A Quality Framework for Emergency Department Treatment of Opioid Use Disorder

Abstract

Emergency clinicians are on the front lines of responding to the opioid epidemic and are leading innovations to reduce opioid overdose deaths through safer prescribing, harm reduction, and improved linkage to outpatient treatment. Currently, there are no nationally recognized quality measures or best practices to guide emergency department quality improvement efforts, implementation science researchers, or policymakers seeking to reduce opioid-associated morbidity and mortality. To address this gap, in May 2017, the National Institute on Drug Abuse’s Center for the Clinical Trials Network convened experts in quality measurement from the American College of Emergency Physicians’ (ACEP’s) Clinical Emergency Data Registry, researchers in emergency and addiction medicine, and representatives from federal agencies, including the National Institute on Drug Abuse and the Centers for Medicare & Medicaid Services. Drawing from discussions at this meeting and with experts in opioid use disorder treatment and quality measure development, we developed a multistakeholder quality improvement framework with specific structural, process, and outcome measures to guide an emergency medicine agenda for opioid use disorder policy, research, and clinical quality improvement.

INTRODUCTION

Opioid overdose deaths in the United States have nearly doubled in the last decade.¹ In 2016, more than 42,000 people died from an opioid overdose, the number of deaths surpassing that from motor vehicle crashes.² Emergency departments (EDs) are on the front line of the overdose epidemic, caring for increasing numbers of opioid overdose patients. From 2016 to 2017, ED visits for opioid overdose increased 30% nationwide^1,3,4; however, a minority of opioid-related ED visits result in linkage to treatment.^5–7

The ED’s role in the opioid overdose epidemic is often mischaracterized. Although there are certainly opportunities for improvement in ED opioid prescribing practices, EDs account for a small and declining proportion of overall opioid prescriptions.^8–10 EDs are also leading innovative policies and practices to end the overdose epidemic with ED initiatives in harm reduction and opioid use disorder treatment initiation and linkage to care.^9–11 As a key point of access to medical care and the primary provider of acute care diagnostic and unscheduled care, the ED is well positioned to improve care quality and outcomes for patients with opioid use disorder.¹²

Quality measurement and quality improvement initiatives can standardize practice, reduce care inequities,^13,14 accelerate implementation and adoption, and improve patient outcomes and resource use.¹⁵ Although there is a well-identified need to improve quality of care for patients with opioid use disorder nationally,¹⁶ there is a gap between available research evidence and adoption into clinical practice.¹⁷ There are some state-^18,19 and professional-organization-established best practices^20,21 for opioid use disorder primary prevention, treatment, and harm reduction, but there are currently no nationally recognized ED opioid use disorder quality measures or universal quality improvement models for adoption. Care for opioid use disorder is often fragmented, which exacerbates health inequities, produces poor patient outcomes, and wastes resources. To date, most research examining ED opioid use disorder interventions have been institution or state specific,²² in controlled clinical trials,^23,24 or limited to feasibility and use evaluations.^25,26 Research examining the effect of ED opioid use disorder interventions on patient outcomes is needed to guide quality improvement strategies to reduce overdose deaths and improve linkage to treatment.

Given the paucity of indicators and measures available to guide ED opioid use disorder quality improvement initiatives, in May 2017, the National Institute on Drug Abuse’s (NIDA’s) Center for the Clinical Trials Network convened experts in quality measurement from the American College of Emergency Physicians’ (ACEP’s) Clinical Emergency Data Registry, researchers in emergency and addiction medicine, and representatives from federal agencies, including NIDA and the Centers for Medicare & Medicaid Services (CMS). Drawing from discussions at this meeting and experts in opioid use disorder and quality measure development, we developed a multistakeholder quality framework to guide opioid use disorder emergency care policy, research, and clinical quality improvement programs.

