1
|
Yadollahi P, Bozorgian L, Janghorban R. The relationship between Iranian women's perception of their birth team's compliance with medical ethics and their perception of labor pain. BMC Pregnancy Childbirth 2024; 24:70. [PMID: 38245719 PMCID: PMC10799432 DOI: 10.1186/s12884-024-06269-6] [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: 09/22/2023] [Accepted: 01/12/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND A safe and satisfactory childbirth experience with the least amount of pain constitutes one of the main domains of reproductive healthcare. The most important aspect of labor pain management is the moral and professional commitment of the health professionals and caregivers involved in creating a pleasant delivery. The present study examines the relationship between Iranian women's perceptions of their birth team's compliance with medical ethics and their perception of labor pain. METHODS This cross-sectional study was conducted on 200 women opting for natural childbirth. The samples were selected by convenience sampling. Three questionnaires, including a demographic information questionnaire, the perception of labor pain questionnaire, and the medical ethics attitude in vaginal delivery questionnaire, were used to collect data. The data were entered into SPSS 22 and analyzed using correlation coefficient and multiple regression tests. The significance level for data analysis was set as less than 0.05. RESULTS The results of the regression analysis showed that among the four principles of medical ethics, only the second and third principles (beneficence and non-maleficence) predicted the perception of labor pain (B = -0.267, P < 0.037). Among the different domains of these principles, the areas of giving the necessary information to the mother (B = -0.199, P = 0.001), respecting the mother's privacy (B = -0.194, P = 0.001), interaction with the mother (B = -0.287, P = 0.001) and assurance of fetal health (B = -0.492, P = 0.001) were predictors of labor pain perception score. CONCLUSIONS Compliance of the birth team with respecting the mother's privacy, having friendly interactions with the mother and giving fetal health assurance to the mother can be a predictor of the mother's decreased perception of labor pain.
Collapse
Affiliation(s)
- Parvin Yadollahi
- Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Bozorgian
- Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Roksana Janghorban
- Department of Midwifery, School of Nursing and Midwifery, Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
2
|
Keskpaik T, Talving P, Kirsimägi Ü, Mihnovitš V, Ruul A, Starkopf J. Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators. Eur J Trauma Emerg Surg 2023; 49:1375-1381. [PMID: 36995396 DOI: 10.1007/s00068-023-02263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. OBJECTIVES The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals. METHODS This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. RESULTS Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35-105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034). CONCLUSION Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.
Collapse
Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Anni Ruul
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| |
Collapse
|
3
|
Supples MW, Vaizer J, Liao M, Arkins T, Lardaro TA, Faris G, O'Donnell DP, Glober NK. Patient Demographics Are Associated with Differences in Prehospital Pain Management among Trauma Patients. PREHOSP EMERG CARE 2022; 27:1048-1053. [PMID: 36191334 DOI: 10.1080/10903127.2022.2132565] [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: 06/27/2022] [Accepted: 10/01/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics. METHODS We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher's exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol. RESULTS Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively. CONCLUSION Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.
Collapse
Affiliation(s)
| | - Julia Vaizer
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark Liao
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Gregory Faris
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Nancy K Glober
- Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
4
|
Birrenbach T, Bühlmann F, Exadaktylos AK, Hautz WE, Müller M, Sauter TC. Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study. BMC Emerg Med 2022; 22:113. [PMID: 35729502 PMCID: PMC9210626 DOI: 10.1186/s12873-022-00671-z] [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: 02/10/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2–5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0–10). Methods Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales. Results Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute (< 24 h) (n = 16, 30.8%) or subacute (> 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3–7) vs. median post-VR simulation 3 (IQR 2–5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2–5) vs. median post-VR simulation 2 (IQR 0–3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen’s d estimate for pain reduction = 0.59 (95% CI 0.19—0.98), for anxiety level on NRS = 0.75 (95% CI 0.34—1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high. Conclusions Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00671-z.
Collapse
Affiliation(s)
- T Birrenbach
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, 3010, Bern, Switzerland.
| | - F Bühlmann
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, 3010, Bern, Switzerland
| | - A K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, 3010, Bern, Switzerland
| | - W E Hautz
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, 3010, Bern, Switzerland
| | - M Müller
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, 3010, Bern, Switzerland
| | - T C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, 3010, Bern, Switzerland
| |
Collapse
|
5
|
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.
