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Grafeneder J, Baewert A, Katz H, Holzinger A, Niederdoeckl J, Roth D. Immigration bias among medical students: a randomized controlled trial. Eur J Emerg Med 2023; 30:417-423. [PMID: 37650729 DOI: 10.1097/mej.0000000000001057] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND IMPORTANCE Racial bias is found in both physicians and medical students. Immigrants in many parts of the world face challenges similar to racial minorities. Identification of immigrants might however be more subtle than identification by race, and currently, no data are available on a possible bias against the large minority group of migrants in Europe. DESIGN Randomized control trial. SETTINGS AND PARTICIPANTS Second-year medical students were randomized into four groups to watch a video of either a male or female patient with pain, with or without immigrant status. INTERVENTION Students were asked whether they would administer pain medication (primary outcome). OUTCOME MEASURES AND ANALYSIS Immigrant status, patient's gender, student's gender, age, and language skills were covariates in a logistic regression model. Secondary outcomes included pain medication potency and the student's rating of the patient's pain intensity. MAIN RESULTS We recruited 607 students [337 females (56%), 387 (64%) between 18 and 22 years old]. Analgesia was administered in 95% (n = 576). Immigrant status was not associated with the probability of receiving pain medication [95 vs. 95%, odds ratio (OR) 0.81, 95% confidence interval (CI) 0.39-1.70, P = 0.58]. Immigrants received high-potency analgesia less often (26 vs. 33%, OR 0.69, 95% CI 0.50-0.96, P = 0.03). Female students administered pain medication more frequently (96 vs. 93%, OR 2.29, 95% CI 1.05-5.02, P = 0.04), and rated the patients' pain higher (mean numeric rating scale 7.7, SD 0.9 vs. 7.4, SD 1.0, OR 1.36, 95% CI 1.16-1.60, P < 0.001). CONCLUSION Medical students showed no immigration bias with regard to administering pain medication but were less likely to choose high-potency analgesia in immigrants. We also found a gender difference in pain management. These results demonstrate the importance of including knowledge about immigration bias in medical training.
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Affiliation(s)
| | - Andjela Baewert
- Teaching Center, Medical University of Vienna, Wien, Austria
| | - Henri Katz
- Teaching Center, Medical University of Vienna, Wien, Austria
| | - Anita Holzinger
- Teaching Center, Medical University of Vienna, Wien, Austria
| | | | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna
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Hornik ES, Thode HC, Singer AJ. Analgesic use in ED patients with long-bone fractures: A national assessment of racial and ethnic disparities. Am J Emerg Med 2023; 69:11-16. [PMID: 37027957 DOI: 10.1016/j.ajem.2023.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND It is vital to ensure equitable care is given to all patients and to eliminate any disparities in administration of analgesics and opioids in emergency department (ED) patients with long-bone fractures. Our objective was to determine whether sex, ethnic, or racial disparities still exist in administration and prescription of analgesics and opioids in ED patients with long-bone fractures using a current nationally representative database. METHODS This was a retrospective, cross-sectional analysis of ED patients ages 15-55 years with long-bone fractures included in the National Hospital and Medical Care Survey (NHAMCS) database from 2016 to 2019. Our primary and secondary outcomes were administration of analgesics and opioids in the ED and our exploratory outcomes were prescription of analgesics and opioids in discharged patients. Outcomes were adjusted for age, sex, race, insurance, fracture location, number of fractures, and pain severity. RESULTS Of the estimated 2.32 million ED patient visits analyzed, 65% received analgesics and 50% received opioids in the ED. On multivariable analyses, administration of analgesics was associated with female sex (OR 2.11; 95% CI 1.08-4.12) and Black race (OR 2.84; 95% CI 1.03-7.80), but not with Hispanic/Latino ethnicity (OR 2.09; 95% CI 0.72-6.04). No associations were found between opioid administration or analgesic or opioid prescription and female sex, Hispanic/Latino ethnicity, or Black race. CONCLUSIONS Between 2016 and 2019 there were no significant sex, ethnic, or racial disparities in administration or prescription of analgesics or opioids in ED adult patients with long-bone fractures.