THE ROLE OF THE ED IN ADVANCING QUALITY FOR OPIOID USE DISORDER

During the last 50 years, the ED has evolved to serve as a universal point of medical access, diagnosis, treatment, and linkage to definitive care. Broadly, the ED provides 3 basic functions encompassing a spectrum of patient care (Table 1). First, EDs specialize in the identification, stabilization, and treatment of time-sensitive conditions such as sepsis, stroke, acute myocardial infarction, trauma,²⁷ and toxic ingestions, including opioid overdose. Quality improvement initiatives that have successfully improved emergency care quality and patient outcomes in these domains include door-to-balloon time for acute myocardial infarction,^28–30 early goal-directed therapy for sepsis,^31–33 and door-to-needle time for stroke.^34–36 There are currently no agreed-on standards of care after acute opioid overdose.

Table 1.

Emergency medicine work domains and associated quality indicators: 3 domains of ED clinical care, clinical examples with associated quality care indicators, and opioid use disorder corollaries.

Emergency Department Work Domain	Clinical Example	Emergency Care Quality Indicators	Application to OUD
Time-sensitive treatment and stabilization	Acute myocardial infarction	Door-to-balloon time	Overdose reversal and clinical stabilization Treatment of severe withdrawal
	Stroke	Door-to-needle time Door-to-CT time
	Sepsis	Initial sepsis bundle compliance
	Trauma	Appropriate head CT use Protocolized trauma care
Acute diagnostic center	Chest pain	Timely ECG and cardiac biomarkers	Assessment of undifferentiated altered mental status
	Abdominal pain	hCG testing in women	Identification of OUD
	Headache	Appropriate head CT use
	Interpersonal violence	Intimate partner violence screening	Treatment of opioid withdrawal
	Sexual assault	Sexual assault nurse examiner evaluation
	STI testing	STI testing and treatment
Health care access and treatment linkage	Diabetes	Initiation of antihyperglycemics
	Hypertension	Home medication adjustment	Referral to OUD treatment
	Early pregnancy	Linkage to reproductive health care provider
	Tobacco use	Provision of smoking cessation resources	Harm reduction (naloxone,
	Suicidal ideation	Linkage to psychiatric services	overdose education, syringe access)
	Child and elder abuse	Mandatory reporting

hCG; Human chorionic gonadotropin; OUD, opioid use disorder.

Second, the ED is a center for acute diagnostic testing, where emergency testing is conducted to rule out life-threatening illness or injury in circumstances of diagnostic uncertainty. Common examples of quality indicators for these types of clinical encounters include timely ECG and cardiac enzyme testing to evaluate patients for acute coronary syndromes and appropriate use of head computed tomography (CT) for head trauma (Table 1). The opioid use disorder corollaries in this treatment domain are commonly encountered but lack standardized approaches or indicators of quality, namely, the identification of opioid use disorder and treatment of acute opioid withdrawal.³⁷

Third, the ED is a critical point of access to the health care system and providing linkage to definitive treatment.³⁸ If and when a diagnosis is made in the ED, providers commonly initiate treatment and link patients to definitive care in the form of hospitalization or referral to outpatient providers.³⁹ In the setting of newly diagnosed pregnancy, for example, the ED links patients to appropriate obstetrics follow-up (Table 1). In instances of newly diagnosed hyperglycemia without diabetic ketoacidosis, the ED often initiates antihyperglycemics and facilitates referral to primary care. Similarly, for under- or untreated hypertension, providers may adjust a patient’s antihypertensive medications in coordination with his or her primary care provider or link patients to a community primary care provider for follow-up.^38,40 The ED function as an access point to the health care system is especially true for opioid use disorder, but despite evidence supporting the efficacy of ED-initiated treatment for opioid use disorder and linkage to outpatient treatment,^41,42 linkage to opioid use disorder treatment has yet to become standard of care in many EDs. This may be in part due to stigma, lack of available outpatient addiction medicine resources, or gaps in provider knowledge and training. However, because the ED encounter may be an individual’s only contact with the medical system, ED visits present an important opportunity to provide patients with opioid use disorder harm reduction services and linkage to definitive opioid use disorder treatment.^37,43

