Improving acute pain management in emergency medicine

Musculoskeletal Physiotherapy in the Emergency Department – Evaluation of a New Physiotherapy Service in a Swiss University Hospital

Background Many countries report a significant increase in emergency department (ED) visits. Patients with musculoskeletal disorders account for a large proportion of non-urgent cases.

Objective Characterization and evaluation of a new service that provides immediate access to physiotherapy for patients in the ED.

Method To characterize a new service at the Department of Emergency Medicine, Bern University Hospital, and to evaluate first experiences with it, a mixed methods approach was chosen. Data was collected from the electronic patient file and from a logbook kept by the physiotherapists. In addition, guideline-based interviews with involved health care staff were conducted.

Results During the 63 days of the pilot study 79 patients were treated by physiotherapists. The most frequently reported patient complaint was back pain (47 %). Interventions included taking the medical history, performing manual tests and multimodal treatment and developing recommendations for further treatment. In 59 % of patients no medical imaging and in 58 % no additional physiotherapy was prescribed. Patients rated the physiotherapeutic service as very good or excellent (88 %). Physiotherapy was experienced as positive and appreciated by the other professions, and all interviewees emphasized the added value for patients.

Conclusion The pilot study indicates that the physiotherapeutic consultation service has the potential to improve quality of care. The findings of this study are therefore valuable when considering the introduction of such a service in an ED.

Topical Capsaicin for the Treatment of Neuropathic Pain

BACKGROUND

Neuropathic pain (NP) is an egregious problem worldwide. Due to the side-effects of oral drugs, drugs delivered directly to the affected area of pain are preferred.

OBJECTIVE

Capsaicin, a chemical compound isolated from chili peppers, is used as an analgesic in topical ointments and dermal patches to alleviate pain. Objective of the study is to review the application and functionality of topical capsaicin in treatment of neuropathic pain.

DATA SOURCES

To systematically review capsaicin's functions on NP, we retrieved articles from the PubMed database published in the last ten years.

STUDY ELIGIBILITY CRITERIA

The inclusion criteria were capsaicin and the use of capsaicin for the treatment of NP; on the other hand, articles were excluded according to the mentioned criteria such as abstracts, articles written in any language other than English, incomplete articles, and conference papers.

PARTICIPANTS AND INTERVENTIONS

Out of 265 articles, 108 articles were selected after filtering through the inclusion and exclusion criteria. The data and knowledge currently existing for capsaicin treatment in NP are summarized.

RESULTS

This review indicates that capsaicin effectively improves NP treatment without affecting the motor and large nerve fibres involved in sensory function. Transient receptor potential channel vanilloid type 1 (TRPV1) is the capsaicin receptor expressed in central and peripheral terminals of a sensitive primary nerve cell. Conclusions and implications of key findings: Topical capsaicin has a sensible safety profile and is effective in reducing NP. Therefore, studies over the last decade suggest that capsaicin might be a potential drug for NP treatment.

Oligoanalgesia in the emergency setting - An Indian review

Pain is a result of nociceptive tissue injury and results in acute and chronic impact to patients. Acute pain management is the need of the hour as untreated or under-treated pain may progress to chronic pain. Pain irrespective of its temporality causes a negative impact on the quality of life of the patients. Many Indian emergency settings are not adequately equipped to handle pain due to the heavy load of patients and the lack of awareness about the pain management guidelines. This leads to undertreatment of pain or 'oligoanalgesia'. A pain management protocol can help prevent oligoanalgesia in an emergency setting. Proper utilization of triage systems that incorporate pain as one of the vital signs is necessary. The categorization of pain with the help of a pain scale helps determine the severity of pain and its appropriate management. Pain management is an ongoing process that does not end with the discharge of the patient. Post discharge management of pain is also an important factor to prevent chronic pain. This may involve various modalities for pain management under the preview of multimodal management of pain.

