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Vuille M, Foerster M, Foucault E, Hugli O. Pain assessment by emergency nurses at triage in the emergency department: A qualitative study. J Clin Nurs 2017; 27:669-676. [DOI: 10.1111/jocn.13992] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Marilène Vuille
- University Institute for the History of Medicine and Public Health (IUHMSP) University of Lausanne Lausanne Switzerland
| | - Maryline Foerster
- Emergency Department University Hospital of Lausanne Lausanne Switzerland
| | - Eliane Foucault
- Emergency Department University Hospital of Lausanne Lausanne Switzerland
| | - Olivier Hugli
- Emergency Department University Hospital of Lausanne Lausanne Switzerland
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Castillón P, Veloso M, Gómez O, Salvador J, Bartra A, Anglés F. Fascia iliaca block for pain control in hip fracture patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2017.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Frick J, Möckel M, Muller R, Searle J, Somasundaram R, Slagman A. Suitability of current definitions of ambulatory care sensitive conditions for research in emergency department patients: a secondary health data analysis. BMJ Open 2017; 7:e016109. [PMID: 29061605 PMCID: PMC5665266 DOI: 10.1136/bmjopen-2017-016109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the suitability of existing definitions of ambulatory care sensitive conditions (ACSC) in the setting of an emergency department (ED) by assessing ACSC prevalence in patients admitted to hospital after their ED stay. The secondary aim was to identify ACSC suitable for specific application in the ED setting. DESIGN Observational clinical study with secondary health data. SETTING Two EDs of the Charité-Universitätsmedizin Berlin. PARTICIPANTS All medical ED patients of the 'The Charité Emergency Medicine Study' (CHARITEM) study, who were admitted as inpatients during the 1-year study period (n=13 536). OUTCOME MEASURES Prevalence of ACSC. RESULTS Prevalence of ACSC in the study population differed significantly depending on the respective ACSC set used. Prevalence ranged between 19.1% (95% CI 18.4% to 19.8%; n=2586) using the definition by Albrecht et al and 36.6% (95% CI 35.8% to 37.5%; n=4960) using the definition of Naumann et al. (p<0.001). Overall ACSC prevalence (ie, when using all diagnoses used in any of the assessed ACSC-definitions) was 48.1% (95% CI 47.2% to 48.9%; n=6505). Some frequently observed diagnoses such as 'convulsion and epilepsy' (prevalence: 3.4%, 95% CI 3.1% to 3.7%; n=455), 'diseases of the urinary system' (prevalence: 1.4%; 95% CI 1.2% to 1.6%; n=191) or 'atrial fibrillation and flutter' (prevalence: 1.0%, 95% CI 0.8% to 1.2%, n=134) are not included in all of the current ACSC definitions. CONCLUSIONS The results highlight the need for an optimised, ED-specific ACSC definition. Particular ACSC diagnoses (such as 'convulsion and epilepsy' or 'diseases of the urinary system' and others) seem to be of special relevance in an ED population but are not included in all available ACSC definitions. Further research towards the development of a suitable and specific ACSC definition for research in the ED setting seems warranted. TRIAL REGISTRATION German Clinical Trials Register Deutsches Register für Klinische Studien: DRKS-ID: DRKS00000261.
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Affiliation(s)
- Johann Frick
- Department of Emergency and Acute Medicine, Campus Virchow Klinikum, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Möckel
- Department of Emergency and Acute Medicine, Campus Virchow Klinikum, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Reinhold Muller
- Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Julia Searle
- Department of Emergency and Acute Medicine, Campus Virchow Klinikum, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rajan Somasundaram
- Department of Emergency and Acute Medicine, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Slagman
- Department of Emergency and Acute Medicine, Campus Virchow Klinikum, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Levente BZ, Filip MN, Romaniuc N, Gheorghe S. Efficacy and duration of ultrasound guided fascia iliaca block for hip fracture performed in the emergency departments. Rom J Anaesth Intensive Care 2017; 24:167-169. [PMID: 29090270 DOI: 10.21454/rjaic.7518.242.ber] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Blackman VS, Cooper BA, Puntillo K, Franck LS. Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013. J Trauma Nurs 2017; 23:257-74. [PMID: 27618374 DOI: 10.1097/jtn.0000000000000231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.
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Affiliation(s)
- Virginia Schmied Blackman
- Nurse Corps, U.S. Navy, Walter Reed National Military Medical Center, Department of Research Programs, Center for Nursing Science and Clinical Inquiry, Bethesda, Maryland (Dr Blackman); and School of Nursing, University of California, San Francisco (Drs Blackman, Cooper, Puntillo, and Franck)
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Castillón P, Veloso M, Gómez O, Salvador J, Bartra A, Anglés F. Fascia iliaca block for pain control in hip fracture patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:383-389. [PMID: 28890120 DOI: 10.1016/j.recot.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/17/2017] [Accepted: 07/03/2017] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Pain treatment for patients with hip fracture has been based on the use of nonsteroidal anti-inflammatories and opioid derived drugs. These medications have been associated with multiple adverse effects. Fascia iliaca block is a recent pain management alternative for these patients. The objective of this study was to evaluate the effectiveness of fascia iliaca block performed in the emergency room (ER) for patients over 65years of age with hip fracture. MATERIALS AND METHODS A cohort of 216 patients, from January to December 2016, was studied prospectively. Analyzed variables were: pain upon arrival at ER, pain after fascia iliaca block, need for rescue medication, protocol compliance, delay in analgesia administration and delay for surgery. RESULTS Differences between visual analogue scale (VAS), before and after the fascia iliaca block, were statistically significant (P<.001). Pre-block VAS recorded was 6.16 (SD=2.82). The mean VAS reduction after the block was 2.99 (95%CI: 2.45-3.53%). Twenty-six percent of patients required morphine as rescue medication in the first 8hours after diagnosis. Compliance with protocol administration was of 84%. Fascia iliaca block was performed in a mean time of 16minutes (SD=10.33) after diagnosis. The median delay for surgery was 1 day (RIQ 25-75%: 1-2). CONCLUSION Fascia iliaca block is a reproducible, safe and effective technique for pain management. It is a keystone in pain treatment for patients with a proximal femur fracture at our institution. Other objectives in our pain management protocol include early analgesia administration and reduction of time to surgery.
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Affiliation(s)
- P Castillón
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España; Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España.
| | - M Veloso
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - O Gómez
- Servei de Anestesiologia i Reanimació, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - J Salvador
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España; Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España
| | - A Bartra
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - F Anglés
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
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Kotkowski K, Ellison R, Barysauskas C, Barton B, Allison J, Mack D, Finberg R, Reznek M. Association of hospital contact precaution policies with emergency department admission time. J Hosp Infect 2017; 96:244-249. [DOI: 10.1016/j.jhin.2017.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
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Jones J, Sim TF, Hughes J. Pain Assessment of Elderly Patients with Cognitive Impairment in the Emergency Department: Implications for Pain Management-A Narrative Review of Current Practices. PHARMACY 2017; 5:E30. [PMID: 28970442 PMCID: PMC5597155 DOI: 10.3390/pharmacy5020030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/05/2017] [Accepted: 05/26/2017] [Indexed: 01/08/2023] Open
Abstract
Elderly people are susceptible to both falls and cognitive impairment making them a particularly vulnerable group of patients when it comes to pain assessment and management in the emergency department (ED). Pain assessment is often difficult in patients who present to the ED with a cognitive impairment as they are frequently unable to self-report their level of pain, which can have a negative impact on pain management. This paper aims to review how cognitive impairment influences pain assessment in elderly adults who present to the ED with an injury due to a fall. A literature search of EMBASE, ProQuest, PubMed, Science Direct, SciFinder and the Curtin University Library database was conducted using keyword searches to generate lists of articles which were then screened for relevance by title and then abstract to give a final list of articles for full-text review. Further articles were identified by snowballing from the reference lists of the full-text articles. The literature reports that ED staff commonly use visual or verbal analogue scales to assess pain, but resort to their own intuition or physiological parameters rather than using standardised observational pain assessment tools when self-report of pain is not attainable due to cognitive impairment. While studies have found that the use of pain assessment tools improves the recognition and management of pain, pain scores are often not recorded for elderly patients with a cognitive impairment in the ED, leading to poorer pain management in this patient group in terms of time to analgesic administration and the use of strong opioids. All healthcare professionals involved in the care of such patients, including pharmacists, need to be aware of this and strive to ensure analgesic use is guided by appropriate and accurate pain assessment in the ED.