FRAMEWORK DEVELOPMENT

Recognizing the crucial role of the ED in addressing the opioid overdose epidemic, in May 2017, the NIDA Center for the Clinical Trials Network invited experts in quality measurement from ACEP’s Clinical Emergency Data Registry, emergency medicine and addiction medicine researchers, and representatives from NIDA, CMS, and other federal agencies to a consensus meeting titled “Exploring Substance Use Relevant Measures in EHRs and Clinical Quality Measurement in Emergency Settings.” Thirty-four people attended the meeting and during the course of 2 days discussed current opioid use disorder quality measures in the electronic health record, electronic health record data science, quality measure development, CMS quality measure priorities, ways to leverage the ACEP Clinical Emergency Data Registry, emergency medicine substance use disorder research, and trends in emergency medicine opioid use disorder clinical practice.

A summary of the meeting proceedings was composed by NIDA and reviewed by a smaller group of meeting attendees that included quality, emergency medicine, and addiction researchers; representatives from NIDA; and 2 emergency medicine researchers who did not attend the meeting. Current opioid use disorder quality literature and the meeting proceeding summary were rereviewed by the study team. Through iterative discussions, the author team refined the meeting summary into the proposed opioid use disorder quality improvement framework. All items included in the framework were finalized by group consensus.

A QUALITY IMPROVEMENT FRAMEWORK

The development and implementation of quality improvement campaigns for emergency care conditions has yielded substantial improvements in patient outcomes, perhaps best exemplified in acute myocardial infarction and stroke. After national quality improvement campaigns for acute myocardial infarction, there was a 21% reduction in mortality from 1990 to 2006.⁴⁴ Similarly, the adoption of the American Heart Association’s Get With the Guidelines for stroke has been associated with decreased mortality and improved functional status after hospital discharge.^45,46 As with acute myocardial infarction and stroke, using a quality improvement framework, we can improve care and patient outcomes for the prevention, treatment, and reduction of harm associated with opioid use.

The Donabedian framework for quality measurement classifies indicators of quality into 3 basic categories: structural, process, and outcome measures.⁴⁷ Structural measures assess a provider’s or institution’s capacity, systems, and processes.⁴⁷ For acute myocardial infarction, for example, this would be the presence or absence of cardiac catheterization abilities. Process measures assess what a provider does, such as giving aspirin for chest pain, getting to the catheterization laboratory within 90 minutes of ED arrival for ST-elevation myocardial infarction, or administering broad-spectrum antibiotics in sepsis. Outcome measures assess the effect of the health service or intervention on the health of patients. For acute myocardial infarction, common outcome measures are cardiac function and survival, and in stroke, outcome measures are survival and functional status. Historically, researchers and policymakers have linked structural and process measures to population-level patient outcomes and identified structural and process measures that can be used for quality improvement. Clinicians and hospitals have subsequently implemented system changes to meet structural measure requirements and continually assess process measures. Integrated structure, process, and outcome measures may then be used to guide and define quality improvement and accountability programs that pay for performance. However, outcomes evaluated by quality improvement efforts are different from those used in the course of research. Quality measures, regardless of clinical focus, require several considerations, given the high financial stakes of pay-for-performance and public reporting programs. In the case of opioid use disorder, these considerations warrant particular attention.

First, all quality measures are designed for use at a specific “level of analysis,” meaning they are attributed to a certain type of provider or organization, clinical setting, or geography. Proposed ED opioid use disorder process measures focused on opioid prescribing may be well suited for measuring practice of individual clinicians while other process measures, such as naloxone distribution, may be better suited to an entire group of clinicians in an ED or hospital. Given the multiple organizational structures and resources necessary to affect naloxone distribution, both of which are largely outside the control of individual clinicians, a population-based level of analysis is often superior to measure many harm reduction interventions.