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Bond C, Westafer L, Challen K, Milne WK. Hot off the press: the RAMPED trial-methoxyflurane for analgesia in the emergency department. Acad Emerg Med 2021; 28:1179-1182. [PMID: 33772948 DOI: 10.1111/acem.14257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Kirsty Challen
- ScHARR, Regent Court University of Sheffield Sheffield UK
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Guillermo S, Barre-Hemingway M. Pain Perception and Treatment for Adolescents in Racially Concordant Versus Discordant Patient-Provider Scenarios. J Adolesc Health 2020; 66:589-596. [PMID: 32169525 DOI: 10.1016/j.jadohealth.2019.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/04/2019] [Accepted: 12/20/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE We tested assessments of adolescent pain and treatment recommendations in vignette cases that reflected racial concordance or discordance. METHODS Participants, black and white medical professionals, evaluated two vignettes, an acute asthma exacerbation and a leg injury. Vignettes presented either black or white patients. Participants estimated patients' pain level and indicated their agreement with two treatment recommendations-an optimal and an adequate treatment. RESULTS We expected stronger racial bias in pain estimates for white participants, although results did not support this hypothesis. We expected higher agreement with optimal treatment and lower agreement with adequate treatment, in racially concordant versus discordant scenarios. However, the results did not support this prediction. We hypothesized that pain assessments and treatments would be more strongly correlated in racially concordant compared with discordant scenarios. Results supported this hypothesis in the leg vignette and were most pronounced for optimal treatment (F(1, 70) = 4.38; η2 = .059; 95% CI: .007-.280; p = .04). Findings from the asthma vignette contradicted our hypothesis; higher pain estimates more strongly correlated with reduced agreement with an adequate treatment in racially discordant versus concordant scenarios (F(1, 72) = 6.46; η2 = .082; 95% CI: .025-.206; p = .01). CONCLUSIONS There were no race-based differences in pain estimates or agreement with treatment recommendations. Assessments of adolescent pain are more strongly correlated with acute pain treatment, specifically narcotic analgesic treatment, in racially concordant versus discordant scenarios. The correlation between pain assessment and treatment is also present in racially discordant scenarios for asthma treatment.
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Abstract
Background There is a significant upfront cost for the use of neuromodulation devices. The high cost of these devices may lead to disproportionate application in geographical regions with different levels of financial resources. The purpose of this study was to determine if there is geographic based economic inequity in the application of neuromodulation devices in the United States. Methods Population and average household income data by county from the year 2010 were obtained from publicly available databases on the US Census website. The number of stimulators sold by county in the years 2009 and 2010 were provided by two of the four neuromodulation companies with commercially available products. Pearson correlation and t-test statistics were performed. Results Of the 3142 U.S. counties analyzed, only 689 placed neuromodulation devices during this period of time. There was a difference in average household income between counties with device implants ($49,663) and counties with no device implants ($41,314), which was statistically significant (p<0.001). Conclusion Analysis of neuromodulation devices placed in 2009 and 2010 from 50% of neuromodulation companies demonstrated that there was an income disparity between counties in which implantation of devices occurred and counties in which there were no device implantations.
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Affiliation(s)
- James Leiphart
- Neurosurgery, Inova Neuroscience Institute, Falls Church, USA
| | - Megan Barrett
- Neurosurgery, Inova Neuroscience Institute, Falls Church, USA
| | - Mahesh B Shenai
- Neurosurgery, Inova Neuroscience Institute, Falls Church, USA
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Abstract
Racial differences exist in analgesic prescribing for children during emergency department and ambulatory surgery visits in the United States; however, it is unknown whether this is true in the outpatient setting. We examined racial and ethnic differences in outpatient analgesic prescribing using nationally representative data from 113,929 children from the Medical Expenditure Panel Survey. We also examined whether patient-provider race and ethnic concordance was associated with opioid prescription. White children were more commonly prescribed opioids as compared to minorities (3.0% vs 0.9%-1.7%), except for Native American children who had similar rates of opioid prescription (2.6%) as white children. Minorities were more likely to receive nonopioid analgesics than white children (2.0%-5.7% vs 1.3%). Although most white children had race-concordant providers (93.5%), only 34.3% of black children and 42.7% of Hispanic children had race-concordant providers. Among black children, having a race concordant usual source of care provider was associated with a decreased likelihood of receiving an opioid prescription as compared to having a white usual source of care provider (adjusted odds ratio [95% confidence interval] = 0.51 [0.30-0.87]). For all other racial groups, patient-provider race-concordance was not associated with likelihood of opioid prescription. Racial differences exist in analgesic prescriptions to children at outpatient health care visits in the United States, with white children more likely to receive opioids and minorities more likely to receive nonopioid analgesics. Health care providers' race and ethnicity may play a significant role in extant analgesic differences. Further work should focus on understanding the role of provider race and ethnicity in analgesic differences to children in the United States.
