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Hughes JA, Wu Y, Jones L, Douglas C, Brown N, Hazelwood S, Lyrstedt AL, Jarugula R, Chu K, Nguyen A. Analyzing pain patterns in the emergency department: Leveraging clinical text deep learning models for real-world insights. Int J Med Inform 2024; 190:105544. [PMID: 39003790 DOI: 10.1016/j.ijmedinf.2024.105544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/09/2024] [Accepted: 07/06/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To determine the incidence of patients presenting in pain to a large Australian inner-city emergency department (ED) using a clinical text deep learning algorithm. MATERIALS AND METHODS A fine-tuned, domain-specific, transformer-based clinical text deep learning model was used to interpret free-text nursing assessments in the electronic medical records of 235,789 adult presentations to the ED over a three-year period. The model classified presentations according to whether the patient had pain on arrival at the ED. Interrupted time series analysis was used to determine the incidence of pain in patients on arrival over time. We described the changes in the population characteristics and incidence of patients with pain on arrival occurring with the start of the Covid-19 pandemic. RESULTS 55.16% (95%CI 54.95%-55.36%) of all patients presenting to this ED had pain on arrival. There were differences in demographics and arrival and departure patterns between patients with and without pain. The Covid-19 pandemic initially precipitated a decrease followed by a sharp, sustained rise in pain on arrival, with concurrent changes to the population arriving in pain and their treatment. DISCUSSION Applying a clinical text deep learning model has successfully identified the incidence of pain on arrival. It represents an automated, reproducible mechanism to identify pain from routinely collected medical records. The description of this population and their treatment forms the basis of intervention to improve care for patients with pain. The combination of the clinical text deep learning models and interrupted time series analysis has reported on the effects of the Covid-19 pandemic on pain care in the ED, outlining a methodology to assess the impact of significant events or interventions on pain care in the ED. CONCLUSION Applying a novel deep learning approach to identifying pain guides methodological approaches to evaluating pain care interventions in the ED, giving previously unavailable population-level insights.
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Affiliation(s)
- James A Hughes
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Yutong Wu
- Australian e-Health Research Centre, CSIRO, Brisbane, Australia
| | - Lee Jones
- QIMR-Berghoffer Research Institute, Brisbane, Australia
| | - Clint Douglas
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Metro North Health, Queensland, Australia
| | - Nathan Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Sarah Hazelwood
- Emergency Department, The Prince Charles Hospital, Queensland, Australia
| | - Anna-Lisa Lyrstedt
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Rajeev Jarugula
- Emergency Department, The Prince Charles Hospital, Queensland, Australia
| | - Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Anthony Nguyen
- Australian e-Health Research Centre, CSIRO, Brisbane, Australia
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Sadasivam S A, Kumaran A, Manu Ayyan S, Sindujaa SN. Improving door-to-analgesia timing in musculoskeletal injuries in an academic emergency department in India: a quality improvement project. BMJ Open Qual 2024; 13:e002815. [PMID: 38834372 PMCID: PMC11163673 DOI: 10.1136/bmjoq-2024-002815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Pain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many EDs face challenges in pain management and present opportunities for improvement. This initiative aimed to expedite the administration of the first analgesic in patients with musculoskeletal pain in the ED. LOCAL PROBLEM Observations within our ED revealed that patients with musculoskeletal injuries triaged to yellow or green areas experienced prolonged waiting times, leading to delayed analgesic administration, thereby adversely affecting clinical care and patient satisfaction. SPECIFIC AIM The aim of our quality improvement (QI) project was to reduce the time to administration of first analgesia by 30% from baseline, in patients with musculoskeletal injuries presenting to our academic ED, in a period of 8 weeks after the baseline phase. METHODS A multidisciplinary QI team systematically applied Point-of-Care Quality Improvement and Plan-Do-Study-Act (PDSA) cycle methodologies. Process mapping and fishbone analyses identified the challenges in analgesia administration. Targeted interventions were iteratively refined through PDSA cycles. INTERVENTIONS Interventions such as pain score documentation at triage, fast-tracking of patients with moderate-to-severe pain, resident awareness sessions, a pain management protocol and prescription audits were executed during the PDSA cycles. Successful elements were reinforced and adjustments were made to address the identified challenges. RESULTS The median door-to-analgesia timing during the baseline phase was 55.5 min (IQR, 25.75-108 min). During the postintervention phase, the median was significantly reduced to 15 min (IQR, 5-37 min), exceeding the anticipated outcomes and indicating a substantial 73% reduction (p value <0.001) from baseline. CONCLUSION Implementing simple change ideas resulted in a substantial improvement in door-to-analgesia timing within the ED. These findings significantly contribute to ongoing discussions on the optimisation of pain management in emergency care.
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Affiliation(s)
- Anuusha Sadasivam S
- Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Aswin Kumaran
- Emergency Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - S Manu Ayyan
- Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - S N Sindujaa
- Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Langford R, Viscusi ER, Morte A, Cebrecos J, Sust M, Giménez-Arnau JM, de Leon-Casasola O. Efficacy of Co-Crystal of Tramadol-Celecoxib (CTC) in Patients with Acute Moderate-to-Severe Pain: A Pooled Analysis of Data from Two Phase 3 Randomized Clinical Trials. Drugs R D 2024; 24:239-252. [PMID: 38874739 PMCID: PMC11315862 DOI: 10.1007/s40268-024-00469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND AND OBJECTIVES New acute pain medications are needed that provide effective analgesia while minimizing side effects and opioid exposure. Clinical trials of co-crystal of tramadol-celecoxib (CTC) have demonstrated an improved benefit/risk profile versus tramadol or celecoxib alone. We pooled data from two phase 3 clinical trials to evaluate the efficacy of CTC 200 mg twice daily (BID) in acute moderate-to-severe pain. METHODS Efficacy data were pooled from STARDOM1 [acute pain following oral surgery (NCT02982161)] and ESTEVE-SUSA-301 [acute pain following bunionectomy (NCT03108482)]. The primary efficacy outcome was sum of pain intensity difference from 0 to 48 h (SPID0-48). RESULTS A total of 344 patients received CTC 200 mg BID, 342 received tramadol 50 or 100 mg four times a day, 181 received celecoxib 100 mg BID, and 172 received placebo. The least-squares mean difference in SPID0-48 was -21.8 (p = 0.002) for CTC versus tramadol and -72.8 (p < 0.001) for CTC versus placebo. A similar pattern of SPID0-48 was observed with CTC versus comparator whether patients had moderate or severe pain at baseline. Reduction in pain intensity was faster and reached mild intensity earlier with CTC versus comparators. Patients were significantly (p ≤ 0.005) less likely to receive rescue medication within 4 or 48 h with CTC compared with tramadol or placebo. CONCLUSIONS This pooled analysis reinforces the efficacy profile of CTC versus tramadol and, given that CTC permits lower daily tramadol dosing and thereby reduces unnecessary opioid use, this highlights its improved benefit/risk profile and its potential for the management of moderate-to-severe pain.
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Affiliation(s)
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | | | | | - Oscar de Leon-Casasola
- Department of Anesthesiology, University of Buffalo/Roswell Park Cancer Institute, Buffalo, NY, USA
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Lvovschi VE, Carrouel F, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription. Front Public Health 2024; 12:1352833. [PMID: 38454991 PMCID: PMC10918692 DOI: 10.3389/fpubh.2024.1352833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Background Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. Objective This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. Methods A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. Results A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. Conclusion This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.
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Affiliation(s)
- Virginie E. Lvovschi
- Emergency Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratory “Research on Healthcare Performance” (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Florence Carrouel
- Laboratory “Health, Systemic, Process” (P2S), UR4129, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Karl Hermann
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
| | - Frédéric Lapostolle
- SAMU 93, UF Research and Teaching quality, Avicenne Hospital-APHP, Bobigny, France
- INSERM U942, Sorbonne Paris Cité, Paris 13 University, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, Rouen, France
| | - Marie-Pierre Tavolacci
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
- Univ Rouen Normandie, UMR1073 ADEN, Rouen, France
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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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Carrouel F, Dziadzko M, Grégoire C, Galinski M, Dussart C, Lvovschi VE. Relevance of early management by proton-pump inhibitor in acute upper gastro-intestinal tract disorder: A scoping review. Biomed Pharmacother 2023; 167:115523. [PMID: 37742610 DOI: 10.1016/j.biopha.2023.115523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Proton-pump inhibitors (PPI) are frequently used in the emergency and general practice settings in several clinical presentations linked to acute upper gastro-intestinal tract disorders as abdominal or chest pain without recommendations. OBJECTIVE The aim of this scoping review was to assess pain reduction, diagnostic performance, and safety in the first 24 h-management in primary care or emergency medicine. METHODS Search was realized by 2 independent reviewers in PubMed, Embase, and Web of Science following PRISMA-ScR guidelines. Only original articles or systematic reviews in English were included. Studies about chronic and/or bleeding conditions, therapeutic cocktails and studies without pain evaluation were excluded. Two methodologies were used for bias estimation. RESULTS From 4442 titles, 79 full-text articles were assessed, and 9 were included. There is no strong evidence supporting the use of PPI as a first line analgesic or diagnostic test in acute syndromes linked to acute upper gastro-intestinal tract disorder. A small effect in pain reduction was retrieved in patients with low pain scores. A poor additional value in patients with gastric reflux, and a low specificity compared to other diagnostic tests were observed. A short-term PPI administration appears to be safe with low risk of serious allergic reactions, and poor adverse effects (moderate evidence). CONCLUSION Although PPIs may contribute to the multimodal analgesia in acute settings, with few and/or minor side effects, no recommendation can be drawn for their use as a primary analgesic. Data regarding the relevance of the PPI test are much less clear, no data regarding care pathways are available.