Second, attribution is a common challenge when measuring quality of a clinical entity with either multiple types of clinicians or non–health care influences, both of which hold true for opioid use disorder. Although outcome measures such as successful referral to treatment may be attributed to the care provided in an ED and may resonate with clinicians seeking concrete metrics for improvement, maintenance of medication for opioid use disorder is more attributable to available community resources and outpatient providers, rather than care delivered in the ED. Many of the outcome measures presented in Table 2 therefore may be better suited as community- or health-system-level measurements, of which the ED is just one contributor. Specifying quality metrics at the community and organizational level ensures accountability to improvement of overall health outcomes and supports investments at the organizational level and by the public sector for ED opioid use disorder quality improvement projects.

Table 2.

Quality measurement framework for ED treatment of opioid use disorder: structural, process, and ED and population health outcomes for opioid use disorder primary prevention, harm reduction, and treatment.

			Outcome Measures
OUD Domain	Structural Measures	Process Measures	ED	Population
Primary prevention	Availability of nonopioid pain management	Patient education about opioid safe storage and disposal on discharge	Adverse events after ED discharge after receiving new opioids	Patients with unintended prolonged opioid use
	PDMP-EMR integration	Trial of nonopioid analgesics before opioid initiation when indicated	ED revisitation for analgesia-associated adverse medication events	New OUD per-capita incidence
	“Safe prescribing” ED policies	Median days opioids prescribed		OUD prevalence
		Median MME/day per ED visit		Opioid overdose incidence
		Frequency of benzodiazepine and opioid coprescribing
Harm reduction	ED naloxone distribution policy	Proportion ED OUD patients: a) Provision of overdose prevention and response patient education	Risk-adjusted inhospital mortality for overdose	Risk-adjusted repeated nonfatal overdose
	Community syringe access program	b) Discharged with/prescribed naloxone		Risk-adjusted repeated fatal overdose
		c) Referred to a syringe access program	Risk-adjusted 30-day repeated ED visit for nonfatal opioid overdose	Risk-adjusted out-of-hospital overdose mortality
		d) Referred to community resources		HCV and HIV incidence and prevalence
	Buprenorphine-waivered providers (ED and community)	Structured screening and diagnostic questionnaires		Repeated ED visit rates for opioid overdose, opioid withdrawal, or complications of injection drug use
	addiction medicine specialist consultation access	Urine toxicology testing	Opioid withdrawal scale at ED discharge	Proportion patients engaged in formal addiction treatment at 30 days
Treatment	Availability of outpatient providers of medication for OUD	Proportion ED OUD patients:		Proportion patients maintaining receipt of medication for OUD at 30 days
	Community opioid treatment programs and providers	a) With initiated medication for OUD	Risk-adjusted inhospital mortality for overdose	Risk-adjusted repeated nonfatal overdose
	Hospital or community bridge clinics	b) Prescribed medication for OUD		Risk-adjusted repeated fatal overdose
		c) Linked to outpatient OUD treatment		Risk-adjusted out-of-hospital overdosemortality
		d) Counseled by health promotion advocates, counselors, or social workers

Third, when designing quality measures, researchers and quality measure developers must consider whether measures need to be risk adjusted. Many ED and community factors will significantly affect the treatment of ED opioid use disorder patients and patient outcomes. Factors affecting ED opioid use disorder care include workforce training and availability, outpatient addiction treatment availability, existing community resources, stigma, and state policies and regulations. Social determinants of health that contribute to opioid use disorder and overdose—specifically, housing, urbanicity, poverty, transportation, and employment—will affect opioid use disorder development and treatment access. To account for these variations in measure development, we will need to identify which measures will need to be risk adjusted and whether social risk factors should be adjusted for in risk models without masking important disparities.⁴⁸

OPIOID USE DISORDER QUALITY MEASUREMENT

Taking considerations of level of measurement, attribution, and risk-adjustment into account, to evaluate and improve the quality of ED opioid use disorder primary prevention, treatment, and harm reduction, we must develop specific structural, process, and outcome measures (Table 2) that are feasible to implement and measure in the ED. Potential quality measures for opioid use disorder primary prevention, treatment, and harm reduction were identified, developed, and discussed with experts during the NIDA meeting. Some measures are specific to ED quality improvement, whereas others may be more suited for public reporting. Many identified patient outcomes are population-based measures that are affected by multiple factors in addition to treatment provided in the ED. Therefore, ED quality measures and quality improvement initiatives will largely focus on structural and process measures. Many of the measures identified and summarized in Table 2 have already been implemented in US EDs as part of local quality improvement initiatives; however, future research and programmatic evaluations are necessary to determine whether these are valid and reliable measures that can be used to improve the quality of opioid use disorder care and improve patient outcomes nationwide.

