Quality of pain management in the emergency department: results of a multicentre prospective study:

Methoxyflurane Analgesia in Adult Patients in the Emergency Department: A Subgroup Analysis of a Randomized, Double-blind, Placebo-controlled Study (STOP!)

INTRODUCTION

Acute pain remains highly prevalent in the Emergency Department (ED) setting. This double-blind, randomized, placebo-controlled UK study investigated the efficacy and safety of low-dose methoxyflurane analgesia for the treatment of acute pain in the ED in the adult population of the STOP! trial.

METHODS

Patients presenting to the ED requiring analgesia for acute pain (pain score of 4-7 on the Numerical Rating Scale) due to minor trauma were randomized in a 1:1 ratio to receive methoxyflurane (up to 6 mL) or placebo (normal saline), both via a Penthrox® (Medical Developments International Limited, Scoresby, Australia) inhaler. Rescue medication (paracetamol/opioids) was available immediately upon request. Change from baseline in visual analog scale (VAS) pain intensity was the primary endpoint.

RESULTS

300 adult and adolescent patients were randomized; data are presented for the adult subgroup (N = 204). Mean baseline VAS pain score was ~66 mm in both groups. The mean change from baseline to 5, 10, 15 and 20 min was greater for methoxyflurane (-20.7, -27.4, -33.3 and -34.8 mm, respectively) than placebo (-8.0, -11.1, -12.3 and -15.2 mm, respectively). The primary analysis showed a highly significant treatment effect overall across all four time points (-17.4 mm; 95% confidence interval: -22.3 to -12.5 mm; p < 0.0001). Median time to first pain relief was 5 min with methoxyflurane [versus 20 min with placebo; (hazard ratio: 2.32; 95% CI: 1.63, 3.30; p < 0.0001)]; 79.4% of methoxyflurane-treated patients experienced pain relief within 1-10 inhalations. 22.8% of placebo-treated patients requested rescue medication within 20 min compared with 2.0% of methoxyflurane-treated patients (p = 0.0003). Methoxyflurane treatment was rated 'Excellent', 'Very Good' or 'Good' by 77.6% of patients, 74.5% of physicians and 72.5% of nurses. Treatment-related adverse events (mostly dizziness/headache) were reported by 42.2% of patients receiving methoxyflurane and 14.9% of patients receiving placebo; none caused withdrawal and the majority were mild and transient.

CONCLUSION

The results of this study support the evidence from previous trials that low-dose methoxyflurane administered via the Penthrox inhaler is a well-tolerated, efficacious and rapid-acting analgesic.

FUNDING

Medical Developments International (MDI) Limited and Mundipharma Research GmbH & Co.KG.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.

ED triage pain protocol reduces time to receiving analgesics in patients with painful conditions

BACKGROUND

Studies suggest that collaborative nursing protocols initiated in triage improve emergency department (ED) throughput and decrease time to treatment.

OBJECTIVE

The objective of the study is to determine if an ED triage pain protocol improves time to provision of analgesics.

METHODS

Retrospective data abstracted via electronic medical record of patients at a safety net facility with 67 000 annual adult visits. Patients older than 18 years who presented to the ED between March 1, 2011, and May 31, 2013, with 1 of 6 conditions were included: back pain, dental pain, extremity trauma, sore throat, ear pain, or pain from an abscess. A 3-month orientation to an ED nurse-initiated pain protocol began on March 1, 2012. Nurses administered oral analgesics per protocol, beginning with acetaminophen or ibuprofen and progressing to oxycodone. Preimplementation and postimplementation analyses examined differences in time to analgesics. Multivariable analysis modeled time to analgesics as a function of patient factors.

RESULTS

Over a 27-month period, 23 409 patients were included: 13 112 received pain medications and 10 297 did not. A total of 12 240 (52%) were male, 12 578 (54%) were African American, and 7953 (34%) were white, with a mean (SD) age of 39 years (13 years). The pain protocol was used in 1002 patients. There was a significant change in mean time (minutes) to provision of analgesics between preimplementation (238) and postimplementation (168) (P < .0001). Linear regression showed the protocol-delivered medications to younger patients and of lower acuity in a reduced time. Variables not related to time to provision of medication included sex, payer, and race.

CONCLUSION

Emergency department triage pain protocol decreased time to provision of pain medications and did so without respect to payer category, sex, or race.