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Affiliation(s)
- Florence Carrouel
- Laboratory "Health, Systemic, Process" (P2S), UR4129, University Claude Bernard, Lyon 1, University of Lyon, 69008 Lyon, France.
| | - Mikhail Dziadzko
- Laboratory "Research on Healthcare Performance" (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, University of Lyon, 69008 Lyon, France; Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Charles Grégoire
- Emergency Department, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium; Institute of neuroscience (IoNS), UCLouvain, Brussels, Belgium
| | - Michel Galinski
- Pôle Urgences adultes - SAMU, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France; INSERM U1219, Bordeaux Population Health research center, IETO team, Bordeaux university - ISPED, France
| | - Claude Dussart
- Laboratory "Health, Systemic, Process" (P2S), UR4129, University Claude Bernard, Lyon 1, University of Lyon, 69008 Lyon, France
| | - Virginie-Eve Lvovschi
- Laboratory "Research on Healthcare Performance" (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, University of Lyon, 69008 Lyon, France; Emergency Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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Doneddu PE, Pensato U, Iorfida A, Alberti C, Nobile-Orazio E, Fabbri A, Voza A. Neuropathic Pain in the Emergency Setting: Diagnosis and Management. J Clin Med 2023; 12:6028. [PMID: 37762968 PMCID: PMC10531819 DOI: 10.3390/jcm12186028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Neuropathic pain, traditionally considered a chronic condition, is increasingly encountered in the emergency department (ED), accounting for approximately 20% of patients presenting with pain. Understanding the physiology and key clinical presentations of neuropathic pain is crucial for ED physicians to provide optimal treatment. While diagnosing neuropathic pain can be challenging, emphasis should be placed on obtaining a comprehensive medical history and conducting a thorough clinical examination. Patients often describe neuropathic pain as a burning or shock-like sensation, leading them to seek care in the ED after ineffective relief from common analgesics such as paracetamol and NSAIDs. Collaboration between emergency medicine specialists, neurologists, and pain management experts can contribute to the development of evidence-based guidelines specifically tailored for the emergency department setting. This article provides a concise overview of the common clinical manifestations of neuropathic pain that may prompt patients to seek emergency care.
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Affiliation(s)
- Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
| | - Umberto Pensato
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Alessandra Iorfida
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Claudia Alberti
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, 20133 Milano, MI, Italy
| | - Andrea Fabbri
- Emergency Department AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, FC, Italy
| | - Antonio Voza
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
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Gregoire C, Charier D, de Bergeyck R, Mouraux A, Van Ouytsel F, Lambert R, Zhou N, Lavand'homme P, Penaloza A, Pickering G. Comparison between pupillometry and numeric pain rating scale for pain assessments in communicating adult patients in the emergency department. Eur J Pain 2023; 27:952-960. [PMID: 37303073 DOI: 10.1002/ejp.2137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The adequate assessment of pain in the emergency department (ED) can be challenging. Two dynamic pupillary measures used in conscious subjects after a surgical procedure were previously shown to correlate to the magnitude of ongoing pain. The objective of this study was to test the ability of dynamic measures derived from pupillometry to evaluate pain intensity in conscious adult patients admitted to the ED. METHODS This prospective, interventional, single-centre study was performed between August 2021 and January 2022 (NCT05019898). An assessment of self-reported pain intensity was performed on ED admission by the triage nurse using a numeric rating scale (NRS). This was followed by two dynamic measures derived from pupillometry that were previously correlated with pain perception: the pupillary unrest under ambient light (PUAL) and the pupillary light reflex (PLR). RESULTS Among the 313 analysed patients, the median age was 41 years, and 52% were women. No correlation was found between self-reported pain ratings and PUAL (r = 0.007) or PLR (baseline diameter r = -0.048; decrease r = 0.024; latency r = 0.019; slope = -0.051). Similarly, the pupillometry measures could not discriminate patients with moderate to severe pain (defined as NRS ≥4). CONCLUSIONS Pupillometry does not appear to be an effective tool to evaluate pain in the ED environment. Indeed, too many factors influencing the sympathetic system-and thus the dynamic pupillary measures-are not controllable in the ED. SIGNIFICANCE Pupillometry does not appear to be an effective tool to evaluate pain in the ED environment. There are several possible explanations for these negative results. The factors influencing the sympathetic system-and thus the PD fluctuations-are controllable in the postoperative period but not in the ED (e.g. full bladder, hypothermia). In addition, numerous psychological phenomena can impact pupillometry measurements such as emotional reactions or cognitive tasks. These phenomena are particularly difficult to control in the ED environment.
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Affiliation(s)
- Charles Gregoire
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience (IoNS), UCLouvain, Brussels, Belgium
| | - David Charier
- Department of Anesthesiology, University Jean Monnet, University Hospital of Saint-Etienne, INSERM, Saint-Etienne, France
| | - Romane de Bergeyck
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - André Mouraux
- Institute of Neuroscience (IoNS), UCLouvain, Brussels, Belgium
| | - Floor Van Ouytsel
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Romain Lambert
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Nicole Zhou
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Patricia Lavand'homme
- Anesthesiology Department, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gisele Pickering
- Clinical Pharmacology Department, PIC/CIC Inserm 1405-University Hospital CHU, Clermont-Ferrand, France
- Fundamental and Clinical Pharmacology of Pain, Faculty of Medicine, Clermont Auvergne University, Clermont-Ferrand, France
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Schmutz T, Le Terrier C, Ribordy V, Iglesias K, Guechi Y. The Effect of Positive Therapeutic Communication on Pain (POPAIN) and Anxiety During Arterial Blood Gas Standardized Procedures in the Emergency Department Compared to Traditional Communication: Protocol for a Monocentric Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e42043. [PMID: 37310776 DOI: 10.2196/42043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND In the emergency department (ED), medical procedures, such as arterial blood gas (ABG) testing, can cause pain and high stress levels. However, ABG testing is a routine procedure assessing the severity of the patient's condition. To reduce the pain of ABG, several methods have been investigated without significant difference in pain perception. Communication, a key element of care, has shown a significant effect on pain perception. A positive communication strategy, including positive, kind, or reassuring words, can reduce pain perception, while negative words can raise this perception, causing discomfort, known as the "nocebo effect." Although some studies have compared the impact of verbal attitudes, particularly in anesthesia and mainly with staff already trained in hypnosis, to the best of our knowledge, none have investigated the effect of communication in the emergency setting, where patients may be more suggestible to the words used. OBJECTIVE In this study, we will investigate the effect of positive therapeutic communication on pain, anxiety, discomfort, and global satisfaction in patients requiring ABG compared to nocebo and neutral communication. METHODS A single-center, double-blind randomized controlled trial (RCT) with 3 parallel arms will be conducted with 249 patients requiring ABG during their ED visit. Patients will be randomly assigned to 1 of 3 groups before receiving ABG: positive communication group, negative communication (nocebo) group, or neutral communication (neutral) group. The communication and the words used by the physicians during hygiene preparation, artery location, and puncture will be imposed in each group. The study will be proposed to each patient corresponding to the inclusion criteria. The physicians will not be trained in hypnosis or in positive therapeutic communication. The procedure will be recorded with audio recorders to test its quality. Intention-to-treat analysis will be performed. The primary endpoint is the onset of pain. The secondary outcomes are patient comfort, patient anxiety, and global satisfaction of the patient with the communication strategy used. RESULTS On average, 2000 ABG procedures are performed each year in the EDs of hospitals. In this study, 249 patients are expected to be included. With a projected positive response rate of 80%, we intend to include 25 (10%) patients per month. The inclusion period began in April 2023 and will run until July 2024. We hope to publish the results of the study during the fall of 2024. CONCLUSIONS To the best of our knowledge, this study is the first RCT assessing the use of positive communication on pain and anxiety in patients undergoing the ABG procedure in the ED. A reduction in pain, discomfort, and anxiety is expected when using positive communication. If the results are positive, this could be useful to the medical community and encourage clinicians to monitor their communication during care. TRIAL REGISTRATION ClinicalTrials.gov NCT05434169; https://clinicaltrials.gov/ct2/show/NCT05434169. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/42043.
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Affiliation(s)
- Thomas Schmutz
- Department of Emergency Medicine, Fribourg Hospital, Fribourg Faculty of Medicine, Fribourg University, Fribourg, Switzerland
| | - Christophe Le Terrier
- Department of Emergency Medicine, Fribourg Hospital, Fribourg Faculty of Medicine, Fribourg University, Fribourg, Switzerland
- Division of Intensive Care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Vincent Ribordy
- Department of Emergency Medicine, Fribourg Hospital, Fribourg Faculty of Medicine, Fribourg University, Fribourg, Switzerland
| | - Katia Iglesias
- School of Health Sciences, HES-SO University of Applied Sciences and Arts of Western Switzerland, Fribourg, Switzerland
| | - Youcef Guechi
- Department of Emergency Medicine, Fribourg Hospital, Fribourg Faculty of Medicine, Fribourg University, Fribourg, Switzerland
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Ghazali DA, Bouzid D, Frachon A, Ait-Abdesselam S, Kenway P, Choquet C, Casalino E. Pain Self-Management with Inhaled Methoxyflurane by Emergency Department Trauma Patients: A Prospective, Interventional, Single-Center Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6107. [PMID: 37372694 DOI: 10.3390/ijerph20126107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has led to overcrowding in many emergency departments (EDs). The present single-center, prospective, interventional study (conducted at Bichat University Medical Center (Paris, France)) was designed to assess the impact of self-administered, inhaled, low-dose methoxyflurane on trauma pain in a pre-ED fast-track zone dedicated to the management of lower-acuity non-COVID-19 patients. In the first phase of the study, the control group consisted of patients with mild-to-moderate trauma pain, for whom the triage nurse initiated pain management (based on the World Health Organization (WHO)'s analgesic ladder). In the second phase, the intervention group consisted of similar patients who self-administered methoxyflurane as an adjuvant to the standard analgesic ladder. The primary endpoint was the numerical pain rating scale (NPRS) score (from 0 to 10) recorded at different time points during the patient's care (T0: arrival in the ED, T1: exit from the triage box, T2: in the radiology department, T3: clinical examination, and T4: discharge from the ED). The level of agreement between the NPRS and the WHO analgesic ladder was assessed by the calculation of Cohen's kappa. Pairwise comparisons of continuous variables were performed with Student's t-test or a non-parametric Mann-Whitney U test. Changes over time in the NPRS were analyzed in an analysis of variance (with Scheffe's post hoc test if a pairwise comparison was significant) or a non-parametric Kruskal-Wallis H test. In all, 268 and 252 patients were included in the control and intervention groups, respectively. The two groups had similar characteristics. The level of agreement between the NPRS score and the analgesic ladder was high in both the control and intervention groups (Cohen's kappa: 0.74 and 0.70, respectively). The NPRS score decreased significantly between T0 and T4 in both groups (p < 0.001), but the decrease between T2 and T4 was significantly greater in the intervention group (p < 0.001). The proportion of patients still in pain on discharge was significantly lower in the intervention group than in the control group (p = 0.001). In conclusion, a combination of self-administered methoxyflurane and the WHO analgesic ladder improves pain management in the ED.
