208 Alternatives to Opioids in the Emergency Department: The Henry Ford Health System Experience

Document Type

Conference Proceeding

Publication Date


Publication Title

Ann Emerg Med


Study Objectives: The aim of our Alternatives to Opiates (ALTO) program was to decrease opioid administration, measured in morphine milliequivalents (MME) per patient encounter, in all Henry Ford Health System (HFHS) emergency departments (EDs) by 15% in the 1-year period after program implementation as compared to the 3-year MME per patient encounter baseline prior to implementation. To our knowledge, this is the largest evaluation of an ALTO protocol completed. Methods: A multi-disciplinary group of ED providers, pharmacists, and nursing developed an ALTO program for HFHS using existing best practices and publications for implementation at all 9 HFHS EDs. This included 5 hospitals and 4 free-standing EDs, which see approximately 450,000 patient visits annually in total. Henry Ford Hospital (HFH) ED, a 100,000 annual patient visit quaternary care center, was amongst the 9 EDs included. After finalization of a protocol, we implemented an ALTO “Quicklist,” an organized section of non- opiate pain medications for indicated conditions, into our electronic medical record (EMR, Figure 1). Prior to implementation of our ALTO program in November 2019, we provided education surrounding the new tools and protocols to EM providers and nursing staff in different forums including staff meetings, grand rounds, nursing huddles and also email. Feedback was provided to all departments via system meetings and email communication at 4-month and 8-month intervals post-program kick off to monitor progress. A list of all opioids on HFHS pharmaceutical formularies was reviewed and a standard conversion factor to MME was applied to calculate a total number of MME administered per patient encounter (Figure 2). Only opiate medications administered in the ED were included. MME per patient encounter were compared in two groups: pre-intervention (November 2016 through October 2019; n=1, 317, 466) to the 1-year period post implementation (December 2019 through November 2020; n=366, 404). MME per patient encounter were compared for these time periods across HFHS EDs and for each department and the percentage change was calculated. Results: Opiate administration decreased across the entire HFHS from 2.76 MME per patient encounter to 2.62 MME per patient encounter, a 5.1% decrease overall. Only one of 9 EDs did not see any decrease. The other 8 EDs ranged from 0.5% to 29.4% decrease. Sub-analysis showed opiate administration at the HFH ED decreased from 4.60 MME per patient encounter to 4.28 MME per patient encounter, a 6.8% decrease. Conclusions: The HFHS ALTO program decreased opiate administration across the entire system, however, the goal of a 15% reduction in opiate administration was not met. The COVID-19 pandemic likely confounded these results with an increase in acuity and length of boarding in the ED juxtaposed against a decrease in patient volume seen across the country. Additionally, opiate administration was not stratified among discharged, admitted and intubated patients. Continued ALTO program education is ongoing as is further study with more nuanced data analysis, including specific ALTO medication utilization and provider level data. Other departments in the system, such as observation and surgical specialties, have expressed interest in developing similar protocols and QuickLists. [Formula presented] [Formula presented]

PubMed ID

Not assigned




1097-6760, 0196-0644

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