Children receive less analgesia in general ERs than adults: A retrospective study

Background/Introduction: Oligoanalgesia is a common phenomenon in the Emergency Department (ED) with children being especially at risk. However, the extent to which pediatric patients are being undertreated for acute pain in relation to their adult counterparts is not well understood, especially in general (i.e., mixed adult and pediatric) EDs. This study was designed to compare the pain medication received by adult and pediatric patients with appendicitis presenting to a general ED. Methods: A retrospective chart review of 165 patients, 92 adult (mean age: 35.7 ± 15.7 years) and 73 pediatric (mean age: 11.0 ± 3.0 years) with a discharge diagnosis of “appendicitis” were included in this study. Demographic information as well as data regarding type, timing, and received amount of pain medication were collected. Adult and pediatric data were then compared using independent t-test or chi-square analysis. Effect sizes were also calculated. Results: Pediatric patients were significantly more likely than adult patients to not receive any analgesia during their ED stay (58.9% vs 20.7%, p>0.001, Cramer's V = 0.39). They were also significantly less likely to receive opioid analgesics, compared to adults (27.4% vs. 71.7%, p>0.001, Cramer's V = 0.44). Finally, mean pain scores recorded at presentation were significantly lower for children vs. adults (6.5 vs 7.2 out of 10, p = 0.015, r = 0.20). Conclusion: In this sample, pediatric patients with appendicitis presenting to a general emergency department received less opioid pain medication, and less pain medication in general, than their adult counterparts.

Efficacy of Intravenous Paracetamol Versus Intravenous Morphine in Acute Limb Trauma

Background:

Efficient pain management is one of the most important components of care in the field of emergency medicine.

Objectives:

This study was conducted to compare intravenous paracetamol and intravenous morphine sulfate for acute pain reduction in patients with limb trauma.

Patients and Methods:

In a randomized double-blinded clinical trial, all patients (aged 18 years and older) with acute limb trauma and a pain score of greater than 3/10 in the emergency department were recruited; they received either 1 g intravenous paracetamol or 0.1 mg/kg intravenous morphine sulfate over 15 minutes. The primary outcome was the pain score measured on a numerical rating scale at 0, 15 and 30 minutes after commencing drug administration. The requirement for rescue analgesia and the frequency of adverse reactions were also recorded.

Results:

Sixty patients randomly received either IV paracetamol (n = 30) or IV morphine (n = 30). The mean reduction in numerical rating scale pain intensity scores at 30 minutes was 3.86 (± 1.61) for paracetamol, and 2.16 (± 1.39) for morphine. However, pain relief was significantly higher in the paracetamol group compared to the morphine group (P < 0.001). Four patients in the paracetamol group and 15 patients in the morphine group needed rescue analgesia and the difference was significant (P = 0.05).

Conclusions:

Intravenous paracetamol appears to provide better analgesia than intravenous morphine in acute limb trauma. Further larger studies are required.

Assessment of pain in a Norwegian Emergency Department

Background

Although pain management is a fundamental aspect of care in emergency departments (EDs), inadequate treatment of pain is unfortunately common. There are multiple local protocols for pain assessment in the ED. This study evaluated whether the initial assessment and treatment of pain in the ED are in accordance with the in-hospital protocol of the ED at a Norwegian University Hospital.

Materials and methods

Prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation. The patients’ perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10.

Results

Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58 %), only 14 % received pain relief.

Discussion

Assessment and treatment of pain in the ED are inadequate and not in line with the local protocols. A focus on strategies to improve pain treatment in the ED is a necessary aspect of developing optimal acute patient care in Norway in the future.

Variation Between Physicians and Mid-level Providers in Opioid Treatment for Musculoskeletal Pain in the Emergency Department

BACKGROUND

Effective, appropriate, and safe opioid analgesia administration in the Emergency Department (ED) is a complex issue, with risks of both over- and underutilization of medications.

OBJECTIVE

To assess for possible association between practitioner status (physician [MD] vs. mid-level provider [MLP]) and use of opioids for in-ED treatment of musculoskeletal pain (MSP).