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Affiliation(s)
- Daniel Aiham Ghazali
- Emergency Department and Emergency Medical Services, Amiens University Medical Center, 1 Rond-Point du Professeur Christian Cabrol, 80000 Amiens, France
- DREAMS (Department of Research in Emergency Medicine and Simulation) Research Unit, Amiens University Medical Center and Jules Verne University of Picardie, 80000 Amiens, France
- IAME "Infection, Antimicrobials, Modelling, Evolution" Research Unit, INSERM UMR1137, University of Paris Cité, 75018 Paris, France
| | - Donia Bouzid
- IAME "Infection, Antimicrobials, Modelling, Evolution" Research Unit, INSERM UMR1137, University of Paris Cité, 75018 Paris, France
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | - Alix Frachon
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | | | - Philippe Kenway
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | - Christophe Choquet
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
| | - Enrique Casalino
- IAME "Infection, Antimicrobials, Modelling, Evolution" Research Unit, INSERM UMR1137, University of Paris Cité, 75018 Paris, France
- Emergency Department, Bichat University Medical Center, 75018 Paris, France
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11
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Hughes JA, Douglas C, Jones L, Brown NJ, Nguyen A, Jarugula R, Lyrstedt AL, Hazelwood S, Wu Y, Chu K. Identifying patients presenting in pain to the adult emergency department: A binary classification task and description of prevalence. Int Emerg Nurs 2023. [DOI: 10.1016/j.ienj.2023.101272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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12
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Müller M, Passegger O, Zehnder P, Hanschen M, Muggleton E, Biberthaler P, Wegmann H, Greve F. [Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:456-462. [PMID: 37084002 DOI: 10.1007/s00113-023-01315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D‑A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice. MATERIAL AND METHODS In the D‑A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used. RESULTS The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D‑A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D‑A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26). DISCUSSION RA procedures are still performed too rarely following PFF in emergency departments in the D‑A-CH area. In international comparison with GB there is potential for improvement.
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Affiliation(s)
- M Müller
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - O Passegger
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Zehnder
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - M Hanschen
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - E Muggleton
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik für Anästhesiologie, Technische Universität München, München, Deutschland
- Anästhesie am Josephinum, Klinik Josephinum, München, Deutschland
| | - P Biberthaler
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H Wegmann
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - F Greve
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Bosso L, Espejo T, Taffé P, Caillet-Bois D, Christen T, Berna C, Hugli O. Analgesic and Anxiolytic Effects of Virtual Reality During Minor Procedures in an Emergency Department: A Randomized Controlled Study. Ann Emerg Med 2023; 81:84-94. [PMID: 35641354 DOI: 10.1016/j.annemergmed.2022.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE We aimed to assess the analgesic and anxiolytic efficacy of distraction, a nonpharmacologic intervention provided by 3-dimensional (3D) virtual reality (VR) compared with that provided by 2-dimensional (2D) VR during minor emergency department (ED) procedures. METHODS This randomized controlled study conducted in the ED of a teaching hospital included patients aged more than or equal to 18 years undergoing minor procedures. The patients watched the same computer-generated VR world either in 3D in a head-mounted display (intervention) or in 2D on a laptop screen (control). Our main outcomes were pain and anxiety during the procedure, assessed on a 100-mm visual analog scale. Secondary outcomes included the impression of telepresence in the computer-generated world assessed using the Igroup Presence Questionnaire, and the prevalence and intensity of cybersickness measured on a 100-mm visual analog scale. RESULTS The final analysis included 117 patients. The differences in median procedural pain and anxiety levels between the 2D and 3D VR groups were not significant: -3 mm (95% confidence interval [CI] -14 to 8) and -4 mm (95% CI -15 to 3), respectively; the difference in telepresence was 2.0 point (95% CI 0 to 2.0), and the proportion difference of cybersickness was -4% (95% CI -22 to 14), with an intensity difference of -5 mm (95% CI -9 to 3). CONCLUSION During minor procedures in adult patients in the ED, distraction by viewing a 3D virtual world in a head-mounted VR display did not result in lower average levels of procedural pain and anxiety than that by 2D viewing on a screen despite a higher sense of telepresence. There were no significant differences in the prevalence and intensity of cybersickness between the 2 groups.
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Affiliation(s)
- Luca Bosso
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Vaud, Switzerland
| | - Tanguy Espejo
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Vaud, Switzerland
| | - Patrick Taffé
- Center for Primary Care and Public Health (Unisanté), DFRI/Division of Biostatistics, Lausanne, Vaud, Switzerland
| | - David Caillet-Bois
- Emergency Department, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Thierry Christen
- Department of Plastic and Hand Surgery, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Chantal Berna
- Centre for Integrative and Complementary Medicine and Pain Centers, Lausanne University Hospital & Lausanne University, Lausanne, Vaud, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Vaud, Switzerland.
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14
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Tinelli M, Guler N, Goetz C, Aim P, Marchionni S, Ouamara N, Cipolat L, Demarquet M, Seris E, Moreau A, Durand G, Douplat M, Lavignon JP, Hingray C, Abensur Vuillaume L. Study protocol: hypnosis versus standard care for shoulder dislocation reduction in the emergency department - a multicentre, randomised, controlled study protocol. BMJ Open 2022; 12:e062278. [PMID: 36600368 PMCID: PMC9730355 DOI: 10.1136/bmjopen-2022-062278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Anterior shoulder dislocation is a common reason for consultation at the emergency department (ED). Hypnosis could be a safe and effective alternative therapy for pain relief during shoulder dislocation reduction but nowadays, evidence is not sufficient. The main objective of this study is to show that reduction under hypnosis is associated with a decrease in the use of analgesic compared with usual care. METHODS AND ANALYSIS We will conduct an interventional, controlled, multicentre, randomised study. A total of 44 patients with shoulder dislocation will be randomised in two groups: the hypnosis group (N=22) and the usual care group (N=22). The primary endpoint will be the comparison of morphine equivalent analgesic consumption during a shoulder dislocation reduction manoeuvre. Secondary endpoints will include haemodynamic parameters monitoring, patient and practitioner satisfaction using a Likert scale, use of coanalgesic or sedative drugs, number of reduction attempts and time spent at ED. Adverse events will be recorded. Statistical analysis will include parametric tests, multivariate linear regression and descriptive statistics. ETHICS AND DISSEMINATION This study has received ethics approval from the Comité de Protection des Personnes of Sud-Est IV on 03/11/2021 (ANSM informed on 19 November 2021). The results will be published in scientific articles and communicated in national and international conferences. TRIAL REGISTRATION NUMBER ClinicalTrial.gov: NCT04992598; National Clinical trial no ID RCB : 2021-A01382-39.
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Affiliation(s)
| | - Nazmine Guler
- Emergency Department, CHR Metz-Thionville, Metz, France
| | - Christophe Goetz
- Clinical Research Support Unit, CHR Metz-Thionville, Metz, France
| | | | | | | | | | | | | | | | | | - Marion Douplat
- Service d'urgences médicales et chirurgicales - Centre hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Coraline Hingray
- Pole de psychiatrie universitaire du grand Nancy, CPN, Laxou, France
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15
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Wood C. Trauma pain management in the emergency department: use of methoxyflurane as a patient-administered analgesic. Emerg Nurse 2022; 30:25-30. [PMID: 35709005 DOI: 10.7748/en.2022.e2124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 06/15/2023]
Abstract
Evidence suggests that pain is highly prevalent among patients with traumatic injuries who attend emergency departments (EDs), yet accurate assessment and management of patients with acute pain can be challenging in this setting. Effective and rapid pain management is beneficial for patients and can support timely discharge from the ED, which is particularly important in the context of the coronavirus disease 2019 (COVID-19) pandemic. This article describes a service development project that introduced the use of a patient-administered analgesic, methoxyflurane, for patients with traumatic injuries with moderate to severe pain in one ED. The author outlines the benefits and rationale for using methoxyflurane as a first-line analgesic in this patient group and describes the main elements of training sessions for emergency nurses and other ED clinicians in the administration and supervision of patient-administered methoxyflurane.
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Affiliation(s)
- Craig Wood
- Epsom Hospital, Epsom and St Helier University Hospitals NHS Trust, Surrey, England
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16
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Merrer J, Chantry AA, Blondel B, Le Ray C, Bonnet MP. No pain management for labour: individual and organisational determinants: A secondary analysis of the 2016 French National Perinatal Survey. Eur J Anaesthesiol 2022; 39:489-497. [PMID: 35608876 DOI: 10.1097/eja.0000000000001682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Disparities in access to pain management have been identified in several care settings, such as emergency departments and intensive care units, but with regard to labour analgesia, it remains poorly explored. OBJECTIVES To determine the proportion of women without pain management during labour and its individual and organisational determinants. DESIGN Secondary analysis of a nationwide cross-sectional population-based study, the 2016 French National Perinatal Survey. SETTINGS All maternity units in France. PARTICIPANTS Ten thousand and eleven women who attempted vaginal delivery with a labour duration at least 15 min. MAIN OUTCOME MEASURE Absence of pain management, defined as absence of any pharmacological or nonpharmacological analgesic method during labour. RESULTS Among the 10 011 women included, 542 (5.4%) had no labour pain management: 318 (3.7%) of the 8526 women who initially preferred to use neuraxial analgesia and 222 (15.8%) of the 1402 who did not. Using generalised estimating equations stratified according to the maternal antenatal preference for neuraxial analgesia, the common determinants of no labour pain management in both groups were no attendance at childbirth education classes and admission to a delivery unit during the night. Among women who initially preferred to use neuraxial analgesia, those who delivered in units with <1500 annual deliveries compared with units with 2000 to 3499 annual deliveries, were more likely to do without pain management [adjusted odds ratio (OR) = 1.96; 95% confidence interval (CI), 1.39 to 2.78]; among those who did not prefer to use it, women born abroad were more likely to do without labour pain management (adjusted OR = 1.64; 95% CI, 1.12 to 2.40). CONCLUSION In France, 1 : 20 women had no labour pain management, and this proportion was three times higher among women who preferred not to use neuraxial analgesia. Enhancing maternal information on labour pain and its management, especially nonpharmacological methods, and rethinking care organisation, could improve access to analgesia of any kind.
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Affiliation(s)
- Jade Merrer
- From the Université de Paris, Centre of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA (JM, AAC, BB, ClR, M-PB), Midwifery school of Baudelocque, AP-HP, Université de Paris (AAC), Port-Royal Maternity Unit, Department of Obstetrics, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris (ClR) and Sorbonne University, GRC 29, DMU DREAM, Department of Anaesthesiology and Critical Care, Armand Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France (M-PB)
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17
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Abu-Snieneh HM, Alsharari AF, Abuadas FH, Alqahtani ME. Effectiveness of pain management among trauma patients in the emergency department, a systematic review. Int Emerg Nurs 2022; 62:101158. [DOI: 10.1016/j.ienj.2022.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/10/2022] [Accepted: 02/24/2022] [Indexed: 11/05/2022]
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Warnecke T, Djuren O, Hinkelbein J, Mohrman C, Rosner B. Organisation und Durchführung der Schmerztherapie in deutschen Notaufnahmen – eine Onlineumfrage. Notf Rett Med 2022. [DOI: 10.1007/s10049-022-01030-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Einleitung
Obwohl Schmerzen der häufigste Grund für eine Vorstellung in der Notaufnahme sind, ist ihre Erfassung und Therapie sehr heterogen organisiert und wird vielfach von Patienten als unzureichend beschrieben. Eine spezielle Leitlinie existiert bislang nicht und so wird beispielsweise die Delegation an die Notfallpflege nach Standard Operating Procedure (SOP) sehr unterschiedlich gehandhabt.