Higher daily pain severity after emergency department visits is associated with lower return-to-work rates

BACKGROUND

Pain can impair functional status, including a patient's ability to return to work. The purpose of this study was to determine whether there was an association between pain levels and return-to-work status during the first 4 days post-ED discharge in ED patients seen for undifferentiated acute pain.

METHODS

This secondary analysis of data from the Acute Management of Pain from the Emergency Department (AMPED) registry included patients who reported working either full-time or part-time. We used Cox regression models to examine the association between daily self-reported minimum and maximum pain scores and first return to work. We used repeated measures logistic regression models to examine the association between daily minimum and maximum pain scores and daily return-to-work status.

RESULTS

Of the 610 employed patients, 481 (78.9%) were employed full-time and 129 (21.1%) part-time. The average delay in returning to work after ED visit was 2.4 days. For all models, higher minimum and maximum daily pain scores predicted lower daily return-to-work rates in the first four days post-ED discharge. The adjusted hazards ratios for first return to work were 0.91 (0.87, 0.96) and 0.93 (0.89, 0.97), while the adjusted odds ratios for daily return-to-work status were 0.80 (0.75, 0.85) and 0.88 (0.83, 0.93) for every one-point increase in minimum and maximum pain scores, respectively.

CONCLUSION

Higher daily pain severity is associated with decreased return-to-work after ED visits for acute pain, highlighting the importance of adequate discharge pain management from the ED.

Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN)

PURPOSE

Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.

METHODS

We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.

RESULTS

The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).

CONCLUSIONS

Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Nurses' perceptions of pain management adequacy in mechanically ventilated patients

AIMS AND OBJECTIVES

To examine how nurses' knowledge of behaviours indicating pain in mechanically ventilated patients and self-perceived collaboration between nurses and physicians affects the adequacy of departmental pain management.

BACKGROUND

Pain management is a vital factor of medical treatment in a hospital setting. Inadequate pain management requires attention both from a patient-focused perspective and from a departmental one. It would be particularly troubling in the case of inadequate pain management of mechanically ventilated patients.

DESIGN

The study utilised a cross-sectional design. The instruments developed were validated by a focus group of 25 pain management nurses, who reviewed the questionnaire for face validity, feasibility and comprehensibility, and who did not participate in the study. The questionnaire was revised, readjusted and formulated based on their responses and comments.

METHODS

A self-administered questionnaire administered in Israel with a convenience sample of 187 registered nurses (RN) from internal medicine and surgical departments and ICUs. Data were collected during February-May 2015. The "STROBE" EQUATOR checklist was used.

RESULTS

Nurses working in the ICU scored significantly higher on knowledge of behaviours indicating pain in mechanically ventilated patients and on self-perceived collaboration between nurses and physicians. Self-perceived collaboration between physicians and nurses was positively correlated with perceived departmental pain treatment adequacy. Self-perceived collaboration between nurses and physicians, knowledge of behaviours indicating pain in mechanically ventilated patients and seniority (with a borderline significance) explained 27% of the variance of perceived departmental pain management.

CONCLUSION

Nurses' knowledge of behaviours indicating pain in mechanically ventilated patients, as well as self-perceived collaboration between nurses and physicians, promotes reported adequate pain management.

RELEVANCE TO CLINICAL PRACTICE

Pain management would benefit from being conducted as a well-performed interprofessional self-perceived collaborative practice. Knowledgeable nurses tend to critically assess the level of departmental pain management.

A fixed nitrous oxide/oxygen mixture as an analgesic for trauma patients in emergency department: study protocol for a randomized, controlled trial

BACKGROUND

Acute pain is always the most common complaint in Emergency Department admissions and options for analgesia are limited. Nitrous oxide/oxygen possess many properties showing it may be an ideal analgesic method for the Emergency Department; it is quick-acting, well-tolerated, and does not mask signs and symptoms. The aim of this study is to evaluate the safety and analgesic effect of the fixed nitrous oxide/oxygen mixture for trauma patients in a busy emergency environment.

