The need for the hotline is evident. Despite improvements in pain management, doctors remain inadequately trained in pain management, patients and families report that pain is frequently out of control, and expert consultations can be hard to find. The pain hotline addresses each of these issues. "Every call educates a doctor, and what’s learned is applied later to other patients," said project director Michael Gloth, MD.
Like many other states, Maryland has a statewide task force on improving end-of-life care; in Maryland, the task force comes under the purview of the Attorney General. According to Assistant Attorney General, Jack Schwartz, JD, who is also the director of health policy development, "Maryland was one of the first states in which the attorney general’s office tried to promote improvements by identifying ways to help providers." The hotline, Schwartz said, offers a direct way to help health care providers statewide.
Schwartz credits Gloth for bringing the idea to the task force--and for finding funding and recruiting and scheduling physician-volunteers. Initial funding came from a $10,000 grant from Purdue Pharma. Gloth, president of the Hospice Network of Maryland and a geriatrician at Baltimore’s Union Memorial Hospital, explained that the program gives doctors rapid access to experts they might otherwise not be able to reach. Maryland’s Institute of Emergency Medical Resource Center (EMRC), which receives shock-trauma and Medevac calls, volunteered to handle the actual call-routing. Dr. Gloth recruited physician volunteers from among the state’s nineteen board-certified hospice and palliative medicine doctors.
By involving the well-respected EMRC, the project gained credibility with Maryland doctors. Schwartz noted that by using the EMRC, the project was also able to get started without having to set up a new telecommunications program.
Physician-volunteer is Henry Farkas, M.D., medical director of the Northern Chesapeake Hospice, said his participation is a natural outgrowth of his 13 years in hospice and 26 in emergency room medicine. He said that most calls have come from internists and other primary care physicians who are uncertain how to manage complex situations, such as pain control for patients who are known substance abusers.
"In those cases, you assess if they’re the only one in the house with a drug abuse problem and, if not, you’re more likely to go to a pump," he said. "I’ll talk to my colleague about the general situation and then go from there, discussing options and what to do."
Farkas and his fellow physician volunteers return each call within 15 minutes--a standard the group maintains round-the-clock and year-round: 24/7. In its first nine months, the project fielded about 60 calls, each of which lasted for about five minutes.
The advisory panel decided to restrict calls to questions dealing with pain in dying patients--creating a "pain hotline," the group knew, would have been an overwhelming endeavor. Instead, the panel limited initial publicity efforts to reach only physicians, promoting the toll-free number in Maryland’s medical society and state licensing newsletters. A mailer including a phone sticker and Rolodex card has been sent to every physician in the state. After each of these initiatives, call volume increased. The group is now publicizing the program to encourage physician’s assistants and nurse practitioners to call.
Physician-volunteers collect basic data on each call: the caller’s geographic region, and the time and nature of the call. The group has not yet conducted follow-up studies with callers to examine the effectiveness of the process--but such a project seems likely.
The group reports that approximately 80 percent of callers have been physicians, 12 percent nurses, and 8 percent pharmacists. All calls have come between 9 a.m. and 7 p.m. When the EMRC receives a call, it pages the on-call physician-volunteer; if there is no answer within five minutes, another page is made; within five minutes, the backup physician is paged.
Callers have requested a range of advice, but most focus on appropriate use of opioid analgesics. In June, for example, one caller needed advice on managing uncontrolled pain for a cancer patient on a fentanyl patch; another caller described a cancer patient with severe pain who was experiencing severe twitching as a morphine side effect. In each case, the physician-volunteer offered alternatives.
As for concerns about liability and medical malpractice, Maryland’s Good Samaritan laws protect physician-volunteers, final accountability remains with the attending physician.
Schwartz said the hotline is likely to continue its work. "Doctors need to be aware of it, think of it and tap into it The hotline is meant to be a way for health care providers to get quick consults that can make a real difference in patient care."
For more information:
Dr. Michael Gloth
Union Memorial Hospital
201 East University Parkway
Baltimore, MD 21218-2895
MICHAELG@HELIX.ORG
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