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Abstract
Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.
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Huang KT, Hazzard MA, Babu R, Ugiliweneza B, Grossi PM, Huh BK, Roy LA, Patil C, Boakye M, Lad SP. Insurance Disparities in the Outcomes of Spinal Cord Stimulation Surgery. Neuromodulation 2013; 16:428-34; discussion 434-5. [DOI: 10.1111/ner.12059] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/14/2013] [Accepted: 03/05/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Kevin T. Huang
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Matthew A. Hazzard
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Ranjith Babu
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery; Center for Neurosurgical Outcomes Research; Maxine Dunitz Neurosurgical Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Peter M. Grossi
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Billy K. Huh
- Department of Anesthesia; Divison of Pain; Duke University Medical Center; Durham NC USA
| | - Lance A. Roy
- Department of Anesthesia; Divison of Pain; Duke University Medical Center; Durham NC USA
| | - Chirag Patil
- Department of Neurosurgery; Center for Neurosurgical Outcomes Research; Maxine Dunitz Neurosurgical Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Maxwell Boakye
- Department of Neurosurgery; University of Louisville; Louisville KY USA
- Department of Neurosurgery; Robley Rex VA Medical Center; Louisville KY USA
| | - Shivanand P. Lad
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
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Tsai CL, Sullivan AF, Gordon JA, Kaushal R, Magid DJ, Blumenthal D, Camargo CA. Racial/ethnic differences in emergency care for joint dislocation in 53 US EDs. Am J Emerg Med 2012; 30:1970-80. [PMID: 22795991 DOI: 10.1016/j.ajem.2012.04.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/17/2012] [Accepted: 04/19/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of the study was to investigate racial/ethnic differences in emergency care for patients with joint dislocation. METHODS We performed a secondary analysis of the dislocation component of the National Emergency Department Safety Study. Using a principal diagnosis of dislocation, we identified emergency department (ED) visits for joint dislocations in 53 urban EDs across 19 US states between 2003 and 2005. Quality of care was evaluated based on 9 guideline-concordant care measures. RESULTS Of the 1945 patients included in this analysis, 1124 (58%) were white; 561 (29%), black, and 260 (13%), Hispanic. One-third of the 53 EDs cared for 51% of minority patients. After multivariable adjustment, black patients were less likely to receive any analgesic treatment (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.51-0.90) or opioid treatment (OR, 0.64; 95% CI, 0.41-0.997), waited longer to receive analgesia (mean difference in time to analgesic treatment, 32 minutes; 95% CI, 16-52 minutes), and were less likely to receive reassessments of pain (OR, 0.49; 95% CI, 0.34-0.70) compared with white patients. There were no ethnic disparities in most of the care measures between Hispanic and white patients. There were no disparities in initial pain assessment, pre- and postprocedural neurovascular assessment, procedural monitoring, or success of joint reduction across the racial/ethnic groups. CONCLUSIONS Black patients presenting to the ED with joint dislocations received lower quality of care in some, but not all, areas compared with white patients. Future interventions should target these areas to eliminate racial disparities in dislocation care.