Methode
Mithilfe einer Umfrage erfolgte eine Ist-Analyse zur Organisation und Durchführung der akuten Schmerztherapie in deutschen Notaufnahmen. 18 Fragen wurden onlinebasiert erstellt und über das Notaufnahmeverzeichnis der DGINA e. V. (Deutsche Gesellschaft für interdisziplinäre Notfall- und Akutmedizin) und DIVI e. V. (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) an die Leiter von 951 deutschen Notaufnahmen verschickt.
Ergebnis
Es konnten 166 vollständige Fragebögen ausgewertet werden. Die Erfassung der Schmerzen erfolgt bei 77,7 % der Notaufnahmen innerhalb der ersten 10 min nach Erstkontakt, meist mit der numerischen Rating-Skala (46,4 %). Obwohl 17,7 % nicht dauerhaft ärztlich besetzt sind, dürfen in insgesamt 32,5 % der Notaufnahmen Pflegekräfte keine eigenständige Schmerztherapie durchführen. Eine spezielle SOP gab es nur in 44,8 % der befragten Notaufnahmen. Die am häufigsten verwendeten Analgetika sind Piritramid und Morphin sowie Metamizol und Ibuprofen.
Schlussfolgerung
Eine entsprechende nationale Leitlinie könnte Handlungssicherheit geben und als Grundlage für angepasste, örtliche SOP helfen, Verzögerungen bei der akuten Schmerztherapie zu vermeiden.
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19
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Wójcik M, Rogalska A. Analgesic Treatment and the Patients' Opinion on the Hospital Emergency Department. Healthcare (Basel) 2022; 10:healthcare10040623. [PMID: 35455801 PMCID: PMC9030114 DOI: 10.3390/healthcare10040623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 12/04/2022] Open
Abstract
Aim: The aim of the study was to analyze whether a patient’s opinion is related to the effect of analgesic treatment. Methods: The study was conducted using a survey questionnaire among adult patients admitted to the hospital emergency department in March 2021. The Numerical Rating Scale (NRS) was used to assess pain. Patients were asked to rate the intensity of pain during their stay in the emergency department in three situations: (1) at admission; (2) during the stay; and (3) upon discharge. The relationships between qualitative variables were assessed by the chi-squared test. Significance was set at p < 0.05. Results: There was no statistical dependence between the patient’s opinion about the medical institution and results of the effectiveness of analgesic treatments (p = 0.056). The highest percentage of patients satisfied with the received treatment were those who did not feel pain during ED discharge (94.12%), and the lowest were those who complained of severe pain during ED discharge (63.91%). The average mark for the functioning and organization of the emergency department was 7.44 (±2.04). Only 54 patients (29.83%) had taken pain medication before deciding to visit ED. Conclusions: No statistical dependency between the effect of the analgesic treatment and the patient’s opinion has been observed. The majority of patients with pain discomfort visit emergency departments without looking for consultation in other locations or without taking analgesics. In the considered institution, patients were satisfied with the analgesic treatment, staff performance, and with the organization of the department.
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Affiliation(s)
- Michał Wójcik
- Emergency Department, Regional Hospital, 43-316 Bielsko-Biala, Poland;
| | - Anna Rogalska
- Department of Economics and Management in Health Care, School of Health Sciences in Bytom, Medical University of Silesia, 40-055 Katowice, Poland
- Correspondence:
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20
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Lvovschi VE, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices. J Clin Med 2021; 10:jcm10215089. [PMID: 34768612 PMCID: PMC8584399 DOI: 10.3390/jcm10215089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.
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Affiliation(s)
- Virginie Eve Lvovschi
- Emergency Department, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France
- Correspondence:
| | - Karl Hermann
- Rouen University Hospital, INSERM CIC-CRB 1404, F-76000 Rouen, France;
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, INSERM U 942, Hôpital Avicenne, F-93009 Bobigny, France;
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, F-76031 Rouen, France;
| | - Marie-Pierre Tavolacci
- Normandie University, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France;
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21
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Betelman Mahalo Y, Avital G, Radomislensky I, Vysokovsky M, Avital-Cohen R, Gelikas S, Tsur AM, Nadler R, Bodas M, Chen J, Glassberg E, Benov A. Pain management for casualties receiving lifesaving interventions in the prehospital scenario: Raising awareness of our human nature. J Trauma Acute Care Surg 2021; 91:S201-S205. [PMID: 34039916 DOI: 10.1097/ta.0000000000003295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lifesaving interventions (LSIs) are the hallmark of medical care in trauma casualties, reducing mortality and morbidity. Analgesia is another essential treatment, which has been shown to improve outcomes and decrease long-term complications. However, oligoanalgesia is common, and information regarding its relation to the performance of LSIs is scarce. The purpose of this study was to assess the relation between the performance of LSIs and analgesia administration in the prehospital environment. METHODS A retrospective database-based study was performed, including all trauma casualties treated by Israeli Defense Forces physicians and paramedics during 2006 to 2017 and admitted to hospitals participating in the Israeli National Trauma Registry. Included LSIs were tourniquet application, administration of tranexamic acid and freeze-dried plasma, and administration of chest decompression. Casualties treated with endotracheal intubation or cricothyroidotomy were excluded. RESULTS In the multivariable logistic regression analysis, LSIs were associated with prehospital analgesia administration (odds ratio [OR], 3.59; confidence interval [CI], 2.56-5.08; p < 0.001). When assessing for the different LSIs, tourniquet application (OR, 2.83; CI, 1.89-4.27; p < 0.001) and tranexamic acid administration (OR, 4.307; CI, 2.42-8.04; p < 0.001) were associated with prehospital analgesia administration. CONCLUSION A positive association exists between performance of LSIs and administration of analgesia in the prehospital environment. Possible explanations may include cognitive and emotional biases affecting casualty care providers. LEVEL OF EVIDENCE Retrospective study, level IV.
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Affiliation(s)
- Yaar Betelman Mahalo
- From the Trauma and Combat Medicine Branch (Y.B.M., G.A., M.V., S.G., A.M.T., R.N., A.B.), Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan; Division of Anesthesia (G.A.), Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv; National Center for Trauma and Emergency Medicine Research (I.R., M.B.), Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan; Department of Psychology and Cognitive Science Studies (R.A.-C.), Open University of Israel, Raanana; Department of Medicine 'B' (A.M.T.), Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; Department of General Surgery and Transplantation-Surgery B (R.N.), Chaim Sheba Medical Center, Ramat Gan; Department of Emergency Management and Disaster Medicine (M.B.), School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Meir Medical Center (J.C.), Kfar Saba; Sackler Faculty of Medicine (J.C.), Tel-Aviv University, Tel-Aviv; Azrieli Faculty of Medicine (E.G., A.B.), Bar-Ilan University, Safed, Israel; Uniformed Services University of the Health Sciences (E.G.), Bethesda, Maryland; and Surgeon General's Headquarters (E.G.), Israel Defense Forces, Ramat Gan, Israel
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Inhaled methoxyflurane for the management of trauma related pain in patients admitted to hospital emergency departments: a randomised, double-blind placebo-controlled trial (PenASAP study). Eur J Emerg Med 2021; 27:414-421. [PMID: 32282467 DOI: 10.1097/mej.0000000000000686] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Oligo-analgesia is common in the emergency department (ED). This study aimed at reporting, when initiated by triage nurse, the superior efficacy of inhaled methoxyflurane plus standard of care (m-SoC) analgesia versus placebo plus SoC (p-SoC) for moderate-to-severe trauma-related pain in the hospital ED. METHODS A randomised, double-blind, placebo-controlled trial was conducted at eight EDs. Adults with pain score ≥4 (11-point numerical rate scale, NRS) at admission were randomised to receive one or two inhalers containing m-SoC or p-SoC. Primary outcome measure was time until pain relief ≤30 mm, assessed on the 100-mm Visual Analogic Scale (VAS). RESULTS A total of 351 patients were analysed (178 m-SoC; 173 p-SoC). Median pain prior to first inhalation was 66 mm, 75% had severe pain (NRS 6-10). Median time to pain relief was 35 min [95% confidence interval (CI), 28-62] for m-SoC versus not reached in p-SoC (92 - not reached) [hazard ratio), 1.93 (1.43-2.60), P < 0.001]. Pain relief was most pronounced in the severe pain subgroup: hazard ratio, 2.5 (1.7-3.7). As SoC, 24 (7%) patients received weak opioids (6 versus 8%), 4 (1%) strong opioid and 44 (13%) escalated to weak or strong opioids (8 versus 17%, respectively, P = 0.02). Most adverse events were of mild (111/147) intensity. CONCLUSIONS In this study, we report that methoxyflurane, initiated at triage nurse as part of a multimodal analgesic approach, is effective in achieving pain relief for trauma patients. This effect was particularly pronounced in the severe pain subgroup.
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Liu H, Fu X, Ren YF, Tan SY, Xiang SR, Zheng C, You FM, Shi W, Li LJ. Does Inhaled Methoxyflurane Implement Fast and Efficient Pain Management in Trauma Patients? A Systematic Review and Meta-Analysis. Pain Ther 2021; 10:651-674. [PMID: 33837931 PMCID: PMC8119536 DOI: 10.1007/s40122-021-00258-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/16/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction Evidence on the use of inhaled methoxyflurane in the management of trauma pain is conflicting and obfuscated. This study aimed to determine the efficacy and safety of inhaled methoxyflurane for trauma pain on the basis of published randomized controlled trials (RCTs). Methods RCTs assessing the efficacy of methoxyflurane in adults or adolescents with acute trauma pain published in PubMed, Web of Science, Embase, Cochrane Library, and Google Scholar were searched. The control groups were those that received placebo or standard analgesic treatment (SAT). The primary outcome was the change from baseline in pain scores during the first 30 min of treatment. Secondary outcomes included time to first pain relief, the proportion of patients experiencing pain relief, rescue analgesia rate, the treatment satisfaction of patients and investigators, and the methoxyflurane-related treatment-emergent adverse events (TEAEs). Results A total of nine RCTs (1806 patients) were identified. Results revealed that methoxyflurane provided a clinically unimportant benefit by improving the mean difference of change from baseline in pain intensity (from − 0.44 to − 1.23 cm, p < 0.001) at various time points within the first 20 min compared to control treatment. Besides, methoxyflurane decreased the time of onset of pain relief (mean difference − 5.29 min; 95% CI − 6.97 to − 3.62) and the proportion of patients who needed rescue analgesic medication (risk ratio 1.41; 95% CI 1.17–1.70) despite it increasing the risk of non-severe TEAEs (risk ratio 3.09; 95% CI 1.72–5.57). Notably, the benefit of almost all secondary pain-related outcomes was rendered clinically nonsignificant between methoxyflurane and SAT strata besides the time of onset of pain relief. The quality of evidence was low or very low in all outcomes. Conclusions In emergency situations without effective therapy, this systematic review and meta-analysis provides low-quality evidence that methoxyflurane can be used as a rapid-acting and effective treatment for acute trauma pain, although its utilization is associated a risk of non-severe TEAEs. However, the current evidence does not support the notion that inhaled methoxyflurane offered superior analgesic efficacy to SAT. Clinical Trial Number PROSPERO registration number CRD42020223000. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-021-00258-9.