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Affiliation(s)
- Joshua Jones
- School of Pharmacy, Curtin University, Western Australia 6102, Australia.
| | - Tin Fei Sim
- School of Pharmacy, Curtin University, Western Australia 6102, Australia.
| | - Jeff Hughes
- School of Pharmacy, Curtin University, Western Australia 6102, Australia.
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Brouns SHA, van der Schuit KCH, Stassen PM, Lambooij SLE, Dieleman J, Vanderfeesten ITP, Haak HR. Applicability of the modified Emergency Department Work Index (mEDWIN) at a Dutch emergency department. PLoS One 2017; 12:e0173387. [PMID: 28282406 PMCID: PMC5345800 DOI: 10.1371/journal.pone.0173387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 02/20/2017] [Indexed: 11/28/2022] Open
Abstract
Background Emergency department (ED) crowding leads to prolonged emergency department length of stay (ED-LOS) and adverse patient outcomes. No uniform definition of ED crowding exists. Several scores have been developed to quantify ED crowding; the best known is the Emergency Department Work Index (EDWIN). Research on the EDWIN is often applied to limited settings and conducted over a short period of time. Objectives To explore whether the EDWIN as a measure can track occupancy at a Dutch ED over the course of one year and to identify fluctuations in ED occupancy per hour, day, and month. Secondary objective is to investigate the discriminatory value of the EDWIN in detecting crowding, as compared with the occupancy rate and prolonged ED-LOS. Methods A retrospective cohort study of all ED visits during the period from September 2010 to August 2011 was performed in one hospital in the Netherlands. The EDWIN incorporates the number of patients per triage level, physicians, treatment beds and admitted patients to quantify ED crowding. The EDWIN was adjusted to emergency care in the Netherlands: modified EDWIN (mEDWIN). ED crowding was defined as the 75th percentile of mEDWIN per hour, which was ≥0.28. Results In total, 28,220 ED visits were included in the analysis. The median mEDWIN per hour was 0.15 (Interquartile range (IQR) 0.05–0.28); median mEDWIN per patient was 0.25 (IQR 0.15–0.39). The EDWIN was higher on Wednesday (0.16) than on other days (0.14–0.16, p<0.001), and a peak in both mEDWIN (0.30–0.33) and ED crowding (52.9–63.4%) was found between 13:00–18:00 h. A comparison of the mEDWIN with the occupancy rate revealed an area under the curve (AUC) of 0.86 (95%CI 0.85–0.87). The AUC of mEDWIN compared with a prolonged ED-LOS (≥4 hours) was 0.50 (95%CI 0.40–0.60). Conclusion The mEDWIN was applicable at a Dutch ED. The mEDWIN was able to identify fluctuations in ED occupancy. In addition, the mEDWIN had high discriminatory power for identification of a busy ED, when compared with the occupancy rate.
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Affiliation(s)
- Steffie H. A. Brouns
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- * E-mail:
| | | | - Patricia M. Stassen
- Department of Internal Medicine, division of general medicine, section acute medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Suze L. E. Lambooij
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Jeanne Dieleman
- Máxima Medical Centre Academy, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | | | - Harm R. Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- Department of Internal Medicine, division of general medicine, section acute medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
- Maastricht University, Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, Maastricht, the Netherlands
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Moschinski K, Kuske S, Andrich S, Stephan A, Gnass I, Sirsch E, Icks A. Drug-based pain management for people with dementia after hip or pelvic fractures: a systematic review. BMC Geriatr 2017; 17:54. [PMID: 28196525 PMCID: PMC5310008 DOI: 10.1186/s12877-017-0446-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/08/2017] [Indexed: 01/17/2023] Open
Abstract
Background Studies indicate that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent drug-based pain management is performed for people with dementia following a hip or pelvic fracture. The aim of this systematic review was to identify and analyse studies that investigate drug-based pain management for people with dementia with a hip or pelvic fracture in all settings. Treatment could be surgical or conservative. We also analysed study designs, methods and variables, as well as which assessments were applied to measure pain management and mental status. Method/design The development of this systematic review protocol was guided by the PRISMA-P requirements, which were taken into consideration during the review procedures. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect were searched. Studies published up to January 2016 were included. The data extraction, content and quantitative descriptive analysis were carried out systematically, followed by a critical appraisal. Results Eight of the 13 included studies focusing on patient data showed that people with dementia received less drug-based pain management than people without cognitive impairment. Four studies based on surveys of healthcare professionals stated that cognitive impairment is a major barrier for effective pain management. There was heterogeneity regarding the assessment of the mental status and the pain assessment of the patients. The assessment of the drugs administered in all of the studies working with patient data was achieved through chart reviews. Conclusion People with dementia do not seem to receive the same amount of opioid analgesics after hip fracture as people without cognitive impairment. There is need to enhance pain assessment and management for these patients. Future research should pay more attention to the use of the appropriate items for assessing cognitive impairment and pain in people with dementia. Trial registration This systematic review was registered at Prospero (CRD42016037309); on 11 April 2016, and the systematic review protocol was published (Syst Rev. 5(1):1, 2016).
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Affiliation(s)
- Kai Moschinski
- Heinrich Heine University, Faculty of Medicine, Institute for Health Services Research and Health Economics, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Silke Kuske
- Heinrich Heine University, Faculty of Medicine, Institute for Health Services Research and Health Economics, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Silke Andrich
- Heinrich Heine University, Faculty of Medicine, Institute for Health Services Research and Health Economics, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Astrid Stephan
- Heinrich Heine University, Faculty of Medicine, Institute for Health Services Research and Health Economics, Moorenstraße 5, 40225, Düsseldorf, Germany.,Department of Nursing, University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Irmela Gnass
- Heinrich Heine University, Faculty of Medicine, Institute for Health Services Research and Health Economics, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Erika Sirsch
- Faculty of Nursing Science, Vallendar College of Philosophy and Theology (PTHV Catholic University), Palottistraße 3, 56179, Vallendar, Germany
| | - Andrea Icks
- Heinrich Heine University, Faculty of Medicine, Institute for Health Services Research and Health Economics, Moorenstraße 5, 40225, Düsseldorf, Germany
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Mahmoudi E, Swiatek PR, Chung KC. Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter? Plast Reconstr Surg 2017; 139:444e-454e. [PMID: 28121876 PMCID: PMC5300165 DOI: 10.1097/prs.0000000000002936] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation. METHODS Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only. RESULTS For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation. CONCLUSION Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Elham Mahmoudi
- Assistant Research Professor of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Peter R. Swiatek
- Medical Student, University of Michigan Medical School, Ann Arbor, MI
| | - Kevin C Chung
- Professor of Surgery, Department of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, MI
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Warner LSH, Pines JM, Chambers JG, Schuur JD. The Most Crowded US Hospital Emergency Departments Did Not Adopt Effective Interventions To Improve Flow, 2007-10. Health Aff (Millwood) 2017; 34:2151-9. [PMID: 26643637 DOI: 10.1377/hlthaff.2015.0603] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Emergency department (ED) crowding adversely affects patient care and outcomes. Despite national recommendations to address crowding, it persists in most US EDs today. Using nationally representative data, we evaluated the use of interventions to address crowding in US hospitals in the period 2007-10. We examined the relationship between crowding within an ED itself, measured as longer ED lengths-of-stay, and the number of interventions adopted. In our study period the average number of interventions adopted increased from 5.2 to 6.6, and seven of the seventeen studied interventions saw a significant increase in adoption. In general, more crowded EDs adopted greater numbers of interventions than less crowded EDs. However, in the most crowded quartile of EDs, a large proportion had not adopted effective interventions: 19 percent did not use bedside registration, and 94 percent did not use surgical schedule smoothing. Thus, while adoption of strategies to reduce ED crowding is increasing, many of the nation's most crowded EDs have not adopted proven interventions.