Opioid use disorder primary prevention focuses on decreasing excessive opioid prescribing, which has been shown to be associated with the development of opioid use disorder,⁴⁹ and reducing coprescribing with benzodiazepines. Structural measures EDs and hospitals can implement are the development and expansion of nonopioid pain management services, such as regional anesthesia, the development and implementation of alternatives-to-opioids programs, and integration of prescription drug monitoring program databases within the electronic health record. Process measures include patient education on opioid use, storage, and disposal; trial of nonopioid analgesics before opioid initiation; and presence of and adherence to institutional “safe prescribing” policies. Safe prescribing policies would include limits on number of days prescribed,⁴⁹ adherence to outpatient care plans for patients with outpatient pain contracts, not providing opioid refills for chronic pain, and avoidance of opioid and benzodiazepine coprescribing. Decreased opioid and benzodiazepine coprescribing to patients with opioid use disorder has been shown to have mortality benefit.⁵⁰ ED-relevant quality measures in this domain may be focused on structural and process measures because patient outcomes, such as development of opioid use disorder, are distal in relation to the time of the ED visit. Population outcome measures for research, program, and policy evaluation in this arena include prevalence of unintended prolonged opioid use, incidence of new opioid use disorder per capita, and opioid use disorder prevalence.

Opioid use disorder harm reduction goals include reducing opioid overdoses and opioid overdose mortality. Structural measures within this domain include the ability to distribute naloxone or refer patients to a community syringe access program. Process measures would be the provision of patient education for overdose education and response, proportion of patients at risk of overdose with a harm reduction care plan, referral to outpatient services, and either given or prescribed naloxone at discharge. Harm reduction outcome measures for research, program, and policy evaluations include risk-adjusted repeat fatal and nonfatal overdose, risk-adjusted mortality, and hepatitis C and HIV incidence and prevalence. Given the psychosocial aspects of addiction and the criminalization of drug use, there are other broader patient outcomes outside of the ED quality framework that should be considered markers of higher-quality opioid use disorder treatment, including incarceration, employment, and education. Community harm reduction goals include these, as well as prevention and reduction of HIV and HCV transmission.

Opioid use disorder treatment goals include reduction of opioid overdose mortality and opioid overdose and increased engagement in addiction treatment. Structural measures for opioid use disorder treatment are the presence of ED buprenorphine-waivered providers, access to addiction medicine specialists for consultation, and community availability of medication for opioid use disorder and opioid treatment programs for outpatient referral. Other structural measures EDs could implement are evaluation by a patient navigator, such as a community health worker, peer navigator or coach, or social worker. Opioid use disorder treatment process measures, then, would assess the use of structured screening and diagnostic questionnaires,⁵¹ use of ED-outpatient opioid use disorder treatment care plans, urine toxicology testing, proportion of patients with opioid use disorder initiating medication for opioid use disorder, and proportion of patients linked to a program of community medication for opioid use disorder.⁵² The National Quality Forum and the Agency for Healthcare Research and Quality National Quality Measure Clearinghouse have specified similar process measures in regard to initiation of medication for opioid use disorder and referrals to outpatient treatment.⁵² Psychosocial treatment and quarterly physician visits are other potential process measures that have been shown to have mortality benefit among patients with opioid use disorder.⁵⁰ Outcome measures for research, program, and policy evaluations include proportion of individuals with opioid use disorder engaged in an opioid treatment program, proportion of people maintaining medication use for opioid use disorder at 30 days, risk-adjusted fatal and nonfatal repeated overdose, and risk-adjusted inhospital and out-of-hospital overdose mortality.