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Affiliation(s)
- Hong Liu
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Xi Fu
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Yi-Feng Ren
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China.
| | - Shi-Yan Tan
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Si-Rui Xiang
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Chuan Zheng
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Feng-Ming You
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Wei Shi
- Department of Anesthesiology, West China Hospital, Sichuan University and the Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China.
| | - Lin-Jiong Li
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China.
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Dylst P, Solaman A, Gillis M, Dickerson S, Kenworthy J, Hachimi-Idrissi S. Healthcare resource use and cost implications of low dose methoxyflurane for severe trauma-related pain: a qualitative study. TRAUMA-ENGLAND 2021. [DOI: 10.1177/14604086211002987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims Management of moderate-to-severe trauma-associated pain is often reported as suboptimal, due in part to limitations associated with frequently used analgesics. Low-dose methoxyflurane (LDM) is an inhaled, non-opioid analgesic, recently approved for emergency relief of moderate-to-severe trauma-associated pain in conscious adults. This study assessed the perspective of healthcare professionals (HCPs) with regard to the time to analgesia and healthcare cost of LDM versus morphine IV, for patients with severe trauma-related pain receiving emergency care in Belgium. Materials and methods Interviews and questionnaires were completed by four healthcare HCPs providing emergency care at different hospitals in Belgium. Processes describing analgesic provision in pre-hospital and hospital emergency department (ED) settings were qualitatively mapped and a cost model applied which included reimbursed analgesic costs, time spent by HCPs making analgesic treatment decisions, preparing and administering the analgesic, and post-dose monitoring and management of analgesic-related adverse events (AEs). Results LDM was associated with substantial time and costs savings per patient, largely due to no requirement for AE monitoring. Compared with morphine IV, LDM in the hospital ED was associated with a time saving of 4 minutes to analgesic provision (35 vs 39 min) and ≥224 min in total (35 vs ≥259 min; including monitoring and managing AEs). In the pre-hospital setting, LDM was also associated with a time saving of 4 minutes to analgesic provision (21 vs 25 min) and 198 minutes in total. The corresponded total cost savings with LDM vs morphine IV were ≥€27.32 and ≥€17.95 in the ED or prehospital setting, respectively. Conclusions The cost model showed that LDM was associated with substantial time and costs savings versus morphine IV for severe trauma-related emergency pain in pre-hospital and hospital ED settings in Belgium.
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Opiophobia in Emergency Department Healthcare Providers: A Survey in Western Switzerland. J Clin Med 2021; 10:jcm10071353. [PMID: 33805916 PMCID: PMC8038057 DOI: 10.3390/jcm10071353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 01/14/2023] Open
Abstract
Opiophobia contributes to oligoanalgesia in the emergency department (ED), but its definition varies, and its association to healthcare providers’ personality traits has been scantly explored. Our purpose was to study the different definitions of opiophobia and their association with two personality traits of doctors and nurses working in EDs, namely the stress from uncertainty and risk-taking. We used three online questionnaires: the ‘Attitude Towards Morphine Use’ Score (ATMS), the Stress From Uncertainty Scale (SUS) and the Risk-Taking Scale (RTS). Doctors and nurses from nine hospital EDs in francophone Switzerland were invited to participate. The ATMS score was analyzed according to demographic characteristics, SUS, and RTS. The response rate was 56%, with 57% of respondents being nurses and 63% women. Doctors, less experienced and non-indigenous participants had a significantly higher ATMS (all p ≤ 0.01). The main contributors of the ATMS were the fear of side effects and of addiction. In multivariate analysis, being a doctor, less experience and non-indigenous status were predictive of the ATMS; each point of the SUS increased the ATMS by 0.24 point. The fear of side effects and of addiction were the major contributors of opiophobia among ED healthcare providers; opiophobia was also associated with their personality traits.
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26
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Sardo S, Galletta M, Coni E, Aviles Gonzalez CI, Piras I, Pia G, Evangelista M, Musu M, Finco G. Nurses' Behavior Regarding Pain Treatment in an Emergency Department: A Single-Center Observational Study. J Pain Res 2020; 13:2355-2359. [PMID: 33061550 PMCID: PMC7519805 DOI: 10.2147/jpr.s266087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/11/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of this prospective study was to assess the behavior of emergency department (ED) nurses with regard to pain and their role in pain management in a real-life clinical setting. Methods A total of 509 consecutive patients were enrolled during a 6-week period. A case-report form was used to collect data on nurses’ approaches to pain, time to analgesia provision, and patient-perceived quality of analgesia. Results Triage nurses actively inquired about pain in almost every case, but they did not estimate pain intensity in a third of patients. In the majority of cases, triage nurses did not report pain-related findings to the physician, who was the only professional that could prescribe analgesia to patients. The assignment of the color-coding of triage by nurses appears to be related to the perceived severity of the clinical case and a more comprehensive evaluation of pain. More than half of patients were at least fairly satisfied with analgesia. Conclusion Pain is increasingly screened during triage, but its comprehensive assessment and management still lack systematic application. We believe that further education and implementation of analgesia protocols may empower nurses to manage ED patients’ pain more effectively and in a more timely manner.
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Affiliation(s)
- Salvatore Sardo
- Anesthesia and Intensive Care Unit, University of Cagliari, Cagliari, Italy.,Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Maura Galletta
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Erica Coni
- RN-BC, University of Cagliari, Cagliari, Italy
| | | | | | - Giorgio Pia
- ATS Sardegna, ASSL Cagliari SS, Cagliari, Italy
| | - Maurizio Evangelista
- Department of Anesthesiology and Pain Medicine, Cattolica University, Rome, Italy
| | - Mario Musu
- Anesthesia and Intensive Care Unit, University of Cagliari, Cagliari, Italy.,Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Gabriele Finco
- Anesthesia and Intensive Care Unit, University of Cagliari, Cagliari, Italy.,Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Woolner V, Ahluwalia R, Lum H, Beane K, Avelino J, Chartier LB. Improving timely analgesia administration for musculoskeletal pain in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000797. [PMID: 31986116 PMCID: PMC7011892 DOI: 10.1136/bmjoq-2019-000797] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/05/2019] [Accepted: 12/10/2019] [Indexed: 12/23/2022] Open
Abstract
Delays to adequate analgesia result in worse patient care, decreased patient and provider satisfaction and increased patient complaints. The leading presenting symptom to emergency departments (EDs) is pain, with approximately 34 000 such patients per year in our academic hospital ED and 3300 visits specific for musculoskeletal (MSK) injuries. Our aim was to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 min) in 9 months' time (May 2018). Our outcome measures included mean TTA and ED length of stay (LOS). Process measures included rates of analgesia administration and of use of medical directives. We obtained weekly data capture for Statistical Process Control (SPC) charts, as well as Mann-Whitney U tests for before-and-after evaluation. We performed wide stakeholder engagement, root cause analyses and created a Pareto Diagram to inform Plan-Do-Study-Act (PDSA) cycles, which included: (1) nurse-initiated analgesia at triage; (2) a new triage documentation aid for medication administration; (3) a quick reference medical directive badge for nurses; and (4) weekly targeted feedback of the project's progress at clinical team huddle. TTA decreased from 129 min (n=153) to 100 min (22.5%; n=87, p<0.05). Special cause variation was identified on the ED LOS SPC chart with nine values below the midline after the first PDSA. The number of patients that received any analgesia increased from 42% (n=372) to 47% (n=192; p=0.13) and those that received them via medical directives increased from 22% (n=154) to 44% (n=87; p<0.001). We achieved a significant reduction of TTA and an increased use of medical directives through front-line focused improvements.
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Affiliation(s)
- Victoria Woolner
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Reena Ahluwalia
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Hilary Lum
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kevin Beane
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jackie Avelino
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
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Hachimi-Idrissi S, Dobias V, Hautz WE, Leach R, Sauter TC, Sforzi I, Coffey F. Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations. Intern Emerg Med 2020; 15:1141-1155. [PMID: 32930964 DOI: 10.1007/s11739-020-02411-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind. METHODS With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings. RESULTS AND CONCLUSIONS This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.
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Affiliation(s)
- Saïd Hachimi-Idrissi
- Department of Emergency Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | | | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Robert Leach
- Department of Emergency Medicine Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | | | - Frank Coffey
- Nottingham University Hospitals' NHS Trust, Nottingham, UK
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Hachimi-Idrissi S, Coffey F, Hautz WE, Leach R, Sauter TC, Sforzi I, Dobias V. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med 2020; 15:1125-1139. [PMID: 32930965 DOI: 10.1007/s11739-020-02477-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.
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Affiliation(s)
- Saïd Hachimi-Idrissi
- Department of Emergency Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Frank Coffey
- Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Robert Leach
- Department of Emergency Medicine, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
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Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative. Eur J Emerg Med 2020; 27:33-39. [PMID: 30807371 PMCID: PMC6946096 DOI: 10.1097/mej.0000000000000597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain. PATIENTS AND METHODS A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important. RESULTS Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%). CONCLUSION These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.
