aurora Health system.  The researchers wanted to determine acceptability of the acupuncture program by the patients and the ED staff.  This was a quality improvement study.

Methods
This was a retrospective observational study of patients in the Emergency Department. 

Patients admitted to the ED were offered acupuncture treatment for their acute pain condition based on their:
·         Emergency severity index (ESI)[3]
·         Reason for visit
·         Their physician’s approval

What Electronic Health Record (EHR) program do you use?
Aurora uses EPIC for documentation.  Dr. Burns worked with IT staff to create a specific data field in the EHR to track outcomes from the acupuncturists’ progress notes. 

Measurements/Metrics Used in ED study
In the ED study, they tracked patient-reported outcomes.  The top 3 measures were:  pain, stress, and anxiety.  The symptoms were measured on the numeric rating scale (NRS), of 0-10 for each.

Striking aspects to note about the study
The demographics of the patients treated represented the demographics of the local ED.
When patients were treated by the ED acupuncturist, they received only acupuncture.  For example, some patients had less than 8 needles per acupuncturist’s discretion, and some did not retain the needles past 20 minutes due to other services needed (such as x-rays).

What are important points/take-aways from this study?
  • Acupuncture reduced acute pain.  In the study, patients who received acupuncture reported 50% pain relief (average)
  • Acupuncture reduced symptoms of nausea by about 60%
  • Acupuncture in the ED setting is feasible

Where is the Emergency Department (ED) research published?
Dr. Burns’ paper was published April 29th, 2019, in the peer-reviewed scientific journal, Journal of Patient-Centered Research and Reviews (JPCRR).  See reference section below for citations and links.

Review of Clinical Program Implications for this Study
Availability of acupuncture services in the ER increases ease of access to non-pharm pain relief. And, for someone admitted to the hospital, having acupuncture as an option in the ER and the inpatient unit may decrease the complexity of their medication panel.  It may reduce the medication panel complexity because it reduces the common symptoms of nausea, stress, anxiety, and pain without medication (non-pharm therapy).

Considerations for future studies
Dr. Burns noted: “This [study] was only a pilot program to determine if acupuncture would be accepted by ED patients and staff.  This was not a controlled study or a study that followed patients over a period to determine changes in their behavior.” 
He says, “Next plan is to repeat the study with a different demographic and provide free follow-up care.”
  • Reproduce the ED project in Milwaukee, WI, in next year with different patient demographics
  • Track whether availability of acupuncture in the ED reduces opioid prescriptions
  • Follow up with patients who receive acupuncture in the ED at an outpatient clinic.  No follow up with the patients was performed for this pilot program due to study limitations.  They found that "following discharge from the ED, less than 2% received acupuncture services within 30 days."  Assumptions about why this may be:  patient choice, lack of reimbursement, even though outpatient services were available at the West Allis site.


Part 3: Acupuncture in the Aurora System
The acupuncture program at Advocate Aurora began in 2002 with one acupuncturist.  The program now employees 11 acupuncturists, full-time and part-time, who provide care in 11 oncology clinics, 7 outpatient clinics, 2 inpatient units, and one emergency department. Acupuncturists in the program are employees of Aurora.

The acupuncture program is part of Aurora’s Department of Integrative Medicine (IM).  The IM department employs practitioners who provide the following services:  massage therapy, chiropractic care, acupuncture, aromatherapy, and mind-body exercise.  The mind-body exercise therapy program is at Aurora’s psychiatric hospital.

Program Funding and Sustainability
How do they sustain the program?
Program is sustained through philanthropic funding and cash-based service.
Outpatient acupuncture services are cash-based except for the ED study program.  The ED program is sponsored by Aurora at no charge to the patients.  The oncology clinic acupuncture program is supported through both philanthropic funding and cash-based services.

How is program success or failure measured?
The Aurora IM programs are measured with the new model of care: value-based metrics, particularly outcome-based measures.  Program success is not measured solely by RVUs or patient load.

More about what Dr. John Burns does and where he works
Dr. Burns teaches Tai Chi and Qi Gong to patients in the mental health clinic and psychiatric hospital.  This clinical care has been well-received by patients and by staff who have seen patients’ positive response to it.  Dr. Burns also does in-service presentations to the following provider types: acupuncturists, physical therapists, nurses, occupational therapists, and physicians.

Dr. Burns’ Vision for the Aurora Acupuncture program:
Dr. Burns believes acupuncture, as an integrative health paradigm, has a “patient empowering philosophy”.  His hopes to see acupuncture available in all services lines, but especially incorporated into the following services:  neurology, palliative care, and the back and spine group.  He feels the integrative medicine program will benefit when acupuncture services are covered by the following insurances:  Medicare, Medicaid, and the Aurora employee health benefits system.  He would like to bring acupuncture into the mental health clinic as part of the substance abuse treatment program. 

On being a manager of an integrative health program:
Dr. Burns has been in a management position for 4 years.  He wants his LAcs maintain work-life balance.  He understands that clinician resilience and program sustainability are inter-related.  So, he makes this a priority in his role as program manager.

What learning opportunities are available to integrative health students and practitioners interested in hospital-based practice?
Shadowing opportunities are available in his program.  The integrative health courses that teach self-care may be soon be open to the public.

Part 4: References
Contact information for Dr. Burns and the Aurora Acupuncture Program

Links to related publications on the Aurora ED Study

References

Related Blogposts
Videos highlighting the Aurora integrative medicine program


Tags:  #AIHM #AIHM18 #EDacupuncture

Advocate Aurora's Oncology Acupuncture and Integrative Therapies Program (update Oct 2020)
  • New* in Sept 2020, published in JACM, with information on Advocate Aurora's (Wisconsin) oncology acupuncture and massage therapy programs. "A Quality Brief of an Oncological Multisite Massage and Acupuncture Therapy Program to Improve Cancer-Related Outcomes" by Jennifer Fink, John Burns, Ana Christina Perez Moreno, Jessica J.F. Kram, Melissa Armstrong, Sara Chopp, Scott J. Maul, and Nancy Conway. The Journal of Alternative and Complementary Medicine (JACM), Sept 2020. 822-826. https://doi.org/10.1089/acm.2019.0371.
  • More on the topic of oncology acupuncture programs and defining "success" at this post.

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[1] Adam S. Reinstein, Lauren O. Erickson, Kristen H. Griffin, Rachael L. Rivard, Christopher E. Kapsner, Michael D. Finch, Jeffery A. Dusek; Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study, Pain Medicine, Volume 18, Issue 1, 1 January 2017, Pages 169–178, https://doi.org/10.1093/pm/pnv114
https://academic.oup.com/painmedicine/article/18/1/169/2924684 

[2] The Consortium’s Pain Task Force White Paper. 
Tick H, Nielsen A, Pelletier KR, et al.  Evidence-Based Nonpharmacological Strategies for Comprehensive Pain Care.  The Consortium Pain Task Force White Paper.  2018.

[3] Emergency Severity Index (ESI) is a triage algorithm that measures urgency of case on a scale of 1 to 5. “1” indicates the highest degree of urgency and “5” is the lowest degree, developed by Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services (HHS). https://www.ahrq.gov/professionals/systems/hospital/esi/index.html

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