Collapse
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;
| |
Collapse
|
6
|
Saulnier KM. Telling, Hearing, and Believing: A Critical Analysis of Narrative Bioethics. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:297-308. [PMID: 32180110 DOI: 10.1007/s11673-020-09973-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/04/2020] [Indexed: 06/10/2023]
Abstract
Narrative ethics taps into an inherent human need to tell our own stories centred on our own moral values and to have those stories heard and acknowledged. However, not everyone's words are afforded equal power. The use of narrative ethics in bioethical decision-making is problematized by a disparity in whose stories are told, whose stories are heard, and whose stories are believed. Here, I conduct an analysis of narrative ethics through a critical theory lens to show how entrenched patterns of narrative neglect in medicine are harming not only our capacity to make use of narrative ethics but also our capacity to deliver effective healthcare. To illustrate this point, I use three examples where the patient's gender affects how their stories unfold: autism, weight, and pain management. From these, I argue that the use of narrative ethics without the application of a critical theory lens risks the exacerbation of what Miranda Fricker refers to as "testimonial injustice," the prima facie harm experienced by individuals whose credibility is undermined by others' prejudices. Finally, I suggest that narrative ethics can be a powerful tool for mitigating oppressive practices in medicine if we couple it with critical analysis that enables us to understand the power dynamics at play in storytelling.
Collapse
Affiliation(s)
- K M Saulnier
- Centre of Genomics and Policy, 740 Dr Penfield Ave, Room 5206, Montreal, Quebec, H3A 0G1, Canada.
| |
Collapse
|
7
|
Sikka N, Shu L, Ritchie B, Amdur RL, Pourmand A. Virtual Reality-Assisted Pain, Anxiety, and Anger Management in the Emergency Department. Telemed J E Health 2019; 25:1207-1215. [DOI: 10.1089/tmj.2018.0273] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Neal Sikka
- Department of Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Liqi Shu
- Department of Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Brandon Ritchie
- Department of Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Richard L. Amdur
- Department of Surgery, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Ali Pourmand
- Department of Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| |
Collapse
|
8
|
Venkat A, Kim D. Ethical Tensions in the Pain Management of an End-Stage Cancer Patient with Evidence of Opioid Medication Diversion. HEC Forum 2017; 28:95-101. [PMID: 25381648 DOI: 10.1007/s10730-014-9257-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
At the end of life, pain management is commonly a fundamental part of the treatment plan for patients where curative measures are no longer possible. However, the increased recognition of opioid diversion for secondary gain coupled with efforts to treat patients in the home environment towards the end of life creates the potential for ethical dilemmas in the palliative care management of terminal patients in need of continuous pain management. We present the case of an end-stage patient with rectal cancer who required a continuous residential narcotic infusion of fentanyl for pain control due to metastatic disease. His functional status was such that he had poor oral intake and ability to perform other activities of daily living, but was able to live at home with health agency nursing care. The patient presented to this institution with a highly suspect history of having lost his fentanyl infusion in a residential accident and asking for a refill to continue home therapy. The treating physicians had concerns of diversion of the infusion medication by caregivers and were reluctant to continue the therapeutic relationship with the patient. This case exemplifies the tension that can exist between wanting to continue with palliative care management of an end-stage patient and the fear of providers when confronted by evidence of potential diversion of opioid analgesic medications. We elucidate how an ethical framework based on a combination of virtue and narrative/relationship theories with reference to proportionality can guide physicians to a pragmatic resolution of these difficult situations.
Collapse
Affiliation(s)
- Arvind Venkat
- Department of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA.
| | - David Kim
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| |
Collapse
|
9
|
|
10
|
Taylor DM, Chen J, Khan M, Lee M, Rajee M, Yeoh M, Richardson JR, Ugoni AM. Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department. Emerg Med J 2016; 34:13-19. [PMID: 27789567 DOI: 10.1136/emermed-2016-206044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the patient and clinical variables associated with administration of any analgesia, nurse-initiated analgesia (NIA, prescribed and administered by a nurse) and early analgesia (within 30 min of presentation). METHODS We undertook a retrospective cohort study of patients who presented to a metropolitan ED in Melbourne, Australia, during July and August, 2013. The ED has an established NIA programme. Patients were included if they were aged 18 years or more and presented with a painful complaint. The study sample was randomly selected from a list of all eligible patients. Data were extracted electronically from the ED records and by explicit extraction from the medical record. Logistic regression models were constructed to assess associations with the three binary study end points. RESULTS 1289 patients were enrolled. Patients were less likely to receive any analgesia if they presented 08:00-15:59 hours (OR 0.67, 95% CI 0.46 to 0.98) or 16:00-24:00 hours (OR 0.55, 95% CI 0.37 to 0.80) were triage category 5 (OR 0.20, 95% CI 0.08 to 0.49) or required an interpreter (OR 0.34, 95% CI 0.14 to 0.86). Patients were less likely to receive NIA or early analgesia if they were aged 56 years or more (OR 0.70 and 0.63; OR 0.57 and 0.21, respectively) or if they had received ambulance analgesia (OR 0.59, 95% CI 0.36 to 0.95; OR 0.38, 95% CI 0.20 to 0.74, respectively). CONCLUSIONS Patients who present during the daytime, have a triage category of 5 or require an interpreter are less likely to receive analgesia. Older patients and those who received ambulance analgesia are less likely to receive NIA or early analgesia.