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31
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Fabbri A, Ruggiano G, Garcia Collado S, Ricard-Hibon A, Restelli U, Sbrana G, Marinangeli F, Farina A, Coffey F. Role of Inhaled Methoxyflurane in the Management of Acute Trauma Pain. J Pain Res 2020; 13:1547-1555. [PMID: 32612382 PMCID: PMC7323816 DOI: 10.2147/jpr.s252222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/06/2020] [Indexed: 11/23/2022] Open
Abstract
Adequate treatment of trauma pain is an integral part of the management of trauma patients, not just for ethical reasons but also because undertreated pain can lead to increased morbidities and worse long-term outcomes. Trauma pain management presents challenges in the pre-hospital setting, particularly in adverse or hostile environments as well as in busy emergency departments (EDs). Inhaled methoxyflurane, administered at analgesic doses via a disposable inhaler, has recently become available in Europe for the emergency treatment of moderate to severe pain in conscious adult trauma patients. A growing body of evidence demonstrates that inhaled methoxyflurane is well tolerated and effective in providing a rapid onset of analgesia. In this paper, we discuss the rationale for methoxyflurane use in trauma pain management, data from clinical trials recently conducted in Europe, its efficacy and safety profile compared to current standard treatments, its place in therapy and organizational impact. We conclude that inhaled methoxyflurane represents an effective treatment option in the different settings where trauma patients require rapid and flexible pain resolution, with potential organizational advantages.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Germana Ruggiano
- Emergency Medicine Department, Santa Maria Annunziata Hospital, Florence, Italy
| | | | - Agnes Ricard-Hibon
- Service SAMU-SMUR-SAU, GHT Nord Ouest Vexin Val d’Oise, Pontoise95, France
| | - Umberto Restelli
- Center for Health Economics, Social and Health Care Management, LIUC - Università Cattaneo, Castellanza, VA, Italy
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Giovanni Sbrana
- Anaesthesia, Intensive Care, Emergency Medicine, Grosseto HEMS, ASL Toscana Sud Est, Grosseto, Italy
| | - Franco Marinangeli
- Department of Anesthesiology and Intensive Care, University of L’Aquila, L’Aquila, Italy
| | - Alberto Farina
- Medical Affairs Department, Mundipharma Pharmaceuticals Srl, Milan, Italy
| | - Frank Coffey
- DREEAM - Department of Research and Education in Emergency Medicine Acute Medicine and Major Trauma, Nottingham University Hospitals’ NHS Trust, Nottingham, UK
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Commenoz C, Labrousse T, Verneau C, Chandre-Couturier C, Lefort H. [Pain management at the emergency room reception desk]. REVUE DE L'INFIRMIÈRE 2020; 69:28-30. [PMID: 32532438 DOI: 10.1016/j.revinf.2020.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pain is the main complaint during an emergency room visit. Whether it is a reason in itself or associated with other symptoms, its management determines the proper course of care. They are also potentially a source of new pain, or added strain for the patient, relatives and caregivers. The nurse organizing the reception area prioritizes the passage of patients according to their potential seriousness. The pain assessment is part of this evaluation, renewed during the time of treatment with anticipated analgesia protocols.
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Affiliation(s)
- Camille Commenoz
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27 avenue de Plantières, 57077 Metz cedex 3, France
| | - Thomas Labrousse
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27 avenue de Plantières, 57077 Metz cedex 3, France
| | - Cyril Verneau
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27 avenue de Plantières, 57077 Metz cedex 3, France
| | - Claire Chandre-Couturier
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27 avenue de Plantières, 57077 Metz cedex 3, France
| | - Hugues Lefort
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27 avenue de Plantières, 57077 Metz cedex 3, France.
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Young L, Bailey GP, McKinlay JAC. Service Evaluation of Methoxyflurane Versus Standard Care for Overall Management of Patients with Pain Due to Injury. Adv Ther 2020; 37:2520-2527. [PMID: 32232663 PMCID: PMC7467480 DOI: 10.1007/s12325-020-01294-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Inhaled methoxyflurane is an analgesic used for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain that is increasingly being used in hospital emergency departments to provide rapid analgesia. It is widely accepted that effective pain relief can facilitate patient care and flow through the emergency department (ED). The main aim of this evaluation was to assess the impact of inhaled methoxyflurane on patient length of stay (LOS) in the ED compared with standard care. METHODS Adult patients with moderate to severe trauma pain and Glasgow coma score of 15 were included in the evaluation. Evaluation forms were completed for 79 patients who received methoxyflurane and were matched with 80 patients who received standard care. RESULTS Overall the mean time spent in the ED was reduced by 71 min in those patients who were administered methoxyflurane compared with patients who received standard care. Furthermore, analysis of LOS by injury type demonstrated a reduction in ED LOS by 183 min for patients with shoulder dislocation who were treated with methoxyflurane compared with patients who received standard care. There was no reduction in ED LOS for patients with lower limb, hip or pelvic injuries between the two treatment groups. CONCLUSION Use of methoxyflurane in adult patients with trauma pain significantly reduced the ED LOS and may potentially improve patient flow through the ED.
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Mubita WM, Richardson C, Briggs M. Patient satisfaction with pain relief following major abdominal surgery is influenced by good communication, pain relief and empathic caring: a qualitative interview study. Br J Pain 2020; 14:14-22. [PMID: 32110394 DOI: 10.1177/2049463719854471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Monitoring and improving the quality of care is an ever increasing concern for health care organisations. Measuring the effectiveness of clinical outcomes is done by looking at specific markers of high quality care. Pain management is considered one of the markers of high quality care and satisfaction with pain management is a crucial and important quality assurance marker; yet, we know little about what contributes to a patient's decision about satisfaction. Methods A qualitative study drawing on phenomenological approach aiming to evaluate the perspective of patients experiencing post-operative pain. Patients undergoing major abdominal surgery were recruited from a Renal Transplant and Urology ward in the North of England, UK. Data were collected using in-depth semi-structured interviews and were analysed using Colaizzi's approach. Results Ten patients participated in the study and three themes emerged from the analysis. The findings of this study revealed that in order to achieve satisfaction with the management of pain, patient care has to include information delivery which is timely and adequate according to a patient's individual needs, nurses should have a caring attitude and pain should be well controlled. Conclusion Satisfaction with pain management is influenced by good communication and information transfer, appropriate pain management and an empathic presence throughout.
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Affiliation(s)
- Womba Musumadi Mubita
- Research and Innovation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Clinical Trials Management Offices, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Cliff Richardson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Michelle Briggs
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Viglino D, Termoz Masson N, Verdetti A, Champel F, Falcon C, Mouthon A, Mabiala Makele P, Collomb Muret R, Maindet Dominici C, Maignan M. Multimodal oral analgesia for non-severe trauma patients: evaluation of a triage-nurse directed protocol combining methoxyflurane, paracetamol and oxycodone. Intern Emerg Med 2019; 14:1139-1145. [PMID: 31290084 DOI: 10.1007/s11739-019-02147-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/03/2019] [Indexed: 01/03/2023]
Abstract
Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled methoxyflurane) initiated by triage nurse. We performed a prospective, observational study in an emergency department (Grenoble Alpes University Hospital, France) between December 2017 and April 2018. Adult non-severe trauma patients with a numerical pain rating scale (NRS) score ≥ 4 were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤ 3 at 15 min. Pain intensity was measured for 60 min and during radiography. Data on adverse events and satisfaction were recorded. A total of 200 adult patients were included (median [interquartile range (IQR)] age: 32 [23-49] years; 126 men (63%)). Sixty-six patients (33%) reported an NRS score ≤ 3 at 15 min. The time required to achieve a decrease of at least 2 points in the NRS score was 10 (5-20) min. The median [IQR] pain intensity was 4 [2-5] before radiography and 4 [2-6] during radiography. Adverse events were frequent (n = 128, 64%). No serious adverse events were reported. The patients and caregivers reported good levels of satisfaction. The administration of a nurse-driven multimodal analgesia protocol (combining paracetamol, oxycodone, and methoxyflurane) was feasible on admission to the emergency department. It rapidly produced long-lasting analgesia in adult trauma patients.Trial registration: NCT03380247.
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Affiliation(s)
- Damien Viglino
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Nicolas Termoz Masson
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Agnès Verdetti
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Flore Champel
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Cédric Falcon
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Alexis Mouthon
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Prudence Mabiala Makele
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | | | - Maxime Maignan
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France.
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Truchot J, Mezaïb K, Ricard-Hibon A, Vicaut E, Claessens YE, Soulat L, Milon JY, Serrie A, Plaisance P. Assessment of procedural pain in French emergency departments: a multi-site, non-interventional, transverse study in patients with minor trauma injury. Hosp Pract (1995) 2019; 47:143-148. [PMID: 31343374 DOI: 10.1080/21548331.2019.1646074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To determine the mean number of procedural painful episodes per patient, and to retrieve information regarding diagnosis, therapeutic procedures and analgesic management, in patients visiting Emergency Departments (EDs) for minor trauma. Methods: This observational, non-interventional, multicenter study in adult patients was performed in 35 French EDs. All patients entering the EDs for minor trauma on a specified day between noon and 10 pm were registered; consenting patients were included in the study. Pain intensity was assessed using a verbal Numerical Rating Scale from 0 (no pain) to 10 (worst possible pain). An episode was described as painful if the difference in pain intensity between pain just before the procedure and maximal pain during the procedure was ≥2. Two independent nurses recorded data on 1 day in each center. Results: Overall, 909 patients were registered, 422 were included in the study, and complete data for 409 patients (1899 procedures) were available for analysis. The mean number of painful episodes per patient was 1.0 ± 1.3. Fifty-one percent of patients reported at least one painful procedure episode. Twenty-one percent of procedures were considered painful. Clinical examination was the procedure most often reported as painful. No preventive or curative analgesic treatment was reported in 95.1% of procedures. Conclusions: There is a need for improvement in routine pain assessment and, therefore, procedural pain management for ED patients. Specific protocols should be developed for procedural pain management, and teams should be trained especially for procedures usually not considered painful.
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Affiliation(s)
- Jennifer Truchot
- Department of Emergency Medicine, Lariboisière University Hospital, AP-HP, Paris Diderot University , Paris , France
| | - Karima Mezaïb
- Department of Pain Medicine, Institut Gustave Roussy , Villejuif , France
| | | | - Eric Vicaut
- Clinical Research Unit, Fernand Widal University Hospital , Paris , France
| | | | - Louis Soulat
- Department of Emergency Medicine, Rennes University Hospital , Rennes , France
| | | | - Alain Serrie
- Department of Pain and Palliative Medicine, Lariboisière University Hospital , Paris , France
| | - Patrick Plaisance
- Department of Emergency Medicine, Lariboisière University Hospital, AP-HP, Paris Diderot University , Paris , France
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Chukwulebe SB, Kim HS, McCarthy DM, Courtney DM, Lank PM, Gravenor SJ, Dresden SM. Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits. J Am Geriatr Soc 2019; 67:719-725. [PMID: 30687938 DOI: 10.1111/jgs.15722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED. DESIGN Retrospective cohort study. SETTING Large urban academic ED from January 1, 2013, to December 31, 2015. PARTICIPANTS Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits). MEASUREMENTS Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return. RESULTS Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9-day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54-0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10-3.70). CONCLUSIONS These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient-centered outcomes. J Am Geriatr Soc 67:719-725, 2019.