OPIOID USE DISORDER QUALITY IMPROVEMENT OPPORTUNITIES

Changes in ED clinical practice are driven by research evidence, benefit to patients, cost-effectiveness, decreased provider burden, financial incentives for policy compliance, alignment with national goals, available resources, and fit with local values. The changing needs of our patient population, current gaps in care, emerging clinical evidence about ED opioid use disorder treatment initiation and linkage,²³ potential patient benefit, and national goals and priorities to reduce opioid overdose deaths are well aligned to expand the scope of ED care to include not only opioid use disorder prevention, treatment, and harm reduction but also the development of quality improvement initiatives to accelerate implementation and adoption of high-quality practices.

Clinical guidelines can help change clinical practice and improve care quality in combination with or in the absence of quality measurements. Guidelines, in addition to consensus recommendations and clinical protocols, are useful tools for care standardization and rapid dissemination. Although guidelines are not quality measures, they are an important underpinning in setting professional standards of care.^53–55 ED clinical practice guidelines for management of opioid use disorder in emergency medicine settings are currently limited. Establishing practice guidelines and best practices can guide care improvement initiatives while patient outcome research and opioid use disorder quality measures are in development. To develop quality measures, numerous research, health policy, and clinical practice opportunities in each opioid use disorder care domain were identified during the meeting at NIDA (Figure).

Figure.

Learning health care system for research, policy, and practice to improve outcomes for ED patients with opioid use disorder. EHR, Electronic health record; MAT, medication-assisted treatment.

Opioid Use Disorder Primary Prevention

Currently, we lack the necessary ED opioid use disorder quality measure “building blocks” that link primary prevention, treatment, and harm reduction initiatives to patient outcomes. Opioid use disorder primary prevention research opportunities should focus on the efficacy of nonopioid analgesics for pain control; patient education about safe opioid use, storage, and disposal; opioid prescribing guideline adherence; development and use of care plans for patients with outpatient pain contracts; and evaluation of population trends in the development of unintended prolonged opioid use or opioid use disorder. Policy opportunities include development and implementation of ED pain control and prescribing guidelines, electronic health record linkage between health systems and departments of health, and increasing coverage of nonpharmacologic and nonopioid pain management alternatives by insurers. In clinical practice, developing and implementing opioid use disorder screening practices³⁷ and using nonopioid pain management strategies such as nerve blocks and nonopioid analgesics can improve care. The implementation of organized systematic efforts to promote nonopioid analgesic pain management programs across EDs (eg, alternatives-to-opioids programs, Colorado Opioid Safety Collaborative) has been associated with significant decreases in ED opioid prescribing.^56,57 The electronic health record can also be used to alert providers about unsafe prescribing, either because of coprescribing with benzodiazepines or prescribing opioids at high daily morphine milliequivalents.⁵⁸

Opioid Use Disorder Harm Reduction

Although evidence shows that community naloxone distribution has resulted in a reduction in overdose deaths⁴² and is supported by a 2018 advisory from the Office of the Surgeon General,⁵⁹ patient outcomes of ED naloxone distribution have yet to be thoroughly evaluated.^25,26,60,61 Future research should focus on the development and use of harm reduction care plans for patients with opioid use disorder, out-of-hospital patient use of naloxone for overdose reversal, ED transport refusal and associated patient mortality, and repeated overdose. Policy opportunities to expand opioid use disorder harm reduction initiatives include passage of Good Samaritan and syringe-access legislation in states that lack these protections, allowance of third-party naloxone prescribing, centralized overdose reporting, pharmacist naloxone dispensing, and cost containment or cost sharing to decrease naloxone distribution cost. Finally, although any ED clinician can refer patients to a syringe access program or prescribe take-home naloxone, establishing a clinical infrastructure that ensures naloxone provision before hospital discharge and access to syringes requires a structured quality improvement program.