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Affiliation(s)
- Chu-Lin Tsai
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Tsze DS, Asnis LM, Merchant RC, Amanullah S, Linakis JG. Increasing Computed Tomography Use for Patients With Appendicitis and Discrepancies in Pain Management Between Adults and Children: An Analysis of the NHAMCS. Ann Emerg Med 2012; 59:395-403. [DOI: 10.1016/j.annemergmed.2011.06.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 05/17/2011] [Accepted: 06/15/2011] [Indexed: 01/07/2023]
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Sills MR, Fairclough DL, Ranade D, Mitchell MS, Kahn MG. Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures. Acad Emerg Med 2011; 18:1330-8. [PMID: 22168199 DOI: 10.1111/j.1553-2712.2011.01136.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures. METHODS This cross-sectional, retrospective study included patients 0-21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children's hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested. RESULTS The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding-an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p < 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles. CONCLUSIONS Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, Children's Outcomes Research Program, University of Colorado School of Medicine, Aurora, USA.
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Fortuna RJ, Robbins BW, Mani N, Halterman JS. Dependence on emergency care among young adults in the United States. J Gen Intern Med 2010; 25:663-9. [PMID: 20306149 PMCID: PMC2881978 DOI: 10.1007/s11606-010-1313-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 01/22/2010] [Accepted: 02/12/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Young adults have a high prevalence of many preventable diseases and frequently lack a usual source of ambulatory care, yet little is known about their use of the emergency department. OBJECTIVE To characterize care provided to young adults in the emergency department. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of visits from young adults age 20 to 29 presenting to emergency departments (N = 17,048) and outpatient departments (N = 14,443) in the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. MAIN MEASURES Visits to the emergency department compared to ambulatory offices. RESULTS Emergency department care accounts for 21.6% of all health care visits from young adults, more than children/adolescents (12.6%; P < 0.001) or patients 30 years and over (8.3%; P < 0.001). Visits from young adults were considerably more likely to occur in the emergency department for both injury-related and non-injury-related reasons compared to children/adolescents (P < 0.001) or older adults (P < 0.001). Visits from black young adults were more likely than whites to occur in the emergency department (36.2% vs.19.2%; P < 0.001) rather than outpatient offices. The proportion of care delivered to black young adults in the emergency department increased between 1996 and 2006 (25.9% to 38.5%; P = 0.001 for trend). In 2006, nearly half (48.5%) of all health care provided to young black men was delivered through emergency departments. The urgency of young adult emergency visits was less than other age groups and few (4.7%) resulted in hospital admission. CONCLUSIONS A considerable amount of care provided to young adults is delivered through emergency departments. Trends suggest that young adults are increasingly relying on emergency departments for health care, while being seen for less urgent indications.
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Affiliation(s)
- Robert J Fortuna
- Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY 14609, USA.
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Lord B, Cui J, Kelly AM. The impact of patient sex on paramedic pain management in the prehospital setting. Am J Emerg Med 2009; 27:525-9. [PMID: 19497456 DOI: 10.1016/j.ajem.2008.04.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2008] [Revised: 04/06/2008] [Accepted: 04/08/2008] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting. METHODS This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, chi2 test, and logistic regression. RESULTS Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84). CONCLUSION Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.
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Affiliation(s)
- Bill Lord
- Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria 3800, Australia.
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Safdar B, Heins A, Homel P, Miner J, Neighbor M, DeSandre P, Todd KH. Impact of Physician and Patient Gender on Pain Management in the Emergency Department—A Multicenter Study. PAIN MEDICINE 2009; 10:364-72. [DOI: 10.1111/j.1526-4637.2008.00524.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009; 54:158-68.e1-4. [PMID: 19201064 DOI: 10.1016/j.annemergmed.2008.12.011] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 11/18/2008] [Accepted: 12/09/2008] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA.