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Affiliation(s)
- Leah S Honigman Warner
- Leah S. Honigman Warner is an attending physician in the Department of Emergency Medicine at Long Island Jewish Medical Center, in New Hyde Park, New York. At the time this research was completed, she was an attending physician in the Department of Emergency Medicine at the George Washington University, in Washington, D.C
| | - Jesse M Pines
- Jesse M. Pines is director of the Office for Clinical Practice Innovation, School of Medicine and Health Sciences, and a professor of emergency medicine and health policy, both at the George Washington University
| | - Jennifer Gibson Chambers
- Jennifer Gibson Chambers is a resident in emergency medicine at Albany Medical College, in New York
| | - Jeremiah D Schuur
- Jeremiah D. Schuur is an attending physician; chief of the Division of Health Policy Translation; and director of quality, patient safety, and performance improvement, all in the Department of Emergency Medicine, Brigham and Women's Hospital, in Boston, Massachusetts. He is also an assistant professor of emergency medicine at Harvard Medical School
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Friesgaard KD, Christensen EF, Kirkegaard H, Bendtsen MD, Jensen FB, Nikolajsen L. Prehospital intravenous fentanyl to patients with hip fracture: an observational cohort study of risk factors for analgesic non-treatment. Scand J Trauma Resusc Emerg Med 2017; 25:5. [PMID: 28103892 PMCID: PMC5244577 DOI: 10.1186/s13049-017-0348-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with proximal femoral neck fracture have a high short-term mortality, a high risk of postoperative complications, and impaired quality of life. One of the challenges related to the prehospital treatment of these patients is to administer systemic opioids fast and properly. Effective analgesic prehospital treatment ought be initiated rapidly in order to alleviate the stress that follows acute pain, to facilitate transportation, and to improve quality of care. The objectives of this study were to explore the prevalence of prehospital administration of intravenous fentanyl to patients with proximal femoral neck fracture in the ambulances and to assess risk factors for analgesic non-treatment. METHODS This was a register-based observational cohort study of patients with proximal femoral neck fracture from the North Denmark Region transported by ambulance. The patients were identified via the Danish Interdisciplinary Hip Fracture Registry over a 3-year period from 1 July 2011 to 30 June 2014. This hospital registry contains data on several patient characteristics used for the risk factor analysis. Data on prehospital treatment (intravenous fentanyl) and patient monitoring were registered in an electronic prehospital patient record. A modified Poisson regression with robust standard errors was carried out with intravenous fentanyl as the primary binary outcome and the following explanatory variables: age, sex, Charlson Comorbidity Index score, housing, body mass index, type of fracture, fracture displacement, prior consultation with general practitioner, dispatch triage level, and time with ambulance personnel. RESULTS In total, 2,140 patients with proximal femoral neck fracture were transported by ambulance, of which 584 (27.3%, 95% CI: 25.4-29.2) were treated with intravenous fentanyl. Risk factors for non-treatment were: older age, male sex (RR 0.77, 95% CI: 0.64-0.91), institutional housing (RR 0.72, 95% CI: 0.56-0.92), medial fracture (RR 0.74, 95% CI: 0.60-0.92), short time with ambulance personnel, Charlson Comorbidity Index score > 1, year of fracture (2011), low levels of urgency at dispatch, and if seen by general practitioners prior to transport. DISCUSSION Education of ambulance personnel in assessing and treating patients with hip fracture seems to be required. Also, future studies should consider alternative or supportive pain treatment options with suitable analgesic effects and side effects. CONCLUSIONS Few patients with proximal femoral neck fracture were treated with intravenous fentanyl, and several risk factors were associated with prehospital analgesic non-treatment. Future prospective studies should explore covariates of socioeconomic, cultural, and psychological origin to provide further insight into the multifactorial causes of non-treatment of acute pain.
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Affiliation(s)
- Kristian D Friesgaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus N, Denmark. .,Department of Anesthesiology, Regional Hospital of Horsens, Horsens, Denmark.
| | - Erika F Christensen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark.,Department of Anesthesiology and Intensive Care, Emergency Clinic Aalborg University Hospital, Aalborg, Denmark
| | - Hans Kirkegaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus N, Denmark
| | - Mette D Bendtsen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Flemming B Jensen
- Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Lone Nikolajsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Siddiqui A, Belland L, Rivera-Reyes L, Handel D, Yadav K, Heard K, Eisenberg A, Khelemsky Y, Hwang U. A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures. PAIN MEDICINE 2017; 18:41-48. [PMID: 27245631 DOI: 10.1093/pm/pnw072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients. Design Secondary analysis of retrospective cohort study. Setting Five EDs (four academic, one community) in the United States. Participants Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]). Measurements Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type. Results A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P < 0.001) and higher opioid-doses (parameter estimate = 0.268; 95 CI = 0.239 to 0.297; P < 0.001). When LBF were examined separately, older-patients had a trend to longer analgesic wait-times (99 [55-163] vs. 76 [35-149] minutes, P = 0.057), but no other differences in process outcomes were found. Conclusion Long bone fractures were associated with more aggressive pain care than SBF. When fracture types were examined separately, older patients did not appear to receive more aggressive pain care. This difference should be accounted for in further research.
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Affiliation(s)
- Ammar Siddiqui
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Belland
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Rivera-Reyes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Daniel Handel
- Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amanda Eisenberg
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, New York, USA
| | - Yury Khelemsky
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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Sharma G, Wong D, Arnaoutakis DJ, Shah SK, O'Brien A, Ashley SW, Ozaki CK. Systematic identification and management of barriers to vascular surgery patient discharge time of day. J Vasc Surg 2017; 65:172-178. [PMID: 27658897 PMCID: PMC5819890 DOI: 10.1016/j.jvs.2016.07.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/24/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Length of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and postanesthesia care unit, delayed time to treatment, increased in-hospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics. METHODS The study was divided into three periods: preintervention, "wash-in," and postintervention. During the preintervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face-to-face and mobile application-based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e-mail was developed with input from all stakeholders. Following a 4-week wash-in implementation phase, data collection was repeated. RESULTS The pre- and postintervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The postintervention group was discharged 78 minutes earlier (14:00:32 vs 15:18:37; P = .03) with a trend toward increased discharge by noon (94% vs 88%; P = .09). Readmission rates did not differ (P = .44). CONCLUSIONS Implementation of a focused, interdisciplinary, frontline provider-driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.
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Affiliation(s)
- Gaurav Sharma
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Danny Wong
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Dean J Arnaoutakis
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Samir K Shah
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Alice O'Brien
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - C Keith Ozaki
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
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Hughes JA, Cabilan CJ, Staib A. Effect of the 4-h target on time-to-analgesia in an Australian emergency department: a pilot retrospective observational study. AUST HEALTH REV 2017; 41:185-191. [DOI: 10.1071/ah16025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
Objectives
The aim of the present study was to assess the relationship between and the effect of the 4-h target or National Emergency Access Target (NEAT) on the time-to-analgesia (TTA), as well as the provision of analgesia in an adult emergency department (ED).
Methods
The present study was a pilot descriptive explorative retrospective cohort study conducted in a public metropolitan ED. Eligible presentations for analysis were adults presenting with a documented pain score of ≥4 out of 10 between 1 and 14 September 2014. Triage Category 1, pregnant, chest pain and major trauma cases were excluded from the study. As a result, data for 260 patients were analysed.
Results
Of 260 patients, 176 had analgesia with a median TTA of 49 min. Increased NEAT compliance did not significantly decrease TTA. However, when the factors that affected the provision of analgesia were analysed, an association was demonstrated between Admitted and Short Stay NEAT performance and the provision of analgesia. The likelihood of receiving analgesia at all increased as Admitted and Short Stay NEAT compliance improved.
