1
|
Kefyalew M, Deyassa N, Gidey U, Temesgen M, Mehari M. Improving the time to pain relief in the emergency department through triage nurse-initiated analgesia - a quasi-experimental study from Ethiopia. Afr J Emerg Med 2024; 14:161-166. [PMID: 39040944 PMCID: PMC11260836 DOI: 10.1016/j.afjem.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction Pain management is crucial for improving patients' quality of care. Persistent pain has been linked to higher depression, anxiety, and work-related difficulties. This study aimed to enhance the time to pain relief in the emergency department through triage nurse-initiated analgesia. It evaluated the impact of nurse-led analgesia on patient satisfaction compared to standard pain management at Tikur Anbessa Specialized Hospital and Kidus Paulos Specialized Hospital. Additionally, it compared the time to analgesia between the two hospitals and assessed the effect of nurse-led analgesia on reducing the length of stay for patients with pain. Methods Using a quasi-experimental design, the study included an intervention group and a control group. Data was collected using an open data kit, and after ensuring data completeness, it was exported to SPSS and Excel for analysis. To assess the effectiveness of the intervention, the time to analgesia was compared between the intervention and control groups using an independent samples t-test. This statistical test allowed for a comparison of the mean time to analgesia between the two groups.Patient satisfaction scores were also compared between the intervention and control groups using the Mann-Whitney U test. Kaplan-Meier curves were employed to compare the time to analgesia between the intervention and control groups within both settings. A point bi-serial correlation analysis was performed to examine the association between the length of stay and the intervention of nurse-led analgesia in both hospital settings. Result and discussion The study enrolled 179 participants, with a median age of 34 years (range: 9-80) and 67% female. The most common events leading to pain were medical conditions (21%), followed by trauma/quarrel/war, fall accidents, and underlying diseases (15%, 13%, and 13%, respectively). There was a significant correlation between the degree of pain on arrival and time to analgesia. Additionally, a significant correlation (p < 0.01) was found between time to analgesia and patient satisfaction. Conclusion and recommendation Implementing a nurse-led analgesia protocol in the emergency department is crucial for reducing time to analgesia and improving patient satisfaction. It is recommended to scale up this approach to other healthcare facilities by incorporating it into the nursing practice guidelines of the country.
Collapse
Affiliation(s)
- Merahi Kefyalew
- Department of Emergency and Critical Care Medicine, Addis Ababa University College of Health Science, Ethiopia
| | - Negussie Deyassa
- Epidemiology, Department of Public Health, Addis Ababa University College of Health Science, Ethiopia
| | - Uqubay Gidey
- Department of Emergency and Critical Care Medicine, Addis Ababa University College of Health Science, Ethiopia
| | - Maligna Temesgen
- Department of Internal Medicine, Kidus Paulos Specialized Hospital, Ethiopia
| | - Maraki Mehari
- Department of Orthopedic Surgery, Kidus Paulos Specialized Hospital, Ethiopia
| |
Collapse
|
2
|
Calder J, Wanbon R, Thompson J, Colella P, Wale J, Cassidy S, McLeod S, Kirkwood R. Canadian nurse initiated analgesia protocol to reduce delays in the emergency department: A quality improvement study. Int Emerg Nurs 2024; 75:101488. [PMID: 39002430 DOI: 10.1016/j.ienj.2024.101488] [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: 03/23/2024] [Revised: 06/10/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024]
Abstract
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.
Collapse
Affiliation(s)
- Julia Calder
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada.
| | - Richard Wanbon
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| | - James Thompson
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| | - Paul Colella
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| | - Jason Wale
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| | - Sara Cassidy
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| | - Sandra McLeod
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| | - Rebecca Kirkwood
- Island Health Authority, Royal Jubilee Hospital, 1952 Bay St, Victoria V8R 1J8, Canada; Island Health Authority, Victoria General Hospital, 1 Hospital Way, Victoria V8Z 6R5, Canada
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Ayano WA, Fentie AM, Tileku M, Jiru T, Hussen SU. Assessment of adequacy and appropriateness of pain management practice among trauma patients at the Ethiopian Aabet Hospital: A prospective observational study. BMC Emerg Med 2023; 23:92. [PMID: 37592216 PMCID: PMC10433567 DOI: 10.1186/s12873-023-00869-9] [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: 02/24/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Pain is unpleasant sensory and emotional experiences associated with actual and/or potential tissue damage. It is the most common and prevalent reason for emergency departments (ED) visits with prevalence over 70% in the world. AIM OF THE STUDY The study aimed to assess the adequacy and appropriateness of pain management at Aabet Hospital, Addis Ababa, Ethiopia. METHODS A hospital-based prospective cross-sectional study was conducted at Aabet hospital from December 1, 2020 to March 30, 2021. Adult trauma patients having pain (at least score 1 on Numeric Rating Scale) with Glasgow Coma Scale score > 13 were eligible to participate in the study. The pain intensity was evaluated at the time of admission (o minute) and then at 60, 120, 180, and 240 minutes. The time of the first analgesics was registered. The adequacy and the appropriateness of the pain management were calculated through pain management index (PMI). RESULTS Two hundred thirty-two (232) participants were included in this study of which 126 (54.3%) were admitted due to road traffic accident followed by fall 44(19%). Only 21 (9.1%) study participants received the first analgesic treatment within 30 minutes while 27(11.6%) participants had no treatment at all within 240 minutes. The mean pain intensity score at admission was 5.55 ± 2.32 and reduced to 4.09 ± 2.69. Nearly half 110 (47.4%) of the study participants were treated inadequately (PMI (-) score). There was a weak and negative correlation between PMI and time to analgesia (r = - .159, p = 0.0001). The type of analgesia used, the time to analgesia, and the degree of pain may predict 65% of the variance in PMI score (R2 = 0.65, P = .001). CONCLUSION From the results of this study, it can be concluded that acute pain in trauma patients was under and inappropriately treated.