METHODS

The randomized, double-blind, prospective, placebo-controlled study will be carried out in the Emergency Department of General Hospital of Ningxia Medical University. The target research objects are trauma patients who present to the Emergency Department and report moderate to severe intensities of acute pain. A total of 90 patients will be recruited and randomly assigned into the treatment and control group. The treatment group will receive conventional pain treatment plus nitrous oxide/oxygen mixture and the control group will receive conventional pain treatment plus oxygen. Neither patients, nor investigators, nor data collectors will know the nature of the gas mixture in each cylinder and the randomization list. Outcomes will be monitored at baseline(T0), 5 min (T1), and 15 min (T2) after the beginning of intervention and at 5 min post intervention (T3) for each group. The primary outcome is the level of pain relief after the initial administering of the intervention at T1, T2, and T3. Secondary outcomes include adverse events, physiological parameters, total time of the gas administration, satisfaction from both patients and healthcare professionals, and the acceptance of patients.

DISCUSSION

Our previous studies suggested that a fixed nitrous oxide/oxygen mixture was an efficacious analgesic for the management of burning dressing pain and breakthrough cancer pain. The results of this study will provide a more in-depth understanding of the effect of this gas. If this treatment proves successful, it could help to generate preliminary guidelines and be implemented widely in trauma patients with pain in Emergency Departments.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR-INR-16007807 . Registered on 21 January 2016.

Educational Intervention Effect on Pain Management Quality in Emergency Department; a Clinical Audit

Introduction

Pain is a frequent complaint of patients who are referred to the emergency department (ED), which is ignored or mismanaged and, almost always, approached in terms of determining the cause of pain instead of pain management. Pain management is a challenging issue in the ED.

Objective

This study was conducted to determine the effect of emergency resident's education about pain assessment and pain-relief drugs in the improvement in pain management.

Method

A clinical audit was carried out during the year 2015 in the ED of Imam Hossein Hospital, Tehran, Iran. All patients over 16-year-old who had been complaining of pain or another complaint that included pain were eligible. Data were collected using a preformed checklist. One senior emergency medicine resident was responsible for filling the checklist. In the first phase, patients were enrolled into the study and were divided into two groups according to whether they had or did not have a pain management order. In the second phase, the first- and second-year emergency medicine residents were trained during the various classes that they were required to attend, through a workshop conducted by experienced professors, and based on existing valid guidelines. In the third phase, patients were enrolled into the study, and the same checklists were completed.

Results

A total of 803 patients (401 before training and 402 after) were assessed. The mean age of the patients before and after training of the residents was 59.19 ± 44.45 and 40.24 ± 19.40 years, respectively. The demographic characteristics of patients were not significantly different before and after the training period (p > 0.05). The most common cause of pain was soft tissue injury, both before (36.3%) and after training (34.3%). The most frequent drug that was administered for pain control was morphine, both before (62.5%) and after (41.4%) training. Although the number of patients with moderate pain intensity was higher during the after-training period, pain control quality was described to be better in this group and success rate of pain control was significantly increased after training (p < 0.001).

Conclusion

Findings from the present study showed that there was a significant deficiency in pain management of the admitted patients, and the most common reason for this was the physician's fear of the drug's side effects. However, significant progress was seen after the training regarding pain management process in ED.

Quantitative sensory testing measures individual pain responses in emergency department patients

Background

Refining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients.

Materials and methods

In three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests.

Results

First, all QST measures had high inter-rater reliability and test–retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen’s d_z 0.10–0.19). Verbal pain scores (0–10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen’s d_z 0.97) but did not covary with the changes in PPT and PPR (r=0.05–0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen’s d_z 0.26–0.43) or with baseline hyperalgesia (Cohen’s d_z 0.40–0.88).

Conclusion

QST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.