Conclusion
NEAT is a significant health policy initiative with little clinical evidence supporting its implementation. However, as the Admitted NEAT compliance increases, the probability of receiving analgesia increases, demonstrating a possible link between hospital function and clinical care provision that needs to be explored further.
What is known about the topic?
The 4-h target or NEAT is a widely used initiative in EDs to allay crowding and access block. However, little is known of its impact on clinical endpoints, such as TTA.
What does this paper add?
TTA was not significantly reduced as NEAT compliance increased. However, when the focus was on the probability of receiving analgesia, the results demonstrated that an improvement in Admitted and Short Stay NEAT compliance was associated with an increase in the likelihood of patients receiving analgesia.
What are the implications for practitioners?
NEAT is a relatively recent initiative, hence evidence of its effect on clinically orientated outcomes is limited. Nevertheless, evidence of safety and effectiveness is emerging. The results of the present pilot study provide preliminary data on the timeliness of patient-centred care as demonstrated by TTA and administration of analgesia when required. Further, the results would seem to suggest that the provision of analgesia is affected by how timely patients are moved out of the ED to the in-patient setting. As for future investigations on TTA as a result of NEAT, a wider time period should be considered so that the accurate effect of compliance thresholds (e.g. ≥90%, 81–89%, ≤80%) of NEAT can be explored.
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Han CY, Lin CC, Goopy S, Hsiao YC, Barnard A, Wang LH. Waiting and hoping: a phenomenographic study of the experiences of boarded patients in the emergency department. J Clin Nurs 2016; 26:840-848. [PMID: 27805751 DOI: 10.1111/jocn.13621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2016] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand the experiences and concerns of patients in the emergency department during inpatient boarding. BACKGROUND Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients. DESIGN The qualitative approach of phenomenography was used in the study. METHODS The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department. RESULTS The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure. CONCLUSION The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients. RELEVANCE TO CLINICAL PRACTICE Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care.
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Affiliation(s)
- Chin-Yen Han
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Chun-Chih Lin
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Suzanne Goopy
- Faculty of Nursing, University of Calgary, Calgary, Canada
| | - Ya-Chu Hsiao
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Alan Barnard
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Li-Hsiang Wang
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
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Emergency department crowding affects triage processes. Int Emerg Nurs 2016; 29:27-31. [DOI: 10.1016/j.ienj.2016.02.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/10/2016] [Accepted: 02/21/2016] [Indexed: 11/19/2022]
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Morrison RS, Dickman E, Hwang U, Akhtar S, Ferguson T, Huang J, Jeng CL, Nelson BP, Rosenblatt MA, Silverstein JH, Strayer RJ, Torrillo TM, Todd KH. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:2433-2439. [PMID: 27787895 DOI: 10.1111/jgs.14386] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture. DESIGN Multisite randomized controlled trial from April 2009 to March 2013. SETTING Three New York hospitals. PARTICIPANTS Individuals with hip fracture (N = 161). INTERVENTION Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82). MEASUREMENTS Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects. RESULTS Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents. CONCLUSION Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.
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Affiliation(s)
- R Sean Morrison
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.,James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | | | - Ula Hwang
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.,James J. Peters Veterans Affairs Medical Center, Bronx, New York.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | | | - Taja Ferguson
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jennifer Huang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Christina L Jeng
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York.,Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Bret P Nelson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Meg A Rosenblatt
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jeffrey H Silverstein
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Reuben J Strayer
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Toni M Torrillo
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Knox H Todd
- Mount Sinai Beth Israel, New York City, New York.,University of Texas MD Anderson Cancer Center, Houston, Texas
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Haydar SA, Strout TD, Baumann MR. Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay. Acad Emerg Med 2016; 23:776-85. [PMID: 26999707 DOI: 10.1111/acem.12967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/29/2016] [Accepted: 02/23/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to evaluate the effect of an emergency clinician-initiated "ED admission holding order set" on emergency department (ED) treatment times and length of stay (LOS). We further describe the impact of a performance improvement strategy with sequential plan-do-study-act (PDSA) cycles used to influence the primary outcome measures, ED LOS, and disposition decision to patient gone (DDTPG) time, for admitted patients. METHODS We developed and implemented an expedited, emergency physician-facilitated admission protocol that bypassed typical inpatient workflows requiring inpatient evaluations prior to the placement of admission orders. During the 48-month study period, ED flow metrics generated during the care of 27,580 admissions from the 24-month period prior to the intervention were compared to the 29,978 admissions that occurred during the 24-month period following the intervention. The intervention was the result of an in-depth, five-phase PDSA cycle quality improvement intervention evaluating ED flow, which identified the requirement of bedside inpatient evaluations prior admission order placement as being a "non-value-added" activity. ED output flow metrics evaluating the admission process were tracked for 24 months following the intervention and were compared to the 24 months prior. RESULTS The use of an emergency physician-initiated admission holding order protocol resulted in sustainable reductions in ED LOS when comparing the 2 years prior to the intervention, with median LOS of 410 (interquartile range [IQR] = 295 to 543) and 395 (IQR = 283 to 527) minutes, to the 2 calendar years following the intervention, with the median LOS of 313 (IQR = 21 to 431) and 316 (IQR = 224 to 438) minutes, respectively. This overall reduction in ED LOS of nearly 90 minutes was found to be primarily the result of a decrease in the time from the emergency physician's admitting DDTPG times with median times of 219 (IQR = 150 to 306) and 200 (IQR = 136 to 286) minutes for the 2 years prior to the intervention compared to 89 (IQR = 58 to 138) and 92 (IQR = 60 to 147) minutes for the 2 years following the intervention. It is notable that there was a modest increase in the door to disposition decision of admission times during this same study period with annual medians of 176 (IQR = 112 to 261) and 178 (IQR = 129 to 316) minutes, respectively, for the 2 years prior to 207 (IQR = 129 to 316) and 202 (IQR = 127 to 305) minutes following the intervention. CONCLUSIONS We conclude that the use of emergency physician-initiated holding orders can lead to marked reductions in ED LOS for admitted patients. Continued improvement can be demonstrated with an effective performance improvement initiative designed to continuously optimize the process change.
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Affiliation(s)
- Samir A. Haydar
- Maine Medical Center and the Department of Emergency Medicine; Tufts University School of Medicine; Portland ME
| | - Tania D. Strout
- Maine Medical Center and the Department of Emergency Medicine; Tufts University School of Medicine; Portland ME
| | - Michael R. Baumann
- Maine Medical Center and the Department of Emergency Medicine; Tufts University School of Medicine; Portland ME
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Chew KS, Shaharudin AH. An open-label randomised controlled trial on the efficacy of adding intranasal fentanyl to intravenous tramadol in patients with moderate to severe pain following acute musculoskeletal injuries. Singapore Med J 2016; 58:601-605. [PMID: 27193080 DOI: 10.11622/smedj.2016096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The use of intranasal fentanyl as an alternative type of analgesia has been shown to be effective in paediatric populations and prehospital settings. There are a limited number of studies on the use of intranasal fentanyl in adult patients in emergency settings. METHODS An open-label study was conducted to evaluate the effectiveness of the addition of 1.5 mcg/kg intranasal fentanyl to 2 mg/kg intravenous tramadol (fentanyl + tramadol arm, n = 10) as compared to the administration of 2 mg/kg intravenous tramadol alone (tramadol-only arm, n = 10) in adult patients with moderate to severe pain due to acute musculoskeletal injuries. RESULTS When analysed using the independent t-test, the difference between the mean visual analogue scale scores pre-intervention and ten minutes post-intervention was 29.8 ± 8.4 mm in the fentanyl + tramadol arm and 19.6 ± 9.7 mm in the tramadol-only arm (t[18] = 2.515, p = 0.022, 95% confidence interval 1.68-18.72 mm). A statistically significant, albeit transient, reduction in the ten-minute post-intervention mean arterial pressure was noted in the fentanyl + tramadol arm as compared to the tramadol-only arm (13.35 mmHg vs. 7.65 mmHg; using Mann-Whitney U test with U-value 21.5, p = 0.029, r = 0.48). There was a higher incidence of transient dizziness ten minutes after intervention among the patients in the fentanyl + tramadol arm. CONCLUSION Although effective, intranasal fentanyl may not be appropriate for routine use in adult patients, as it could result in a significant reduction in blood pressure.