Collapse
Affiliation(s)
- Wondwossen Alemu Ayano
- Department of Pharmacy, Addis Ababa Burn, Emergency and Trauma Hospital, Addis Ababa, Ethiopia
| | - Atalay Mulu Fentie
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Melaku Tileku
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tilahun Jiru
- Department of Emergency Medicine and Critical Care, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Shemsu Umer Hussen
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| |
Collapse
|
6
|
Weiss BZ, Gordon ES, Zalut T, Alpert EA. Factors that affect pain management in adults diagnosed with acute appendicitis in the emergency department: A retrospective study. Am J Emerg Med 2023; 71:31-36. [PMID: 37327709 DOI: 10.1016/j.ajem.2023.05.038] [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: 11/17/2022] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Analgesic treatment, including with opioids, can safely be given to patients who are suspected of having appendicitis. The study examined factors which may influence the treatment of pain in appendicitis in the adult emergency department (ED). A secondary objective was to determine if analgesia affected clinical outcomes. METHODS This single-center retrospective study examined medical records of all adult patients with a discharge diagnosis of appendicitis. Patients were categorized based on the type of analgesia received in the ED. Variables included the day of week and staffing shift of presentation, gender, age, and triage pain scale, as well as time to ED discharge, imaging, operation, and hospital discharge. Univariable and multivariable logistic regression models were performed to determine which factors influenced treatment and affected outcomes. RESULTS Records of 1839 patients were categorized into three groups - 883 (48%) did not receive analgesia, 571 (31%) received only non-opioid medications, and 385 (21%) received at least one opioid. Patients with a higher triage pain level were significantly more likely to receive analgesia (4-6: OR = 1.85; 95% CI = 1.2-2.84, 7-9: OR = 3.36; 95% CI = 2.18-5.17, 10: OR = 10.78; 95% CI = 6.38-18.23) and at least one opioid (4-6: OR = 2.88; 95% CI = 1.13-7.34, 7-9: OR = 4.36; 95% CI = 1.73-11.01, 10: OR = 6.23; 95% CI = 2.42-16.09). Male gender was associated with a significantly lower likelihood of receiving analgesia (OR = 0.74; 95% CI = 0.61-0.9), but a significantly greater likelihood of receiving at least one opioid given that they received any pain medication (OR = 1.87; 95% CI = 1.41-2.48). Patients aged 25-64 years old were significantly more likely to receive at least one opioid if they received any pain medication (25-44: OR = 1.47; 95% CI = 1.08-2.02, 45-64: OR = 1.78; 95% CI = 1.15-2.76). Presentation to the ED on Sundays was associated with lower rates of opioid treatment (OR = 0.63; 95% CI = 0.42-0.94). Regarding clinical outcomes, patients who received analgesia waited longer for imaging (+0.58 h; 95% CI = 0.31-0.85), stayed longer in the ED (+2.2 h; 95% CI = 1.60-2.79), and had a slightly longer hospitalization (+0.62d; 95% CI = 0.34-0.90). CONCLUSIONS Almost half of patients with appendicitis didn't receive analgesia, with most of those treated receiving only non-opioid analgesia. Older age and Sunday presentations were associated with less opioid treatment. Patients who received analgesia waited longer for imaging, stayed longer in the ED, and had a longer hospitalization.