Opioid Use Disorder Treatment

Interventions that have well-established evidence outside of the ED are being adapted in EDs, such as buprenorphine initiation for opioid use disorder,^62–64 with linkage to outpatient addiction treatment and harm reduction services.^37,65,66 Clinical research and training to be conducted includes pain control for patients receiving medication for opioid use disorder and presenting with acute injury or illnesses, buprenorphine safety and efficacy after overdose and for acute opioid withdrawal, and feasibility of use of newer buprenorphine formulations such as extended-release buprenorphine injections. Implementation research needs to be conducted about ED provider buprenorphine waiver training, acceptance, uptake, and use; ED-outpatient opioid use disorder treatment care plan development and use; barriers and facilitators to brief interventions in the ED; initiation of medication for opioid use disorder and linkage to outpatient treatment; counseling and navigation efficacy and intensity; and evaluation of repeated overdose and mortality among ED patients who have begun receiving medication for opioid use disorder. Policy work should include the development of ED opioid use disorder clinical treatment guidelines, insurance reimbursement for ED patient counseling and navigation services, removal of buprenorphine waiver requirements for emergency physicians, and mandated insurance coverage for medication for opioid use disorder and naloxone without previous authorization. Clinical practice initiatives include trainee, provider, and staff education on opioid use disorder identification, harm reduction, treatment, and referral³⁷; development of streamlined addiction treatment linkage processes; clinical protocols for initiating medication for opioid use disorder; and hospital dispensing of a limited supply of buprenorphine until outpatient care can be established.

Clinical data registries are resources for measure development that can be used for data collection and measuring the effect of an intervention. Nationally, emergency medicine is adopting electronic clinical quality measurement for participation in the CMS Quality Payment Program through the ACEP Clinical Emergency Data Registry. The registry is a CMS-designated Qualified Clinical Data Registry, which includes information from EDs across the United States and is used to improve quality measure development and quality reporting efficiency. Including common opioid use disorder–relevant data elements in this registry would aid in the development of ED opioid use disorder quality measures and align ED efforts to reduce opioid-associated harm with existing financial and regulatory incentives.

Inclusion of opioid use disorder–relevant elements in the Clinical Emergency Data Registry, and therefore in the electronic health record, for data collection and clinical quality measurement will embed data collection in routine ED work flow, minimizing requirements of additional work or documentation. This will enable standardized data collection; the development and monitoring of ED opioid use disorder structural, process, and outcome measures; and, ultimately, the evaluation of ED quality improvement intervention effectiveness. In addition to data collection, the electronic health record can also be used for decision support to promote current best practices and reduce variability in care. Actualizing the potential of digitally based quality improvement, however, will require the participation and coordination of numerous parties, including clinicians, hospitals, and electronic health record vendors. Improving the accessibility or availability of scalable data-collection tools, decision support, and platforms by electronic health record vendors such as Epic App Orchard or the Cerner App Gallery/Open Platform may present new opportunities to rapidly scale and standardize tools that previously did not exist.

Beyond quality measurement, the creation of national quality improvement initiatives will also be essential to engaging clinicians in opioid use disorder–focused quality measures and identifying best practices for quality improvement across each domain of ED opioid use disorder care. Recently, ACEP launched the Emergency Quality Network (E-QUAL) Opioid Initiative to engage emergency physicians in a quality improvement-based approach to reducing opioid-associated harm, and the American Hospital Association has also released a Stem the Tide toolkit including quality improvement tools for hospital-based EDs. The coordination of these types of efforts has the potential to normalize the implementation of local initiatives to improve ED opioid use disorder care, using well-established QI methods such as the Plan-Do-Study-Act cycle, lean engineering, or the Institute for Healthcare Improvement’s Model for Improvement in a manner and language familiar to emergency clinicians.

CONCLUSION

As the primary provider of acute illness stabilization, timely diagnosis, and linkage to appropriate care, the ED is uniquely positioned to improve the quality of care for patients with opioid use disorder and has an essential role in addressing the opioid epidemic and preventing overdose deaths. The quality framework described above provides a clear outline for future research and policy approaches to ED opioid use disorder quality improvement. Successful initiatives will use cross-sector partnerships and national learning collaboratives to develop an emergency care learning health care system capable of developing and disseminating safe and effective ED opioid use disorder care.