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Affiliation(s)
- Keng Sheng Chew
- Emergency Medicine Department, School of Medical Sciences, Universiti Sains Malaysia, Malaysia
| | - Abdul Hafiz Shaharudin
- Emergency Medicine Department, School of Medical Sciences, Universiti Sains Malaysia, Malaysia
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Abstract
BACKGROUND Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders. OBJECTIVE A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes. RESEARCH DESIGN A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009. SUBJECTS A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included. MEASURES The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity. RESULTS On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357). DISCUSSION In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.
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Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures. Am J Emerg Med 2015; 34:586-9. [PMID: 26809928 DOI: 10.1016/j.ajem.2015.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB). DESIGN A multicenter, prospective, randomized, clinical trial. SETTING The study was conducted in the emergency departments of 3 academic hospitals located in New York City. SUBJECTS Patients aged ≥60 years presenting to the emergency department with hip fracture. METHODS A subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours. RESULTS Seventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P < .0001) at 2 hours and from 6.23 to 3.87 (P < .0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P < .0001) at 2 hours and from 6.62 to 3.46 (P < .0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38). CONCLUSION Ultrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.
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Tosounidis TH, Sheikh H, Stone MH, Giannoudis PV. Pain relief management following proximal femoral fractures: Options, issues and controversies. Injury 2015; 46 Suppl 5:S52-8. [PMID: 26323378 DOI: 10.1016/j.injury.2015.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of pain in elderly need to be taken into account and unique considerations should be made regarding the effective analgesia due to different elderly physiology, and their response to trauma and subsequent surgery. The pain management should start as soon as possible and special emphasis should be paid to contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the perioperative period. The present review summarises the contemporary treatment options and controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK.
| | - Hassaan Sheikh
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street, LS1 3EX Leeds, UK
| | - Martin H Stone
- Hip Reconstruction Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, LS7 4SA, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
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Dale J, Bjørnsen LP. Assessment of pain in a Norwegian Emergency Department. Scand J Trauma Resusc Emerg Med 2015; 23:86. [PMID: 26514633 PMCID: PMC4625614 DOI: 10.1186/s13049-015-0166-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/21/2015] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Jostein Dale
- Emergency Department, Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim, Norway
| | - Lars Petter Bjørnsen
- Emergency Department, Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim, Norway.
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McCoy JV, Gale AR, Sunderram J, Ohman-Strickland PA, Eisenstein RM. Reduced Hospital Duration of Stay Associated with Revised Emergency Department-Intensive Care Unit Admission Policy: A before and after Study. J Emerg Med 2015; 49:893-900. [PMID: 26409680 DOI: 10.1016/j.jemermed.2015.06.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 04/22/2015] [Accepted: 06/25/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients. OBJECTIVE To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level. METHODS We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex. RESULTS We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged. CONCLUSIONS A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.
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Affiliation(s)
- Jonathan V McCoy
- Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alexa R Gale
- Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jag Sunderram
- Division of Pulmonary and Critical Care Medicine, Director Medical Intensive Care Unit, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Robert M Eisenstein
- Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti MLA, Rowe BH, Dreyer J, Bell R, Schull M. Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ Qual Saf 2015; 25:489-98. [PMID: 26271919 PMCID: PMC4941160 DOI: 10.1136/bmjqs-2015-004189] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/15/2015] [Indexed: 12/18/2022]
Abstract
Background We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions. Methods Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators. Results Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26). Conclusions These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.
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Affiliation(s)
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Therese A Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ashif Kachra
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Dreyer
- Division of Emergency Medicine, University of Western Ontario, London, Ontario, Canada
| | - Robert Bell
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Schull
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients--A Retrospective Cohort Study. PLoS One 2015; 10:e0135066. [PMID: 26267794 PMCID: PMC4534295 DOI: 10.1371/journal.pone.0135066] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 07/17/2015] [Indexed: 11/19/2022] Open
Abstract
Study objective To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old). Methods A retrospective cohort study of internal medicine patients visiting the emergency department between September 1st 2010 and August 31st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75th percentile of ED-LOS in the study population, which was 208 minutes. Results Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3–4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16–1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0–8.8 and OR 2.3, 95% CI 1.4–3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4–4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients. Conclusion Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way.
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Mears SC, Kates SL. A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2. Geriatr Orthop Surg Rehabil 2015; 6:58-120. [PMID: 26246957 DOI: 10.1177/2151458515572697] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.
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Šteinmiller J, Routasalo P, Suominen T. Older people in the emergency department: a literature review. Int J Older People Nurs 2015; 10:284-305. [PMID: 26183883 DOI: 10.1111/opn.12090] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 06/17/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency departments (EDs) play a unique role in healthcare systems throughout the world by providing acute interventions for older patients with acute/emergency and multiple health problems. The aim of this review was to identify studies that focused on older patients admitted to EDs and to determine the reasons for the visits. DESIGN AND METHODS The literature review was based on a comprehensive search of electronic databases. Inclusion criteria were original research written in English; published 2002-2012; focused on older people; reasons for ED visit; and factors that affect the discharge process and those associated with a repeat ED visit. Other literature reviews and studies unrelated to the ED context, and studies examining patients aged ≥65 years, were excluded. Content analysis was performed. Twenty-five studies were identified and critically evaluated. RESULTS The highest proportion of older people visited the ED because of multiple health conditions. The reasons for the visits were cardiovascular, mental health, musculoskeletal and abdominal conditions; adverse drug reactions; dermatological, neurological and respiratory conditions; poor health status; accidents; and the influence of time factors such as time of day, week or season. Factors that affected the discharge process were unresolved problems, health risk identification, aftercare instructions, medication prescribed at discharge and patient's residence before ED admission. Factors associated with repeat ED visits were sociodemographic characteristics, social problems, health problems, need for systematic health assessment, healthcare service use and inadequacy of care provided. CONCLUSIONS The current review showed that older people are the main population visiting EDs; important factors required for planning and providing nursing care for older people in EDs were identified. More research is needed to determine how EDs support older people and their families. IMPLICATIONS FOR PRACTICE The findings of the current review identified that older people visit ED quite often because of different reasons. Discharge process and repeat visits may be influenced by various factors. To ensure quality nursing care in ED nurses need to be aware why do older people visit the ED, what factors may influence discharge and what factors are associated with repeat ED visits.
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Affiliation(s)
| | | | - Tarja Suominen
- School of Health Sciences, Nursing Sciences, University of Tampere, Tampere, Finland
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Stang AS, Crotts J, Johnson DW, Hartling L, Guttmann A. Crowding measures associated with the quality of emergency department care: a systematic review. Acad Emerg Med 2015; 22:643-56. [PMID: 25996053 DOI: 10.1111/acem.12682] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Despite the substantial body of literature on emergency department (ED) crowding, to the best of our knowledge, there is no agreement on the measure or measures that should be used to quantify crowding. The objective of this systematic review was to identify existing measures of ED crowding that have been linked to quality of care as defined by the Institute of Medicine (IOM) quality domains (safe, effective, patient-centered, efficient, timely, and equitable). METHODS Six major bibliographic databases were searched from January 1980 to January 2012, and hand searches were conducted of relevant journals and conference proceedings. Observational studies (cross-sectional, cohort, and case-control), quality improvement studies, quasi-experimental (e.g., before/after) studies, and randomized controlled trials were considered for inclusion. Studies that did not provide measures of ED crowding were excluded. Studies that did not provide quantitative data on the link between crowding measures and quality of care were also excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality using the Newcastle-Ottawa Quality Assessment Scale (NOS) for observational studies and a modified version of the NOS for cross-sectional studies. RESULTS The search identified 7,413 articles. Thirty-two articles were included in the review: six cross-sectional, one case-control, 23 cohort, and two retrospective reviews of performance improvement data. Methodologic quality was moderate, with weaknesses in the reporting of study design and methodology. Overall, 15 of the crowding measures studied had quantifiable links to quality of care. The three measures most frequently linked to quality of care were the number of patients in the waiting room, ED occupancy (percentage of overall ED beds filled), and the number of admitted patients in the ED awaiting inpatient beds. None of the articles provided data on the link between crowding measures and the IOM domains reflecting equitable and efficient care. CONCLUSIONS The results of this review provide data on the association between ED crowding measures and quality of care. Three simple crowding measures have been linked to quality of care in multiple publications.