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Affiliation(s)
- Steve B Chukwulebe
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Howard S Kim
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patrick M Lank
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie J Gravenor
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Martorella G, Kostic M, Lacasse A, Schluck G, Abbott L. Knowledge, Beliefs, and Attitudes of Emergency Nurses Toward People With Chronic Pain. SAGE Open Nurs 2019; 5:2377960819871805. [PMID: 33415252 PMCID: PMC7774372 DOI: 10.1177/2377960819871805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/16/2019] [Accepted: 08/01/2019] [Indexed: 11/16/2022] Open
Abstract
More and more people suffering from chronic pain (CP) utilize the emergency department (ED). However, their needs are not properly addressed. Stigmatization toward people with CP can partially explain this gap. Most studies in the ED have been focused on measuring nurses' pain management knowledge in general, not negative attitudes toward CP. Hence, understanding of the determinants of the stigma related to CP is needed. The objectives of this study were to (a) describe the knowledge, beliefs, and attitudes of ED nurses toward people suffering from CP and (b) identify nurses' characteristics associated with these perceptions. A cross-sectional web-based survey design was conducted using the KnowPain-12 questionnaire and the Chronic Pain Myth Scale. A total of 571 participants from 20 different states across the United States were recruited among whom 482 completed the entire survey. The sample included about one third of the ED nurses suffering from CP. Negative beliefs and attitudes toward people with CP were present in a considerable proportion of participants (up to 64%), even in nurses suffering from CP (up to 47.5%). Nevertheless, our results suggest that higher levels of education and suffering from CP were associated with better beliefs and attitudes toward people with CP. The ED presents an increased risk of stigmatization of people with CP as compared with the general population. Identifying determinants of the stigma associated with CP is crucial, as it will help tailoring awareness and educational campaigns. In addition, CP patients utilizing the ED often have complex needs which are difficult to address in this clinical environment. This situation can contribute to negative beliefs and attitudes. Given the scarcity of specialized care clinics for this population, health-care stakeholders should devise solutions to improve continuity of care in primary care settings and between the latter and ED.
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Affiliation(s)
- Geraldine Martorella
- TMH Center for Research and Evidence-Based Practice, College of Nursing, Florida State University, Tallahassee, FL, USA
| | - Michelle Kostic
- College of Nursing, Florida State University, Tallahassee, FL, USA
| | - Anaïs Lacasse
- Laboratoire de recherche en épidémiologie de la douleur chronique, Département des sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
| | - Glenna Schluck
- TMH Center for Research and Evidence-Based Practice, College of Nursing, Florida State University, Tallahassee, FL, USA
| | - Laurie Abbott
- TMH Center for Research and Evidence-Based Practice, College of Nursing, Florida State University, Tallahassee, FL, USA
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Pasiorowski A, Olson K, Ghosh S, Ray L. Oligoanalgesia in Adult Colles Fracture Patients Admitted to the Emergency Department. Clin Nurs Res 2018; 30:23-31. [PMID: 30585090 DOI: 10.1177/1054773818820175] [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: 01/23/2023]
Abstract
Pain is a complex symptom to assess properly and it is often poorly managed in the Emergency Department. The majority of research has focused on exploring oligoanalgesia in samples of patients with heterogeneous injuries. The occurrence of oligoanalgesia in a homogeneous injury, such as Colles fracture, has yet to be explored. A retrospective chart review was conducted to determine the incidence of oligoanalgesia in adults with Colles fractures admitted to two urban Emergency Departments in Western Canada. Data were collected from one hundred fifty charts from a 5-year period (2009-2014). Age and gender predicted of pain assessment (p = .019), but were not significantly associated with receipt of an opioid or pain reassessment. Pain reassessment was only completed in 47% of patients who received an initial pain assessment; this was significantly different from current best practice standards (p = .0002).
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Affiliation(s)
| | | | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Lynne Ray
- University of Alberta, Edmonton, Canada
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Ricard-Hibon A, Chareyron A. État des lieux de la prise en charge de la douleur. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Le concept d’oligoanalgésie en structure d’urgences reste une réalité en France comme dans de nombreux pays qui publient sur le sujet. Les motifs de cette oligoanalgésie sont multiples, le plus souvent liés à des contraintes organisationnelles plus que médicales. Les solutions existent, et la douleur aiguë persistante ne doit plus être une fatalité en structure d’urgences. L’analyse des raisons de l’oligoanalgésie avec des audits ciblés et la mise en place de protocoles thérapeutiques locaux sont des prérequis à l’amélioration de la prise en charge. Les nouveaux enjeux de la médecine d’urgence, liés à l’augmentation constante de la sollicitation, mais également en lien avec l’évolution des techniques médicales et des compétences des équipes médicales et soignantes, donnent de nouvelles perspectives pour améliorer la qualité–sécurité de la prise en charge de la douleur en structure d’urgences.
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Krebs H, Perrin Bayard R, Bares A, Dahmani S, Story T, Claret PG, Bobbia X, de La Coussaye J. Délégation de l’évaluation et du traitement de la douleur à l’infirmier de Service mobile d’urgence et de réanimation : étude avant–après monocentrique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction : La prise en charge de la douleur en médecine d’urgence préhospitalière est encore insuffisante. Cette étude a pour objectif d’évaluer les effets d’une délégation de l’évaluation et du traitement de la douleur à l’infirmier diplômé d’État (IDE) en Service mobile d’urgence et de réanimation (Smur) sur le suivi des recommandations de la Société française de médecine d’urgence (SFMU).
Méthode : Étude rétrospective de type avant–après réalisée au Smur du centre hospitalier universitaire (CHU) de Nîmes de janvier à mai 2017. Les IDE ont été formés, entre les deux phases, à un protocole de délégation de l’évaluation et du traitement de la douleur fondé sur les dernières recommandations.
Résultats : Cent quatre-vingt-un patients ont été inclus dans chaque groupe, 74 (40 %) femmes (âge moyen de 60 ± 18 ans). Les groupes étaient comparables à l’exception de la proportion d’interventions traumatologiques (11 % dans le groupe « avant » vs 20 % dans le groupe « après » ; p = 0,02). Les recommandations ont été respectées pour 12 (7 %) patients dans le groupe « avant », 21 (12 %) dans le groupe « après » (p = 0,10). Le seul facteur indépendant de respect des recommandations est le type d’intervention traumatologique (odds ratio = 9,7 ; intervalle de confiance à 95 % : [2,3–53,3] ; p < 0,01). Le nombre de patients ayant bénéficié d’une administration d’antalgique était respectivement de 55 (30 %) dans le groupe « avant » et de 73 (40 %) dans le groupe « après » (p = 0,05). La réévaluation de l’intensité douloureuse en fin de prise en charge a été consignée dans 11 (6 %) cas de la phase avant vs 38 (21 %) dans la phase après (p < 0,01). Dans le sous-groupe des patients n’ayant pas bénéficié de trinitrine, les recommandations ont été respectées respectivement pendant les phases « avant » et « après » chez 7 (6 %) patients vs 17 (14 % ; p = 0,03).
Conclusion : Malgré une augmentation du taux de prescription d’antalgiques et de réévaluation de la douleur, le protocole de délégation IDE n’a pas permis un meilleur respect des recommandations. L’établissement de protocoles spécifiques en fonction du type d’intervention, notamment traumatologique, pourrait être une piste de réflexion.
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Levchenko OK, Polyanskaya TU, Zorenko VY, Galstian GM. Wound analgesia in a patient with hemophilia in a highly traumatic operation. TERAPEVT ARKH 2018; 90:82-85. [PMID: 30701927 DOI: 10.26442/terarkh201890782-85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM The aim of the study was to describe the use of the wound analgesia method in a patient with hemophilia in the case of a clinical case. MATERIALS AND METHODS A patient with severe hemophilia A underwent postoperative analgesia after total knee replacement (within the first 48 hours) with an extended infusion of local anesthetic (ropivacaine) into the wound. RESULTS During the first 8 hours, the patient received 20 mg of morphine (with the aid of a device for patient-controlled analgesia), the pain level ranged from 7 to 4 points. Further, there was a sufficient effect (NRS - 2 points), from anesthesia only with ropivacaine, using a system for anesthetizing surgical wounds. Complications and side effects were not noted. CONCLUSION The clinical case demonstrates an effective and safe method of prolonged analgesia in patients with hemophilia. Considering encouraging data, further study of wound analgesia in this category of patients is necessary.
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Affiliation(s)
- O K Levchenko
- National Research Center for hematology, Moscow,Russia
| | | | - V Y Zorenko
- National Research Center for hematology, Moscow,Russia
| | - G M Galstian
- National Research Center for hematology, Moscow,Russia
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Avallin T, Muntlin Athlin Å, Elgaard Sørensen E, Kitson A, Björck M, Jangland E. Person-centred pain management for the patient with acute abdominal pain: An ethnography informed by the Fundamentals of Care framework. J Adv Nurs 2018; 74:2596-2609. [DOI: 10.1111/jan.13739] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 04/03/2018] [Accepted: 06/01/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Therese Avallin
- Department of Surgical Sciences; Uppsala University; Uppsala Sweden
| | - Åsa Muntlin Athlin
- Department of Emergency Care and Internal Medicine; Uppsala University Hospital; Uppsala Sweden
- Department of Medical Sciences; Uppsala University; Uppsala Sweden
- Department of Public Health and Caring Sciences/Health Services Research; Uppsala University; Uppsala Sweden
| | - Erik Elgaard Sørensen
- Clinical Nursing Research Unit; Aalborg University Hospital; Aalborg Denmark
- Department of Clinical Medicine; Aalborg University; Aalborg Denmark
| | - Alison Kitson
- College of Nursing and Health Sciences Flinders University; Adelaide SA Australia
| | - Martin Björck
- Department of Surgical Sciences; Uppsala University; Uppsala Sweden
| | - Eva Jangland
- Department of Surgical Sciences; Uppsala University; Uppsala Sweden
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Gleason LJ, Escue ED, Hogan TM. Older Adult Emergency Department Pain Management Strategies. Clin Geriatr Med 2018; 34:491-504. [PMID: 30031429 DOI: 10.1016/j.cger.2018.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Older adults frequently present to the emergency department (ED) with pain, which is often underrecognized and undertreated. There is high variability of pain management and prescribing practices by ED providers. This article focuses on treatment of older adults in the ED who present with pain and addresses special considerations for this population. Social supports and follow-up must be considered in discharge treatment recommendations.
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Affiliation(s)
- Lauren J Gleason
- Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637, USA
| | - Emily D Escue
- Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637, USA
| | - Teresita M Hogan
- Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637, USA; Section of Emergency Medicine, L-550A (MC 5068), 5841 S, Maryland Avenue, Chicago, IL 60637, USA.