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O'Connor AB, Lang VJ, Quill TE. Underdosing of Morphine in Comparison with Other Parenteral Opioids in an Acute Hospital: A Quality of Care Challenge. PAIN MEDICINE 2006; 7:299-307. [PMID: 16898939 DOI: 10.1111/j.1526-4637.2006.00183.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We observed that parenteral morphine is routinely prescribed in doses that are quite low in relation to doses of alternative parenteral opioids and in comparison with published effective doses and guidelines. The present study was undertaken to determine: 1) whether different parenteral opioids are dosed equivalently; 2) which patient factors affect equianalgesic dose; and 3) which patient factors affect opioid choice. DESIGN At a 750-bed tertiary care, teaching hospital in Rochester, NY, patients on the medical and surgical floors and in the emergency department who received one or more doses of parenteral morphine, hydromorphone, or meperidine were identified using computerized pharmacy records. A detailed chart review was performed for each patient, recording a variety of patient variables, which were then correlated separately with opioid dose and choice. RESULTS Of the 293 patients treated with boluses of a parenteral opioid, 75% received morphine at a median dose of only 2 mg. Patients prescribed hydromorphone or meperidine received median equianalgesic doses that were 6.7 and 3.4 times higher, respectively. A prescriber's choice of opioid affected the equianalgesic dose more significantly than any of the patient variables studied, including active home opioid use. CONCLUSIONS At our institution, parenteral morphine boluses are routinely given at relatively low doses compared with: 1) other opioids; 2) patient-controlled analgesic dosing; 3) usual doses required for analgesia from previous studies; and 4) a historical control in the same hospital. The reasons for this pattern are largely unexplained by patient variables. Inadequate bolus dosing of morphine may be a barrier to appropriate patient analgesia.
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Affiliation(s)
- Alec B O'Connor
- Hospital Medicine Division, and Department of Medicine, Palliative Care Program, University of Rochester, School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Abstract
OBJECTIVE Evaluate whether, in a primary care setting, Caucasians (C) and African Americans (AA) with moderately to severely disabling migraines differed in regards to: utilizing the health-care system for migraine care, migraine diagnosis and treatment, level of mistrust in the health-care system, perceived communication with their physician, and perceived migraine triggers. BACKGROUND Research has documented ethnic disparities in pain management. However, almost no research has been published concerning potential disparities in utilization, diagnosis, and/or treatment of migraine. It is also important to consider whether ethnic differences exist for trust and communication between patients and physicians, as these are essential when diagnosing and treating migraine. METHODS Adult patients with headache (n = 313) were recruited from primary care waiting rooms. Of these, 131 (AA = 77; C = 54) had migraine, moderate to severe headache-related disability, and provided socioeconomic status (SES) data. Participants completed measures of migraine disability (MIDAS), migraine health-care utilization, diagnosis and treatment history, mistrust of the medical community, patient-physician communication (PPC), and migraine triggers. Analysis of covariance (controlling for SES and recruitment site), chi-square, and Pearson product moment correlations were conducted. RESULTS African Americans were less likely to utilize the health-care setting for migraine treatment (AA = 46% vs. C = 72%, P < .001), to have been given a headache diagnosis (AA = 47% vs. C = 70%, P < .001), and to have been prescribed acute migraine medication (AA = 14% vs. C = 37%, P < .001). Migraine diagnosis was low for both groups, and <15% of all participants had been prescribed a migraine-specific medication or a migraine preventive medication despite suffering moderate to severe levels of migraine disability. African Americans had less trust in the medical community (P < .001, eta2 = 0.26) and less positive PPC (P < .001, eta2 = 0.11). Also, the lower the trust and communication, the less likely they were to have ever seen (or currently be seeing) a doctor for migraine care or to have been prescribed medication. CONCLUSIONS Migraine utilization, diagnosis, and treatment were low for both groups. However, this was especially true for African Americans, who also reported lower levels of trust and communication with doctors relative to Caucasians. The findings highlight the need for improved physician and patient education about migraine diagnosis and treatment, the importance of cultural variation in pain presentation, and the importance of communication when diagnosing and treating migraine.
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Affiliation(s)
- Robert A Nicholson
- Department of Family Medicine, Saint Louis University School of Medicine, MO 63104, USA
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Popenhagen MP. Collaborative practice. Undertreatment of pain and fears of addiction in pediatric chronic pain patients: how do we stop the problem? J SPEC PEDIATR NURS 2006; 11:61-7. [PMID: 16409507 DOI: 10.1111/j.1744-6155.2006.00044.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
This review investigates the use of ketamine for paediatric sedation and analgesia in the emergency department.
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Affiliation(s)
- M C Howes
- Emergency Department, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK.