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Affiliation(s)
- Antonia S. Stang
- Division of Emergency Medicine; Alberta Children's Hospital; Alberta Children's Hospital Research Institute; Department of Pediatrics and Community Health Sciences; University of Calgary; Calgary Alberta
| | - Jennifer Crotts
- Division of Emergency Medicine; Alberta Children's Hospital; Department of Pediatrics; University of Calgary; Calgary Alberta
| | - David W. Johnson
- Division of Emergency Medicine; Alberta Children's Hospital; Alberta Children's Hospital Research Institute; Department of Pediatrics, Physiology and Pharmacology; University of Calgary; Calgary Alberta
| | - Lisa Hartling
- Department of Pediatrics; University of Alberta; Alberta Research Center for Health Evidence; Edmonton Alberta
| | - Astrid Guttmann
- Division of Pediatric Medicine; Hospital for Sick Children; Department of Pediatrics and Health Policy; Management and Evaluation; University of Toronto and Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
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Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department. CAN J EMERG MED 2015; 18:19-27. [PMID: 25990048 DOI: 10.1017/cem.2015.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES This study aimed to ascertain the association between self-reported pain intensity and vital signs in both emergency department (ED) patients and a subgroup of patients with diagnosed conditions known to produce significant pain. METHODS We performed a retrospective analysis of real-time, archived data from an electronic medical record system at an urban teaching hospital and regional community hospital. We included consecutive ED patients ≥16 years old who had a self-reported pain intensity ≥1 as measured during triage, from March 2005 to December 2012. The primary outcome was vital signs for self-reported pain intensity levels (mild, moderate, severe) on an 11-point verbal numerical scale. Changes in pain intensity levels were also compared to variations in vital signs. Both analyses were repeated on a subgroup of patients with diagnosed conditions recognized to produce significant pain: fracture, dislocation, or renal colic. RESULTS We included 153,567 patients (mean age of 48.4±19.3 years; 55.5% women) triaged with pain (median intensity of 7/10±3). Of these, 8.9% of patients had diagnosed conditions recognized to produce significant pain. From the total sample, the difference between mild and severe pain categories was 2.7 beats/minutes (95% CI: 2.4-3.0) for heart rate and 0.13 mm Hg (95% CI: -0.26-0.52) for systolic blood pressure. These differences generated small effect sizes and were not clinically significant. Results were similar for patients who experienced changes in pain categories and for those conditions recognized to produce significant pain. CONCLUSION Health care professionals cannot use vital signs to estimate or substantiate self-reported pain intensity levels or changes over time.
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Abstract
The disciplines of paramedicine and emergency medicine have evolved synchronously over the past four decades, linked by emergency physicians with expertise in prehospital care. Ambulance offload delay (OD) is an inevitable consequence of emergency department overcrowding (EDOC) and compromises the care of the patient on the ambulance stretcher in the emergency department (ED), as well as paramedic emergency medical service response in the community. Efforts to define transfer of care from paramedics to ED staff with a view to reducing offload time have met with resistance from both sides with different agendas. These include the need to return paramedics to serve the community versus the lack of ED capacity to manage the patient. Innovative solutions to other system issues, such as rapid access to trauma teams, reducing door-to-needle time, and improving throughput in the ED to reduce EDOC, have been achieved by involving all stakeholders in an integrative thinking process. Only by addressing this issue in a similar integrative process will solutions to OD be realized.
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Schnitker LM, Martin-Khan M, Burkett E, Brand CA, Beattie ERA, Jones RN, Gray LC. Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments. Acad Emerg Med 2015; 22:273-84. [PMID: 25754936 DOI: 10.1111/acem.12617] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 08/25/2014] [Accepted: 10/15/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). METHODS A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. RESULTS At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. CONCLUSIONS This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.
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Affiliation(s)
- Linda M. Schnitker
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
| | - Melinda Martin-Khan
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
- Centre for Online Health; The University of Queensland; Brisbane Australia
| | - Ellen Burkett
- The Department of Emergency Medicine; Princess Alexandra Hospital; Brisbane Australia
| | - Caroline A. Brand
- The Centre for Research Excellence in Patient Safety; Monash University; Melbourne Australia
| | - Elizabeth R. A. Beattie
- The School of Nursing and Midwifery; Queensland University of Technology; Brisbane Australia
| | - Richard N. Jones
- Hebrew SeniorLife; Institute for Aging Research; Harvard Medical School; Boston MA
| | - Len C. Gray
- The Centre for Research in Geriatric Medicine; The University of Queensland; Brisbane Australia
- Centre for Online Health; The University of Queensland; Brisbane Australia
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Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study. CAN J EMERG MED 2015; 17:253-62. [DOI: 10.1017/cem.2014.39] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroductionEmergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.MethodsA retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.ResultsFrom 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.ConclusionsBetter performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.
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Abstract
Emergency departments (ED) worldwide have experienced dramatic increases in crowding over the past 20 years that now have reached critical levels. One consequence of ED crowding has been the routine use of ED hallways for patient care. This includes ED patients who are awaiting care but are considered unstable to remain in the waiting room, patients who are undergoing active medical and trauma treatment, and patients who have been stabilized but await transfer to an inpatient bed (boarding) or another institution. Compared with licensed hospital or standard ED beds, care in ED hallways results in increased patient morbidity and mortality, as well as patient and staff dissatisfaction. Complications experienced by hallway patients include unrecognized sudden respiratory arrest or unstable cardiac arrhythmias, delay in time-sensitive procedures and laboratory testing, delay in receiving important medications, excessive or unrelieved pain, overall increased length of stay, increased disability, and exposure to traumatic psychological events. While much has been published on the general problems of ED crowding, only recently have studies focused exclusively on the issues of providing care in ED hallways. This review summarizes the current issues, challenges, and solutions for hallway care.
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Plint AC, Newton A, Stang A, Bhatt M, Barrowman N, Calder L. How safe are our paediatric emergency departments? Protocol for a national prospective cohort study. BMJ Open 2014; 4:e007064. [PMID: 25475246 PMCID: PMC4256537 DOI: 10.1136/bmjopen-2014-007064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/11/2014] [Accepted: 11/12/2014] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Adverse events (AEs), defined as unintended patient harm related to healthcare provided rather than an underlying medical condition, represent a significant threat to patient safety and public health. The emergency department (ED) is a high-risk patient safety setting for many reasons including presentation 'outside of regular hours', high patient volumes, and a chaotic work environment. Children have also been identified as particularly vulnerable to AEs. Despite the identification of the ED as a high-risk setting and the vulnerability of the paediatric population, little research has been conducted regarding paediatric patient safety in the ED. The study objective is to generate an estimate of the risk and type of AEs, as well as their preventability and severity, for children seen in Canadian paediatric EDs. METHODS AND ANALYSIS This multicentre, prospective cohort study will enrol patients under 18 years of age from nine paediatric EDs across Canada. A stratified cluster random sampling scheme will be used to ensure patients recruited are representative of the overall ED population. A rigorous, standardised two-stage process will be used for AE identification. The primary outcome will be the proportion of children with AEs associated with ED care in the 3 weeks following the ED visit. Secondary outcomes will include the proportion of children with preventable AEs and the types and severity of AEs. We will aim to recruit 5632 patients over 1 year and this will allow us to detect a proportion of patients with an AE of 5% (to within an absolute margin of error of 0.6%). ETHICS AND DISSEMINATION Ethics approval has been obtained from participating sites. Results will be disseminated through presentations, peer review publications, linkages with emergency research network and a webinars for key knowledge user groups. TRIAL REGISTRATION NUMBER This study is registered at Clinicaltrials.gov (NCT02162147; https://clinicaltrials.gov/ct2/show/NCT02162147).