METHODS

This was a secondary, hypothesis-generating analysis of a subset of subjects who had ED analgesia noted as part of entry into a prospective registry trial of outpatient analgesia. The study was conducted at 12 U.S. academic EDs, 10 of which utilized MLPs. Patients were enrolled as a convenience sample from September 2012 through February 2014. Study patients were adults (>17 years of age) with acute MSP and eligibility for both nonsteroidal antiinflammatory drugs and opioids at ED discharge. The intervention of interest was whether patients received opioid therapy in the ED prior to discharge.

RESULTS

MDs were significantly more likely to order opioids than MLPs for ED patients with MSP. The association between MD/MLP status and likelihood of treatment with opioids was similar in both classical logistic regression (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-4.5, p = 0.019) and in propensity-adjusted modeling (OR 2.1, 95% CI 1.0-4.5, p = 0.049).

CONCLUSIONS

In preliminary analysis, MD/MLP status was significantly associated with likelihood of provider treatment of MSP with opioids. A follow-up study is warranted to confirm the results of this hypothesis-testing analysis and to inform efforts toward consistency in opioid therapy in the ED.

[Pain therapy in emergency medicine. Focus on emergency admissions]

With a prevalence of 50-80 % pain is one of the main symptoms of emergency admission patients worldwide; however, study results demonstrate that only 30-50 % of patients receive adequate analgesia. Therefore, in the USA quality indicators have been established by the Centers for Medicare & Medicaid Services (CMS) since 2010 within the framework of quality assurance of emergency admissions, e.g. the time window until the start of pain therapy. Despite the prescribed pain evaluation as part of many existing triage systems, e.g. the Manchester triage system (MTS), emergency severity index (ESI), Australasian triage scale (ATS), Canadian triage and acuity scale (CATS), in most emergency rooms there is no standardized, documented pain assessment and pain intensity is documented by using the appropriate pain scales in only 30 % of cases. Lack of knowledge and training and lack of awareness by the nursing and medical staff regarding pain perception and management represent the main causal factors. Studies on the situation of pain therapy in German emergency departments are not currently available. Due to the increasing number of central emergency departments and interdisciplinary teams of physicians and nurses, it seems sensible to introduce interdisciplinary standards of treatment to achieve the greatest possible safety in the use of analgesics in the emergency room. It is important to incorporate the experiences of the various clinical departments in the standards. This article aims to provide an overview of the situation in pain management in emergency departments and to serve as a basis for recommendations for pain therapy in German emergency departments. This article particularly discusses the possibilities of pain evaluation, treatment options with various medications and under specific conditions, e.g. for children, pregnant women or the elderly or alternative ways of pain management.

Acupuncture as analgesia for non-emergent acute non-specific neck pain, ankle sprain and primary headache in an emergency department setting: a protocol for a parallel group, randomised, controlled pilot trial

INTRODUCTION

This study aims to assess the feasibility of acupuncture as an add-on intervention for patients with non-emergent acute musculoskeletal pain and primary headache in an emergency department (ED) setting.

METHODS AND ANALYSIS

A total of 40 patients who present to the ED and are diagnosed to have acute non-specific neck pain, ankle sprain or primary headache will be recruited by ED physicians. An intravenous or intramuscular injection of analgesics will be provided as the initial standard pain control intervention for all patients. Patients who still have moderate to severe pain after the 30 min of initial standard ED management will be considered eligible. These patients will be allocated in equal proportions to acupuncture plus standard ED management or to standard ED management alone based on computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. A 30 min session of acupuncture treatment with manual and/or electrical stimulation will be provided by qualified Korean medicine doctors. All patients will receive additional ED management at the ED physician's discretion and based on each patient's response to the allocated intervention. The primary outcome will be pain reduction measured at discharge from the ED by an unblinded assessor. Adverse events in both groups will be documented. Other outcomes will include the patient-reported overall improvement, disability due to neck pain (only for neck-pain patients), the treatment response rate, the use of other healthcare resources and the patients' perceived effectiveness of the acupuncture treatment. A follow-up telephone interview will be conducted by a blinded assessor 72±12 h after ED discharge.

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. The study has been approved by the Institutional Review Boards (IRBs). The results of this study will guide a full-scale randomised trial of acupuncture in an ED context.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02013908.

Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain

OBJECTIVE

We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain.

METHODS

This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics.

RESULTS

Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred.

CONCLUSIONS

Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.

