Smart Dosing, Better Outcomes: An Electronic Medical Record Intervention for Cancer Pain in the Emergency Department.

Abstract

Objectives: We hypothesized that an electronic medical record (EMR)-based best practice advisory (BPA), offering individualized opioid dosing for cancer patients with high opioid tolerance, would improve pain control and reduce hospital admissions in the emergency department (ED).

Methods: We conducted a retrospective cohort study from May 2020 to May 2024 across 2 academic EDs affiliated with a National Comprehensive Cancer Network cancer center. Adult patients with active cancer, a morphine equivalent daily dose (MEDD) ≥100, and an ED opioid order were eligible. The BPA calculated MEDD-based opioid dosing recommendations and provided safety measures. Patients were categorized as BPA+ (recommendation followed) or BPA- (recommendation ignored). The primary outcome was hospital admission. Secondary outcomes included ED length of stay and change in pain scores.

Results: Among 1193 patient encounters, 719 (60.3%) received BPA-directed therapy. BPA+ was associated with a lower odds ratio (OR) of admission compared to BPA- (OR, 0.67; 95% CI, 0.49-0.80). The BPA was associated with decreased admission rates in patients with an Eastern Cooperative Oncology Group performance status of 4 (54% vs 80% admitted) and stage 4 cancer (57% vs 68% admitted). BPA+ was also associated with greater median pain improvement (-2 vs -1) and shorter ED stays (8.2 vs 8.9 hours). Among patients receiving multiple opioid doses, greater BPA adherence was associated with sustained pain reduction, while BPA nonadherence showed diminished response.

Conclusion: An EMR-integrated BPA for opioid-tolerant cancer patients was associated with improved ED pain management and reduced admissions. These findings support broader use of EMR-based tools to promote guideline-concordant, personalized care for cancer-related pain.