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Pershad J, Godambe SA. Propofol for procedural sedation in the pediatric emergency department. J Emerg Med 2004; 27:11-4. [PMID: 15219297 DOI: 10.1016/j.jemermed.2004.02.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2003] [Revised: 12/04/2003] [Accepted: 02/05/2004] [Indexed: 10/26/2022]
Abstract
This retrospective case series reports our experience using propofol for procedural sedation in the Emergency Department over an 18-month period with 52 pediatric patients. Propofol sedation was performed successfully in all children (mean age, 10.2 years; range 0.7-17.4 years). Indications for sedation included orthopedic manipulation, incision and drainage of abscess, sexual assault examination, laceration repair, and non-invasive imaging studies. The mean dose administered with the intermittent bolus and continuous infusion methods of delivery was 4.25 mg/kg (+/- 1.86) and 8.3 mg/kg/h, respectively. The mean recovery time was 27.1 min (+/- 15.84). No patient required assisted ventilation or developed clinically significant hypotension. Respiratory depression requiring airway repositioning or supplemental oxygen was noted in 5.8% (3/52) patients. Propofol is a reasonable alternative to facilitate sedation for a range of procedures performed in a busy Pediatric Emergency Department.
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Affiliation(s)
- Jay Pershad
- Division of Critical Care & Emergency Services, Department of Pediatrics, LeBonheur Children's Medical Center, 50 N. Dunlap Street, Memphis, TN 38103, USA
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Thomas SH, Andruszkiewicz LM. Ongoing visual analog score display improves Emergency Department pain care. J Emerg Med 2004; 26:389-94. [PMID: 15093842 DOI: 10.1016/j.jemermed.2003.11.020] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2003] [Revised: 09/15/2003] [Accepted: 11/03/2003] [Indexed: 11/26/2022]
Abstract
The study purpose was to test two methods of pain assessment and display: ongoing (11 times over 2 h) visual analog scale (VAS) determination with data tabulation in the ED chart (Tabulation group), and similar VAS assessments with display of the information at the head of the ED bed (Graph group). A Control group had initial and 2-h VAS ascertainments charted (not graphed). Tertiary-care university-affiliated ED patients were randomized into the three groups and pain care outcomes assessed. Compared to Controls, those in the Graph group had the following findings (p < 0.05): 1) treating physicians more likely aware of initial and final VAS scores, 2) earlier analgesia, 3) likelier perception (by patients and physicians) that VAS was useful and likelier patient perception that pain care was adequate. Tabulation group results were intermediate to those of Control and Graph patients. The data support further investigation of VAS display as a means of improving ED pain assessment.
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Affiliation(s)
- Stephen H Thomas
- Department of Emergency Services, Massachusetts General Hospital, Boston 02114, USA
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Bassett KE, Anderson JL, Pribble CG, Guenther E. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 2003; 42:773-82. [PMID: 14634602 DOI: 10.1016/s0196-0644(03)00619-x] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE We determine the safety and efficacy of propofol sedation for painful procedures in the emergency department (ED). METHODS A consecutive case series of propofol sedations for painful procedures in the ED of a tertiary care pediatric hospital from July 2000 to July 2002 was performed. A sedation protocol was followed. Propofol was administered in a bolus of 1 mg/kg, followed by additional doses of 0.5 mg/kg. Narcotics were administered 1 minute before propofol administration. Adverse events were documented, as were the sedation duration, recovery time from sedation, and total time in the ED. RESULTS Three hundred ninety-three discrete sedation events with propofol were analyzed. Procedures consisted of the following: fracture reductions (94%), reduction of joint dislocations (4%), spica cast placement (2%), and ocular examination after an ocular burn (0.3%). The median propofol dose was 2.7 mg/kg. Ninety-two percent of patients had a transient (<or=2 minutes) decrease in systolic blood pressure without clinical signs of poor perfusion. Nineteen (5%) patients had hypoxia, 11 (3%) patients required airway repositioning or jaw-thrust maneuvers, and 3 (0.8%) patients required bag-valve-mask ventilation. No patient required endotracheal intubation. CONCLUSION Propofol sedation is efficacious and can be used safely in the ED setting under the guidance of a protocol. Transient cardiopulmonary depression occurs, which requires vigilant monitoring by highly skilled practitioners. Propofol is well suited for short, painful procedures in the ED setting.
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Affiliation(s)
- Kathlene E Bassett
- Division of Pediatric Emergency Medicine, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City 84102, USA.
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