The relationship between time to analgesic administration and emergency department length of stay: A retrospective review

Canadian nurse initiated analgesia protocol to reduce delays in the emergency department: A quality improvement study

BACKGROUND

Australian literature supports nurse-initiated opioid analgesia protocols may be effective, but this practice is not yet widely adopted in Canada.

LOCAL PROBLEM

Previous quality audits of Emergency Departments (EDs) in Victoria (Canada) indicate long delays to administration of analgesia.

METHODS

Two tertiary care hospitals in a Canadian city of approximately 400,000 people were chosen for a quality improvement initiative. A manual retrospective chart review was conducted on a total of 122 patients which was compared to data from 125 patients from a previous audit in 2019.

INTERVENTIONS

ED nursing staff both hospitals were provided education and daily reminders to document pain score at triage, and to flag an acute analgesia opioid order set on the charts of patients with moderate or severe pain (greater than 4 out of 10 in the Numerical Rating Scale (NRS) or by triage nurse's clinical judgment). At Victoria General Hospital (VGH), nurses had the option of finding an emergency physician (EP) to sign the acute analgesia opioid order set, or independently administer IV opioids from a presigned order set without consulting an EP. At Royal Jubilee Hospital (RJH), nursing staff could only administer IV opioids from the order set after an EP was consulted. Median time to opioid analgesia after the intervention was compared to 2019 data for each hospital.

RESULTS

Each hospital significantly reduced median time to administration of opioids: VGH achieved 45.6 % reduction (1 h 8 min improvement, p = 0.001) and RJH achieved a 62.5 % reduction (2 h 11 min improvement, p < 0.001). Secondary outcomes indicated patients may receive analgesia faster when the opioid protocol was nurse initiated (median 43 minutes) vs physician initiated (median 1 h 1 min) at VGH. Pain score documentation at triage improved from <10 % in 2019 to >50 % in 2020 at both sites. Approximately 95 % of EP and nursing staff thought nurse-initiated opioids are safe, effective, and should be supported by regulatory boards.

CONCLUSION

Implementing a new triage protocol to expedite initiation of an analgesic protocol was associated with significantly reduced time to analgesia for patients with moderate to severe pain. Time reductions may be greater with nurse-initiated analgesia before physician assessment.

Short-term outcomes of prehospital opioid pain management for older adults with fall-related injury

BACKGROUND

Opioids are recommended for pain management in patients being cared for and transported by emergency medical services, but no specific guidelines exist for older adults with fall-related injury. Prior research suggests prehospital opioid administration can effectively manage pain in older adults, but less is known about safety in this population. We compared short-term safety outcomes, including delirium, disposition, and length of stay, among older adults with fall-related injury according to whether they received prehospital opioid analgesia.

METHODS

We linked Medicare claims data with prehospital patient care reports for older adults (≥65) with fall-related injury in Illinois between January 1, 2014 and December 31, 2015. We used weighted regression models (logistic, multinomial logistic, and Poisson) to assess the association between prehospital opioid analgesia and incidence of inpatient delirium, hospital disposition, and length of stay.

RESULTS

Of 28,150 included older adults, 3% received prehospital opioids. Patients receiving prehospital opioids (vs. no prehospital opioids) were less likely to be discharged home from the emergency department (adjusted probability = 0.30 [95% CI: 0.25, 0.34] vs. 0.47 [95% CI: 0.46, 0.48]), more likely to be discharged to a non-home setting after an inpatient admission (adjusted probability = 0.43 [95% CI: 0.39, 0.48] vs. 0.30 [95% CI: 0.30, 0.31]), had inpatient length of stay 0.4 days shorter (p < 0.001) and ICU length of stay 0.7 days shorter (p = 0.045). Incidence of delirium did not vary between treatment and control groups.

CONCLUSIONS

Few older adults receive opioid analgesia in the prehospital setting. Prehospital opioid analgesia may be associated with hospital disposition and length of stay for older adults with fall-related injury. However, our findings do not provide evidence of an association with inpatient delirium. These findings should be considered when developing guidelines for prehospital pain management specific to the older adult population.

Improving the emergency services using quality improvement project and Donabedian model in a quaternary teaching hospital in South India

INTRODUCTION

The primary goal of quality improvement is to enhance patient outcomes, particularly in the emergency department (ED). Timely and effective care is crucial in these situations. By comprehending the challenges, evaluating current performance and implementing quality improvement projects, areas in need of enhancement can be pinpointed and addressed, resulting in better outcomes.

METHODOLOGY

This interventional study explores the implementation of quality improvement in the ED of a quaternary care teaching hospital in South India. It follows the Plan-Do-Check-Act (PDCA) cycle guided by the Donabedian model. Descriptive statistics were employed to measure changes in outcomes before and after implementation. To improve processes, Donabedian principles were applied, and a performance audit was conducted based on patient feedback and stakeholder input. Various ED indicators were measured. To address identified issues, formal root cause analysis was performed, leading to the generation of PDCA rapid change cycles. These cycles were implemented over 6 months, with two cycles executed, followed by postimplementation evaluation.

RESULTS

Post implementation, improvements were observed in several aspects of ED operations. These included reduced ED average length of stay, decreased time to analgesia, shorter cross-consultation time, faster transfer time from ED and improved investigation turnaround time (TAT). Additionally, there was a reduction in revisits to ED within 72 hours and a decrease in patients who left without being seen. These positive changes demonstrate the effectiveness of the quality improvement intervention using the PDCA cycle.