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Affiliation(s)
- Amy C Plint
- Departments of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amanda Newton
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Antonia Stang
- Department of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Maala Bhatt
- Departments of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Calder
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
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Henderson K, Boyle A. Exit block in the emergency department: recognition and consequences. Br J Hosp Med (Lond) 2014; 75:623-6. [DOI: 10.12968/hmed.2014.75.11.623] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Katherine Henderson
- Clinical Lead and Consultant in Emergency Medicine in the Emergency Department, Guys and St Thomas' NHS Foundation Trust, London SE1 7EH
| | - Adrian Boyle
- Consultant Emergency Physician in the Emergency Department, Addenbrooke's Hospital, Cambridge and Visiting Senior Research Fellow, Cambridge University
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White BA, Chang Y, Grabowski BG, Brown DF. Using lean-based systems engineering to increase capacity in the emergency department. West J Emerg Med 2014; 15:770-6. [PMID: 25493117 PMCID: PMC4251218 DOI: 10.5811/westjem.2014.8.21272] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 08/08/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION While emergency department (ED) crowding has myriad causes and negative downstream effects, applying systems engineering science and targeting throughput remains a potential solution to increase functional capacity. However, the most effective techniques for broad application in the ED remain unclear. We examined the hypothesis that Lean-based reorganization of Fast Track process flow would improve length of stay (LOS), percent of patients discharged within one hour, and room use, without added expense. METHODS This study was a prospective, controlled, before-and-after analysis of Fast Track process improvements in a Level 1 tertiary care academic medical center with >95,000 annual patient visits. We included all adult patients seen during the study periods of 6/2010-10/2010 and 6/2011-10/2011, and data were collected from an electronic tracking system. We used concurrent patients seen in another care area used as a control group. The intervention consisted of a simple reorganization of patient flow through existing rooms, based in systems engineering science and modeling, including queuing theory, demand-capacity matching, and Lean methodologies. No modifications to staffing or physical space were made. Primary outcomes included LOS of discharged patients, percent of patients discharged within one hour, and time in exam room. We compared LOS and exam room time using Wilcoxon rank sum tests, and chi-square tests for percent of patients discharged within one hour. RESULTS Following the intervention, median LOS among discharged patients was reduced by 15 minutes (158 to 143 min, 95%CI 12 to 19 min, p<0.0001). The number of patients discharged in <1 hr increased by 2.8% (from 6.9% to 9.7%, 95%CI 2.1% to 3.5%, p<0.0001), and median exam room time decreased by 34 minutes (90 to 56 min, 95%CI 31 to 38 min, p<0.0001). In comparison, the control group had no change in LOS (265 to 267 min) or proportion of patients discharged in <1 hr (2.9% to 2.9%), and an increase in exam room time (28 to 36 min, p<0.0001). CONCLUSION In this single center trial, a focused Lean-based reorganization of patient flow improved Fast Track ED performance measures and capacity, without added expense. Broad multi-centered application of systems engineering science might further improve ED throughput and capacity.
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Affiliation(s)
- Benjamin A. White
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Yuchiao Chang
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Beth G. Grabowski
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - David F.M. Brown
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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91
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Quality indicators for the assessment and management of pain in the emergency department: a systematic review. Pain Res Manag 2014; 19:e179-90. [PMID: 25337856 PMCID: PMC4273718 DOI: 10.1155/2014/269140] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Appropriate and timely treatment of pain are very important, particularly in the emergency department, where pain continues to be undertreated. One of the ways in which the undertreatment of pain can be mitigated is the use of defined quality benchmarks. This systematic review of the literature was performed to identify such quality indicators. The resulting 20 quality indicators may be used to improve pain assessment and management protocols in the emergency department setting. BACKGROUND: Evidence indicates that pain is undertreated in the emergency department (ED). The first step in improving the pain experience for ED patients is to accurately and systematically assess the actual care being provided. Identifying gaps in the assessment and treatment of pain and improving patient outcomes requires relevant, evidence-based performance measures. OBJECTIVE: To systematically review the literature and identify quality indicators specific to the assessment and management of pain in the ED. METHODS: Four major bibliographical databases were searched from January 1980 to December 2010, and relevant journals and conference proceedings were manually searched. Original research that described the development or collection of data on one or more quality indicators relevant to the assessment or management of pain in the ED was included. RESULTS: The search identified 18,078 citations. Twenty-three articles were included: 15 observational (cohort) studies; three before-after studies; three audits; one quality indicator development study; and one survey. Methodological quality was moderate, with weaknesses in the reporting of study design and methodology. Twenty unique indicators were identified, with the majority (16 of 20) measuring care processes. Overall, 91% (21 of 23) of the studies reported indicators for the assessment or management of presenting pain, as opposed to procedural pain. Three of the studies included children; however, none of the indicators were developed specifically for a pediatric population. CONCLUSION: Gaps in the existing literature include a lack of measures reflecting procedural pain, patient outcomes and the pediatric population. Future efforts should focus on developing indicators specific to these key areas.
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92
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Lee HK, Kang BS, Kim CS, Choi HJ. Ultrasound-guided regional anesthesia for the pain management of elderly patients with hip fractures in the emergency department. Clin Exp Emerg Med 2014; 1:49-55. [PMID: 27752552 PMCID: PMC5052818 DOI: 10.15441/ceem.14.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 07/19/2014] [Accepted: 07/24/2014] [Indexed: 11/23/2022] Open
Abstract
Objective We examined the pain-relieving effect of ultrasound-guided regional anesthesia performed by emergency physicians on elderly hip fracture patients. Methods This study is a prospective, non-randomized, case-control study. The subjects were patients older than 65 years who visited the emergency department with a hip fracture. After we obtained informed consent, two emergency physicians performed an ultrasound-guided three-in-one femoral block using 20 mL of 0.5% bupivacaine. The pain score was measured just before regional anesthesia, and 0.25, 0.5, 1, 2, 3, and 4 hours after the procedure. Another group of patients was given multiple doses of morphine to control the pain. We compared the change in pain score and the development of adverse reactions between the two groups. Results A total of 47 patients were enrolled in this study, of which 25 were given regional anesthesia. Successful pain control (pain score<4) was significantly higher in the regional anesthesia group (96.0% vs. 40.9%; P<0.001). The decrease in pain score was significantly higher in the regional anesthesia group (7 [interquartile range, 6 to 7] vs. 4 [interquartile range, 3 to 5]; P< 0.001). The only adverse reaction observed was mild nausea in 4 patients (1 out of 25 from the regional anesthesia group and 3 out of 22 from the morphine group). Conclusion Ultrasound-guided regional anesthesia administered by emergency physicians treating elderly hip fracture patients provided faster pain relief and a larger decrease in pain than conventional intravenous injections of morphine.
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Affiliation(s)
- Hee Kyung Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Bo Seung Kang
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chang Sun Kim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hyuk Joong Choi
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
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93
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Davis RA, Dinh MM, Bein KJ, Veillard AS, Green TC. Senior work-up assessment and treatment team in an emergency department: A randomised control trial. Emerg Med Australas 2014; 26:343-9. [DOI: 10.1111/1742-6723.12256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Rebecca A Davis
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Michael M Dinh
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Kendall J Bein
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Anne-Sophie Veillard
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Timothy C Green
- Emergency Department; Royal Prince Alfred Hospital; NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
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94
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Mumma BE, McCue JY, Li CS, Holmes JF. Effects of emergency department expansion on emergency department patient flow. Acad Emerg Med 2014; 21:504-9. [PMID: 24842500 PMCID: PMC4046120 DOI: 10.1111/acem.12366] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 11/12/2013] [Accepted: 12/09/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. METHODS This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. RESULTS The mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). CONCLUSIONS An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.