Collapse
Affiliation(s)
- David McD Taylor
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Chen
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Munad Khan
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Marina Lee
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Mani Rajee
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Yeoh
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Joanna R Richardson
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Antony M Ugoni
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
11
|
Barksdale AN, Hackman JL, Williams K, Gratton MC. ED triage pain protocol reduces time to receiving analgesics in patients with painful conditions. Am J Emerg Med 2016; 34:2362-2366. [PMID: 27663766 DOI: 10.1016/j.ajem.2016.08.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/24/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Studies suggest that collaborative nursing protocols initiated in triage improve emergency department (ED) throughput and decrease time to treatment. OBJECTIVE The objective of the study is to determine if an ED triage pain protocol improves time to provision of analgesics. METHODS Retrospective data abstracted via electronic medical record of patients at a safety net facility with 67 000 annual adult visits. Patients older than 18 years who presented to the ED between March 1, 2011, and May 31, 2013, with 1 of 6 conditions were included: back pain, dental pain, extremity trauma, sore throat, ear pain, or pain from an abscess. A 3-month orientation to an ED nurse-initiated pain protocol began on March 1, 2012. Nurses administered oral analgesics per protocol, beginning with acetaminophen or ibuprofen and progressing to oxycodone. Preimplementation and postimplementation analyses examined differences in time to analgesics. Multivariable analysis modeled time to analgesics as a function of patient factors. RESULTS Over a 27-month period, 23 409 patients were included: 13 112 received pain medications and 10 297 did not. A total of 12 240 (52%) were male, 12 578 (54%) were African American, and 7953 (34%) were white, with a mean (SD) age of 39 years (13 years). The pain protocol was used in 1002 patients. There was a significant change in mean time (minutes) to provision of analgesics between preimplementation (238) and postimplementation (168) (P < .0001). Linear regression showed the protocol-delivered medications to younger patients and of lower acuity in a reduced time. Variables not related to time to provision of medication included sex, payer, and race. CONCLUSION Emergency department triage pain protocol decreased time to provision of pain medications and did so without respect to payer category, sex, or race.
Collapse
Affiliation(s)
| | - Jeff Lee Hackman
- Department of Emergency Medicine, Truman Medical Center/UMKC School of Medicine, Kansas City, MO
| | - Karen Williams
- Department of Biomedical and Health Informatics, UMKC School of Medicine, Kansas City, MO
| | - Matt Christopher Gratton
- Department of Emergency Medicine, Truman Medical Center/UMKC School of Medicine, Kansas City, MO
| |
Collapse
|
12
|
Dale J, Bjørnsen LP. Assessment of pain in a Norwegian Emergency Department. Scand J Trauma Resusc Emerg Med 2015; 23:86. [PMID: 26514633 PMCID: PMC4625614 DOI: 10.1186/s13049-015-0166-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/21/2015] [Indexed: 12/02/2022] Open
Abstract
Background Although pain management is a fundamental aspect of care in emergency departments (EDs), inadequate treatment of pain is unfortunately common. There are multiple local protocols for pain assessment in the ED. This study evaluated whether the initial assessment and treatment of pain in the ED are in accordance with the in-hospital protocol of the ED at a Norwegian University Hospital. Materials and methods Prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation. The patients’ perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10. Results Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58 %), only 14 % received pain relief. Discussion Assessment and treatment of pain in the ED are inadequate and not in line with the local protocols. A focus on strategies to improve pain treatment in the ED is a necessary aspect of developing optimal acute patient care in Norway in the future.
Collapse
Affiliation(s)
- Jostein Dale
- Emergency Department, Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim, Norway
| | - Lars Petter Bjørnsen
- Emergency Department, Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim, Norway.
| |
Collapse
|
13
|
Marcus BS, Venkat A. Ethical pain management in the emergency department: the canary in the coal mine. Pain Manag 2015; 5:251-60. [DOI: 10.2217/pmt.15.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The emergency department serves as the gateway to the acute healthcare system. In the USA and increasingly worldwide, patients view the emergency department as the venue where both diagnostic and therapeutic modalities will be brought to bear regardless of condition or socioeconomic status. At the same time, the emergency department is the canary in the coal mine – the warning location for difficulties in how healthcare is delivered to patients in both the outpatient and inpatient settings. In no area is this more apparent than pain management. Emergency departments are expected to treat patient's pain aggressively, often in the face of incomplete or contradictory histories and the inability to ensure outpatient follow-up. These factors create an ethical challenge for emergency departments in how to approach pain treatment. This paper will provide a framework for how emergency departments can address the ethical challenges posed by pain management.
Collapse
Affiliation(s)
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, USA
| |
Collapse
|