CONCLUSION

A comprehensive understanding of patient profile in the ED and factors influencing care is essential for the hospital to ensure sufficient resources and skilled emergency medicine physicians are available 24/7. By enhancing services in the ED, reducing patient waiting times and improving TAT, the overall efficiency of services can be improved. This leads to provision of timely quality care to patients and ultimately improves their outcomes.

Implementation evaluation of an evidence-based emergency nursing framework (HIRAID): study protocol for a step-wedge randomised control trial

INTRODUCTION

Poor patient assessment results in undetected clinical deterioration. Yet, there is no standardised assessment framework for >29 000 Australian emergency nurses. To reduce clinical variation and increase safety and quality of initial emergency nursing care, the evidence-based emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) was developed and piloted. This paper presents the rationale and protocol for a multicentre clinical trial of HIRAID.

METHODS AND ANALYSIS

Using an effectiveness-implementation hybrid design, the study incorporates a stepped-wedge cluster randomised controlled trial of HIRAID at 31 emergency departments (EDs) in New South Wales, Victoria and Queensland. The primary outcomes are incidence of inpatient deterioration related to ED care, time to analgesia, patient satisfaction and medical satisfaction with nursing clinical handover (effectiveness). Strategies that optimise HIRAID uptake (implementation) and implementation fidelity will be determined to assess if HIRAID was implemented as intended at all sites.

ETHICS AND DISSEMINATION

Ethics has been approved for NSW sites through Greater Western Human Research Ethics Committee (2020/ETH02164), and for Victoria and Queensland sites through Royal Brisbane & Woman's Hospital Human Research Ethics Committee (2021/QRBW/80026). The final phase of the study will integrate the findings in a toolkit for national rollout. A dissemination, communications (variety of platforms) and upscaling strategy will be designed and actioned with the organisations that influence state and national level health policy and emergency nurse education, including the Australian Commission for Quality and Safety in Health Care. Scaling up of findings could be achieved by embedding HIRAID into national transition to nursing programmes, 'business as usual' ED training schedules and university curricula.

TRIAL REGISTRATION NUMBER

ACTRN12621001456842.

The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain

PURPOSE OF REVIEW

Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain.

RECENT FINDINGS

Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.

Factors associated with time to first analgesic medication in the emergency department

AIM AND OBJECTIVE

To examine the factors associated with time to first analgesic medication in the emergency department.

BACKGROUND

Pain is the most common symptom presenting to the emergency department, and the time taken to deliver analgesic medication is a common outcome measure. Factors associated with time to first analgesic medication are likely to be multifaceted, but currently poorly described.

DESIGN

Retrospective cohort study.

METHODS

Cox proportional hazards regression modelling was undertaken to evaluate the associations between person, environment, health and illness variables within Symptom Management Theory and time to first analgesic medication in a sample of adult patients presenting with moderate-to-severe pain to an emergency department over twelve months. This study was completed in line with the STROBE statement.

RESULTS

383 patients were included in the study, 290 (75.92%) of these patients received an analgesic medication in a median time of 45 minutes (interquartile range, 70 minutes). A model containing nine explanatory variables associated with time to first analgesic medication was identified. These nine variables (employment status, discharge location, triage score, Charlson score, arrival pain score, socio-economic status, first location, daily total treatment time and patient time to be seen) represent all of the domains of the Symptom Management Theory.

CONCLUSIONS

Person, environment, health and illness factors are associated with the time taken to deliver analgesic medication to those in pain in the emergency department. This study demonstrates the complexity of factors associated with pain care and the applicability of Symptom Management Theory to pain care in the emergency department.

RELEVANCE TO CLINICAL PRACTICE

Identifying a model of factors that are associated with the time in which the most common symptom presenting to the emergency department is treated allows for targeted interventions to groups likely to receive poor care and a framework for its evaluation.

Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study

Introduction

This study was proposed to compare the ability and accuracy of modified sequential organ failure assessment (mSOFA), quick SOFA (qSOFA), and qSOFA-65 in predicting the status of nontraumatic patients referred to hospital emergency departments (EDs).

Materials and methods

This study was a prospective design that performed on the 746 nontraumatic patients referred to the ED. Each patient data was collected using a demographic questionnaire, mSOFA, qSOFA, and qSOFA-65 scales. Related variables of each scale were recorded based on patients’ medical records. Then, the outcome of each patient in the ED was followed up and recorded. The severity and specificity of each scale were estimated by the area under receiver operating characteristic (AUROC) curve at 99% confidence interval (CI).

Results

The mean and standard deviation of scores were as follows: mSOFA = 4.40 ± 2.58, qSOFA = 0.50 ± 0.70, and qSOFA-65 = 0.92 ± 0.96. Patients requiring admission to the intensive care unit (ICU) were identified with AUROC curve as follows: mSOFA = 0.882 (99% CI = 0.778–0.865); qSOFA = 0.717 (99% CI = 0.662–0.773); and qSOFA-65 = 0.771 (99% CI = 0.721–0.820), which showed that mSOFA has higher sensitivity and specificity than the other two scales in identifying patients requiring admission to the ICU.

Conclusion

All three scales were found to be reliable for identifying nontraumatic patients at risk of death and patients requiring admission to the ICU. However, since the time and data required to complete qSOFA and qSOFA-65 are much less than those of mSOFA, it is recommended that qSOFA and especially qSOFA-65 be used in ED to identify critically ill nontraumatic patients.

How to cite this article

Ebrahimian A, Shahcheragh SMT, Fakhr-Movahedi A. Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study. Indian J Crit Care Med 2020;24(11):1045–1050.

Emergency Department Operations: An Overview

Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.