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Affiliation(s)
- Bryn E Mumma
- The Department of Emergency Medicine, University of California Davis, Sacramento, CA
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95
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O'Connor E, Gatien M, Weir C, Calder L. Evaluating the effect of emergency department crowding on triage destination. Int J Emerg Med 2014; 7:16. [PMID: 24860626 PMCID: PMC4016736 DOI: 10.1186/1865-1380-7-16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 04/04/2014] [Indexed: 11/26/2022] Open
Abstract
Background Emergency Department (ED) crowding has been studied for the last 20 years, yet many questions remain about its impact on patient care. In this study, we aimed to determine if ED crowding influenced patient triage destination and intensity of investigation, as well as rates of unscheduled returns to the ED. We focused on patients presenting with chest pain or shortness of breath, triaged as high acuity, and who were subsequently discharged home. Methods This pilot study was a health records review of 500 patients presenting to two urban tertiary care EDs with chest pain or shortness of breath, triaged as high acuity and subsequently discharged home. Data extracted included triage time, date, treatment area, time to physician initial assessment, investigations ordered, disposition, and return ED visits within 14 days. We defined ED crowding as ED occupancy greater than 1.5. Data were analyzed using descriptive statistics and the χ2 and Fisher exact tests. Results Over half of the patients, 260/500 (52.0%) presented during conditions of ED crowding. More patients were triaged to the non-monitored area of the ED during ED crowding (65/260 (25.0%) vs. 39/240 (16.3%) when not crowded, P = 0.02). During ED crowding, mean time to physician initial assessment was 132.0 minutes in the non-monitored area vs. 99.1 minutes in the monitored area, P <0.0001. When the ED was not crowded, mean time to physician initial assessment was 122.3 minutes in the non-monitored area vs. 67 minutes in the monitored area, P = 0.0003. Patients did not return to the ED more often when triaged during ED crowding: 24/260 (9.3%) vs. 29/240 (12.1%) when ED was not crowded (P = 0.31). Overall, when triaged to the non-monitored area of the ED, 44/396 (11.1%) patients returned, whereas in the monitored area 9/104 (8.7%) patients returned, P = 0.46. Conclusions ED crowding conditions appeared to influence triage destination in our ED leading to longer wait times for high acuity patients. This did not appear to lead to higher rates of return ED visits amongst discharged patients in this cohort. Further research is needed to determine whether these delays lead to adverse patient outcomes.
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Affiliation(s)
- Erin O'Connor
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada
| | - Mathieu Gatien
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada
| | - Cindy Weir
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada
| | - Lisa Calder
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada ; Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Rm F658, 1053 Carling Ave., Ottawa, ON K1Y 4E9, Canada
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96
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Daoust R, Paquet J, Lavigne G, Sanogo K, Chauny JM. Senior patients with moderate to severe pain wait longer for analgesic medication in EDs. Am J Emerg Med 2014; 32:315-9. [DOI: 10.1016/j.ajem.2013.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/03/2013] [Accepted: 12/04/2013] [Indexed: 11/25/2022] Open
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Sokoloff C, Daoust R, Paquet J, Chauny JM. Is adequate pain relief and time to analgesia associated with emergency department length of stay? A retrospective study. BMJ Open 2014; 4:e004288. [PMID: 24667382 PMCID: PMC3975786 DOI: 10.1136/bmjopen-2013-004288] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 02/21/2014] [Accepted: 02/26/2014] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Evaluate the association of adequate analgesia and time to analgesia with emergency department (ED) length of stay (LOS). SETTING AND DESIGN Post hoc analysis of real-time archived data. PARTICIPANTS We included all consecutive ED patients ≥18 years with pain intensity >6 (verbal numerical scale from 0 to 10), assigned to an ED bed, and whose pain was re-evaluated less than 1 h after receiving analgesic treatment. OUTCOME MEASURES The main outcome was ED-LOS in patients who had adequate pain relief (AR=↓50% pain intensity) compared with those who did not have such relief (NR). RESULTS A total of 2033 patients (mean age 49.5 years; 51% men) met our inclusion criteria; 58.3% were discharged, and 41.7% were admitted. Among patients discharged or admitted, there was no significant difference in ED-LOS between those with AR (median (25th-75th centile): 9.6 h (6.3-14.8) and 18.2 h (11.6-25.7), respectively) and NR (median (25th-75th centile): 9.6 h (6.6-16.0) and 17.4 h (11.3-26.5), respectively). After controlling for confounding factors, rapid time to analgesia (not AR) was associated with shorter ED-LOS of discharged and admitted patients (p<0.001 and <0.05, respectively). When adjusting for confounding variables, ED-LOS is shortened by 2 h (95% CI 1.1 to 2.8) when delay to receive analgesic is <90 min compared with >90 min for discharged and by 2.3 h (95% CI 0.17 to 4.4) for admitted patients. CONCLUSIONS In our study, AR was not linked with short ED-LOS. However, rapid administration of analgesia was associated with short ED-LOS.
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Affiliation(s)
- Catalina Sokoloff
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Raoul Daoust
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Jean Paquet
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
- Department of Surgery, Centre for Advanced Research in Sleep Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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98
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The role of fascia iliaca blocks in hip fractures: a prospective case-control study and feasibility assessment of a junior-doctor-delivered service. ISRN ORTHOPEDICS 2014; 2014:191306. [PMID: 24977087 PMCID: PMC4061486 DOI: 10.1155/2014/191306] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/20/2013] [Indexed: 11/23/2022]
Abstract
Hip fractures are common and the incidence is expected to increase. Systemic analgesics, often prescribed to relieve pain after hip fractures, have huge side effects and can delay surgery. We analyse the role and efficacy of alternative forms of analgesia like fascia-iliac blocks (FIB) and assess the feasibility of a service delivered by junior doctors. 104 consecutive hip fracture patients were prospectively recruited and equally divided into cases (patients receiving FIB) and controls (patients receiving systemic analgesia). Outcome measures included time of initial analgesia, total preoperative dose of analgesia, pain scores from admission to 24 hours preoperatively, and complications. The pain scores were significantly lower (P ≤ 0.05) in patients receiving FIB at 2 and 8 hours preoperatively. The timing of initial analgesia was also quicker in patients with FIB (25 compared to 40 minutes). FIB patients required fewer doses of systemic analgesia. The block was successful in 67% of patients. There were no complications. The implementation of EWTD, HAN, and shift-system and the reduction in the number of medical staff have increased the burden on emergency departments. This study demonstrates that FIB performed by junior doctors are not only safe and effective analgesia but also provide an opportunity for junior doctors to improve current clinical practice.
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99
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Rantala M, Hartikainen S, Kvist T, Kankkunen P. Analgesics in postoperative care in hip fracture patients with dementia - reported by nurses. J Clin Nurs 2014; 23:3095-106. [DOI: 10.1111/jocn.12548] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2013] [Indexed: 02/04/2023]
Affiliation(s)
- Maija Rantala
- Department of Nursing Sciences; Faculty of Health Sciences; University of Eastern Finland; Kuopio Finland
| | - Sirpa Hartikainen
- Clinical Pharmacology and Geriatric Pharmacotherapy Unit; School of Pharmacy; Faculty of Health Sciences; University of Eastern Finland; Kuopio Finland
| | - Tarja Kvist
- Department of Nursing Sciences; Faculty of Health Sciences; University of Eastern Finland; Kuopio Finland
| | - Päivi Kankkunen
- Department of Nursing Sciences; Faculty of Health Sciences; University of Eastern Finland; Kuopio Finland
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100
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Body R, Kaide E, Kendal S, Foex B. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners. Emerg Med J 2013; 32:15-20. [DOI: 10.1136/emermed-2013-202860] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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