Randomized clinical trial of efficacy and safety of a single 2-mg intravenous dose of hydromorphone versus usual care in the management of acute pain

OBJECTIVES

The objective was to test the efficacy and safety of 2 mg of intravenous (IV) hydromorphone (Dilaudid) against "usual care" in emergency department (ED) patients with acute severe pain.

METHODS

This was a randomized clinical trial. Patients allocated to 2 mg of IV hydromorphone received their medication in a single dose. Those randomized to usual care received any IV opioid, with type, dose, and frequency chosen by the ED attending. All patients received 2 L/min. nasal cannula oxygen. The primary outcome was the difference in the proportion of patients who achieved clinically satisfactory analgesia by 30 minutes. This was defined as the patient declining additional analgesia when asked the question, "Do you want more pain medicine?" A 10% absolute difference was chosen a priori as the minimum difference considered clinically significant.

RESULTS

Of 175 subjects randomized to each group, 164 in the 2 mg hydromorphone group and 161 in the usual care group had sufficient data for analysis. Additional pain medication was declined by 77.4% of patients in the 2 mg hydromorphone group at 30 minutes, compared to 65.8% in the usual care group. This difference of 11.6% was statistically and clinically significant (95% confidence interval [CI] = 1.8% to 21.1%). Safety profiles were similar and no patient required naloxone. There was more pruritus in the hydromorphone group (18.3% vs. 8.7%; difference = 9.6%, 95% CI = 2.6% to 16.6%).

CONCLUSIONS

Using a simple dichotomous patient-centered endpoint in which a difference of 10% in proportion obtaining adequate analgesia was considered clinically significant, 2 mg of hydromorphone in a single IV dose is clinically and statistically more efficacious when compared to usual care for acute pain management in the ED.

Regional anesthesia outside the operating room: indications and techniques

PURPOSE OF REVIEW

Regional anesthesia is not only performed in the operating room. There are indications for the use of these techniques for pain relief in the emergency department and for anesthesia support of procedures outside the operating room. In this review, we will provide an overview of the indications for the regional techniques performed in the out-of-operating room environment.

RECENT FINDINGS

In the emergency department, patients may experience significant pain, and adequate analgesia is not always provided. Regional analgesia is effective and indicated for many trauma situations including hip fracture, reduction of shoulder dislocation, treatment of upper limb fractures and multiple rib fractures.Ultrasound guidance makes the performance of regional blocks more accessible and safer for use in the emergency department setting.For therapeutic procedures outside the operating room, regional anesthesia is possible for uterine artery embolization and for postoperative analgesia after implantation of cervical brachytherapy needles.

SUMMARY

Regional anesthesia is a valuable option for analgesia in trauma patients, enabling improved pain control in the emergency department and has benefits in the anesthetic management of therapeutic procedures outside the operating room. For many blocks, ultrasound guidance is useful.

Comparison of two doses of ketoprofen to treat pain: a double-blind, randomized, noninferiority trial

The aim of our study was to compare the efficacy and safety of two doses of ketoprofen (200 mg vs. 300 mg/day) in ambulatory emergency patients with pain related to traumatic and nontraumatic bone and joint diseases. We tested the hypothesis that the efficacy of the lower dose was not lower than that of the higher dose in a double-blind, randomized, noninferiority trial. Patients included in the study were aged 18-65 years with closed benign trauma of the motor system or acute noninfectious rheumatologic conditions, with a resting pain intensity ≥3/10 on a numeric pain scale (NPS), requiring ketoprofen for 5 days. The main end-point was based on two efficacy co-criteria: (i) mean change from baseline of resting pain intensity at the end of the day over 5 days and (ii) total intake of concomitant analgesics. We included 409 patients: 200 in the 200-mg group and 209 in the 300-mg group. The mean change in pain intensity at rest (difference between groups: 0.0, 95% CI -0.4 to 0.4; P = 1.00) and in analgesic consumption (difference between groups: -0.6, 95% CI -1.9 to 0.6; P = 0.33) was not significantly different between the two groups, and the differences were lower than the predefined inferiority margins (0.5 and 1.5, respectively), thus demonstrating noninferiority. No significant difference was noted in the incidence of adverse events (21% vs. 20%, P = 0.71). The efficacy of the 200-mg daily dose of ketoprofen in relieving pain in emergency cases was not inferior to that of the 300-mg dose.