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Chen E, Tsoy D, Upadhye S, Chan TM. The Acute Care of Chronic Pain Study: Perceptions of Acute Care Providers on Chronic Pain, a Social Media-based Investigation. Cureus 2018; 10:e2399. [PMID: 29854574 PMCID: PMC5976271 DOI: 10.7759/cureus.2399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The diagnosis of chronic pain involves symptoms of pain of various etiologies lasting longer than six months. The prevalence of chronic pain in society ranges from 19% to 31% in North America. While chronic pain patient perceptions on the care provided to them in the Emergency Department (ED) have been studied, there has not been significant attention given to the attitudes of acute care providers towards these patients. Methods We utilized online questionnaires disseminated on Twitter, Facebook, Reddit, and emergency medicine blogs to gauge care provider attitudes of chronic pain patients. Survey respondents included ED physicians and their trainees, ED nurses and nurse practitioners, paramedics, and physician assistants. Results Responses revealed numerous factors impacting care provider dissatisfaction with treating chronic pain in the ED; significant factors included the lack of longitudinal care and inappropriate medication of chronic pain resulting in dependency. We found that additional chronic pain-specific training was associated with increased care provider confidence in the treatment of chronic pain. Practice patterns were found to be varied, with half of the respondents stating that chronic pain should be medicated acutely. Conclusions We conclude that acute care provider dissatisfaction with chronic pain treatment is multifactorial in origin and that confidence in the acute treatment of chronic pain can be improved with chronic pain-specific training.
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Affiliation(s)
- Eric Chen
- Faculty of Health Sciences, Department of Medicine, Division of Emergency Medicine, McMaster University
| | - Daniel Tsoy
- Faculty of Health Sciences, Department of Medicine, Division of Emergency Medicine, McMaster University
| | - Suneel Upadhye
- Faculty of Health Sciences, Department of Medicine, Division of Emergency Medicine, McMaster University
| | - Teresa M Chan
- Faculty of Health Sciences, Department of Medicine, Division of Emergency Medicine, McMaster University
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Abstract
Background Pain is a common complaint in patients attending the emergency department (ED), and historically, it is under-assessed and undertreated. Previous research is heterogeneous and does not well describe pain in EDs over time. Our aim was to describe pain in a UK ED using a sample that included every adult attendance over the course of 1 week. Methods We retrospectively reviewed every adult attendance (N = 1872) over 1 week to the ED of a large English NHS District General Hospital. We noted the initial pain score and, if the initial score was ≥5, the final recorded pain score. We categorised attendances as 'illness' or 'injury'. Results In all, 62.1% of patients had a pain score recorded, of whom 50.7% had a pain score of zero. Median pain score was 6/10 in patients with pain; 58% had a second score recorded. More patients with illness than injury had a second score recorded. Most patients had an improvement in their pain; however, around one-third had no change or worse pain at the end of their ED stay. Conclusion We have defined the incidence, severity and change in pain in an ED over 1 week. This information will underpin the design of future studies aimed at improving patient care in this important area of emergency medicine practice.
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Affiliation(s)
- Hilary Sarah Thornton
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joseph Reynolds
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Timothy J Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Mura P, Serra E, Marinangeli F, Patti S, Musu M, Piras I, Massidda MV, Pia G, Evangelista M, Finco G. Prospective study on prevalence, intensity, type, and therapy of acute pain in a second-level urban emergency department. J Pain Res 2017; 10:2781-2788. [PMID: 29263692 PMCID: PMC5732548 DOI: 10.2147/jpr.s137992] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim Pain represents the most frequent cause for patient admission to emergency departments (EDs). Oligoanalgesia is a common problem in this field. The aims of this study were to assess prevalence and intensity of pain in patients who visited a second-level urban ED and to evaluate the efficacy of pharmacological treatment administered subsequent to variations in pain intensity. Methods A 4-week prospective observational study was carried out on 2,838 patients who visited a second-level urban ED. Pain intensity was evaluated using the Numeric Rating Scale at the moment of triage. The efficacy of prescribed analgesic therapy was evaluated at 30 and 60 minutes, and at discharge. Data concerning pain intensity were classified as absent, slight, mild, or severe. Pain was evaluated in relation to the prescribed therapy. Results Pain prevalence was 70.7%. Traumatic events were the primary cause in most cases (40.44%), followed by pain linked to urologic problems (13.52%), abdominal pain (13.39%), and nontraumatic musculoskeletal pain (7.10%). Only 32.46% of patients were given pharmacological therapy. Of these, 76% reported severe pain, 19% moderate, and 5% slight, and 66% received nonsteroidal anti-inflammatory drugs or paracetamol, 4% opioids, and 30% other therapies. A difference of at least 2 points on the Numerical Rating Scale was observed in 84% of patients on reevaluation following initial analgesic therapy. Conclusion Pain represents one of the primary reasons for visits to EDs. Although a notable reduction in pain intensity has been highlighted in patients who received painkillers, results show that inadequate treatment of pain in ED continues to be a problem.
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Affiliation(s)
- Paolo Mura
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Elisabetta Serra
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of L'Aquila, L'Aquila, Italy
| | - Sebastiano Patti
- Department of Emergency Medicine, Santissima Trinità Hospital, Cagliari, Italy
| | - Mario Musu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Ilenia Piras
- Department of Emergency Medicine, Santissima Trinità Hospital, Cagliari, Italy
| | | | - Giorgio Pia
- Department of Emergency Medicine, Santissima Trinità Hospital, Cagliari, Italy
| | - Maurizio Evangelista
- Department of Anesthesiology and Pain Medicine, Cattolica University, Rome, Italy
| | - Gabriele Finco
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
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48
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Butti L, Bierti O, Lanfrit R, Bertolini R, Chittaro S, Delli Compagni S, Del Russo D, Mancusi RL, Pertoldi F. Evaluation of the effectiveness and efficiency of the triage emergency department nursing protocol for the management of pain. J Pain Res 2017; 10:2479-2488. [PMID: 29081670 PMCID: PMC5652903 DOI: 10.2147/jpr.s138850] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Pain is a common symptom presented in the emergency department (ED) although it is often underestimated, poorly evaluated and treated. The application of a protocol for timely pain management ensured by the nurse can avoid the delays in the analgesic treatment and improve the patient’s quality of waiting. Aims To check the effectiveness and efficiency of the protocol aimed at early pain management in triage, active in our ED. In particular, the response to analgesic treatment was evaluated 60 minutes after the administration and at discharge. Patient satisfaction was also evaluated using two anonymous questionnaires both at discharge and 48 hours later via telephone. Methods A single-center, observational study was conducted on a prospective cohort of patients (aged ≥4 years) with a pain symptom at admission in ED with no surgical picture. Results In the observation period (June 2015–May 2016), 382 patients were enrolled, and of these, 312 (84.8%) accepted pain therapy during triage stage in the ED. In 97.4% of the cases, orosoluble paracetamol 1000 mg was administered. In the re-evaluation done 60 minutes later, 65.9% of the patients showed a reduction of at least 2 points on Numeric Rating Scale (NRS), equal to a mean reduction of 2.24 points (95% CI: 2.03–2.45). The mean time of analgesia intake was equal to 5.9 minutes (95% CI: 3.8–8.1). In the re-evaluation done at discharge, 33.2% of the patients showed a reduction of NRS score >50%, leading to a mean reduction of 39% (95% CI: 35.3%−41.9%). The level of patient satisfaction was high with a mean value >9 points (maximum satisfaction =10). Conclusion This protocol shows that optimal pain management was achieved by patients rapidly receiving an effective painkiller therapy at triage, leading to substantial patient satisfaction. In moderate pain, orosoluble paracetamol 1000 mg provided a reduction of NRS score by 2 points in 67.6% of the patients, confirming to be the analgesic of choice in ED.
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Affiliation(s)
- Loris Butti
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
| | - Olga Bierti
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
| | - Raffaela Lanfrit
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
| | - Romina Bertolini
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
| | - Sara Chittaro
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
| | | | - Davide Del Russo
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
| | | | - Franco Pertoldi
- S.O.C. Emergency Medicine, AAS3 Ospedale Sant'Antonio di San Daniele del Friuli
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49
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Crellin DJ, Harrison D, Hutchinson A, Schuster T, Santamaria N, Babl FE. Procedural Pain Scale Evaluation (PROPoSE) study: protocol for an evaluation of the psychometric properties of behavioural pain scales for the assessment of procedural pain in infants and children aged 6-42 months. BMJ Open 2017; 7:e016225. [PMID: 28882914 PMCID: PMC5589003 DOI: 10.1136/bmjopen-2017-016225] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Infants and children are frequently exposed to painful medical procedures such as immunisation, blood sampling and intravenous access. Over 40 scales for pain assessment are available, many designed for neonatal or postoperative pain. What is not well understood is how well these scales perform when used to assess procedural pain in infants and children. AIM The aim of this study was to test the psychometric and practical properties of the Face, Legs, Activity, Cry and Consolability (FLACC) scale, the Modified Behavioural Pain Scale (MBPS) and the Visual Analogue Scale (VAS) observer pain scale to quantify procedural pain intensity in infants and children aged from 6-42 months to determine their suitability for clinical and research purposes. METHODS AND ANALYSIS A prospective observational non-interventional study conducted at a single centre. The psychometric and practical performance of the FLACC scale, MBPS and the VAS observer pain scale and VAS observer distress scale used to assess children experiencing procedural pain will be assessed. Infants and young children aged 6-42 months undergoing one of four painful and/or distressing procedures were recruited and the procedure digitally video recorded. Clinicians and psychologists will be recruited to independently apply the scales to these video recordings to establish intrarater and inter-rater reliability, convergent validity responsiveness and specificity. Pain score distributions will be presented descriptively; reliability will be assessed using the intraclass correlation coefficient and Bland-Altman plots. Spearman correlations will be used to assess convergence and linear mixed modelling to explore the responsiveness of the scales to pain and their capacity to distinguish between pain and distress. ETHICS AND DISSEMINATION Ethical approval was provided by the Royal Children's Hospital Human Research Ethics Committee, approval number 35220B. The findings of this study will be disseminated via peer-reviewed journals and presented at international conferences.
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Affiliation(s)
- Dianne J Crellin
- Department of Nursing, The University of Melbourne, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute (MCRI), Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Denise Harrison
- Department of Nursing, The University of Melbourne, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute (MCRI), Melbourne, Australia
- Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
| | | | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, MCRI, Melbourne, Australia
| | - Nick Santamaria
- Department of Nursing, The University of Melbourne, Melbourne, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute (MCRI), Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
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50
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Fry M, Chenoweth L, Arendts G. Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial. Emerg Med J 2017; 35:33-38. [PMID: 28780493 DOI: 10.1136/emermed-2016-206065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/03/2017] [Accepted: 07/16/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine. METHODS A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis. RESULTS We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and non-intervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91). CONCLUSION Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.
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Affiliation(s)
- Margaret Fry
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia.,Director Research and Practice Development, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Lynn Chenoweth
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Glenn Arendts
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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