Collapse
Affiliation(s)
- Boaz Zadok Weiss
- Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.
| | | | - Todd Zalut
- Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Evan Avraham Alpert
- Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Israel
| |
Collapse
|
7
|
Türkmen S, Zaki H, Azad A, Bashir K, Elmoheen A, Shaban E, Iftikhar H, Shallik N. Clinical assessment and risk stratification for prehospital use of methoxyflurane versus standard analgesia in adult patients with trauma pain. Turk J Emerg Med 2023; 23:65-74. [PMID: 37169029 PMCID: PMC10166294 DOI: 10.4103/tjem.tjem_229_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/11/2022] [Accepted: 09/22/2022] [Indexed: 01/28/2023] Open
Abstract
Oligoanalgesia, the undertreatment of trauma-related pain using standard analgesics in prehospital and emergency departments, has been extensively documented as one of the major challenges affecting the effective treatment of trauma-related pain. When administered in low doses, methoxyflurane has been highlighted by numerous medical works of literature to provide an effective, nonopioid, nonnarcotic treatment alternative to standard analgesics for prehospital and emergency department use. Low-dose methoxyflurane has been associated with fast-pain relief in adult patients manifesting moderate-to-severe pain symptoms. This systematic review and meta-analysis aimed to assess the clinical implication of low-dose methoxyflurane use in prehospital and emergency departments in adult patients with moderate-to-severe trauma-related pain. Moreover, the review aimed at assessing the risk stratification associated with using low-dose methoxyflurane in prehospital and emergency departments. The systematic review and meta-analysis performed a comprehensive search for pertinent literature assessing the implications and risks of using low-dose methoxyflurane in adult patients exhibiting moderate-to-severe trauma-related pain in prehospital settings. A comparison between the use of low-dose methoxyflurane and standard-of-care analgesics, placebo, in prehospital settings was reported in four clinically conducted randomized controlled trials (RCTs). These RCTs included the STOP! trial, InMEDIATE, MEDIATA, and the PenASAP trials. A meta-analysis comparing the time taken to achieve first pain relief on initial treatment of patients with moderate-to-severe trauma-related pain favored the use of low-dose methoxyflurane to the standard-of-care analgesics (mean difference = -6.63, 95% confidence interval = -7.37, -5.09) on time taken to establish effective pain relief. Low-dose methoxyflurane has been associated with superior and faster pain relief in prehospital and emergency departments in adult patients exhibiting moderate-to-severe trauma-related pain compared to other standard analgesics.
Collapse
|
8
|
The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain. Curr Oncol Rep 2022; 24:595-602. [PMID: 35192121 DOI: 10.1007/s11912-022-01245-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
Abstract
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.
Collapse
|
9
|
Bond C, Westafer L, Challen K, Milne WK. Hot off the press: the RAMPED trial-methoxyflurane for analgesia in the emergency department. Acad Emerg Med 2021; 28:1179-1182. [PMID: 33772948 DOI: 10.1111/acem.14257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Kirsty Challen
- ScHARR, Regent Court University of Sheffield Sheffield UK
| | | |
Collapse
|
10
|
Friedman J, Lame M, Clark S, Gogia K, Platt SL, Kim JW. Telemedicine Medical Screening Evaluation Expedites the Initiation of Emergency Care for Children. Pediatr Emerg Care 2021; 37:e417-e420. [PMID: 33848095 DOI: 10.1097/pec.0000000000002428] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Prior studies show that staffing a physician at triage expedites care in the emergency department. Our objective was to describe the novel application and effect of a telemedicine medical screening evaluation (Tele-MSE) at triage on quality metrics in the pediatric emergency department (PED). METHODS We conducted a retrospective quasi-experimental pre-post intervention study of patients presenting to an urban PED from December 2017 to November 2019 who received a Tele-MSE at triage. We analyzed 4 diagnostic cohorts: gastroenteritis, psychiatry evaluation, burn injury, and extremity fracture. We matched cases with controls who received standard triage, from December 2015 to November 2017, by age, diagnosis, weekday versus weekend, and season of presentation. Outcome measures included door-to-provider time, time-to-intervention order, and PED length of stay (LOS). RESULTS We included 557 patients who received Tele-MSE during the study period. Compared with controls, patients who received a Tele-MSE at triage had a shorter median door-to-provider time (median difference [MD], 8.4 minutes; 95% confidence interval [CI], 6.0-11.0), time-to-medication order (MD, 27.3 minutes; 95% CI, 22.9-35.2), time-to-consult order (MD, 10.0 minutes; 95% CI, 5.3-12.7), and PED LOS (MD, 0.4 hours; 95% CI, 0.3-0.6). CONCLUSIONS A Tele-MSE is an innovative modality to expedite the initiation of emergency care and reduce PED LOS for children. This novel intervention offers potential opportunities to optimize provider and patient satisfaction and safety during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Jonathan Friedman
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, New York City Health and Hospitals, Jacobi Medical Center; Division of Pediatric Emergency Medicine, Departments of
| | | | - Sunday Clark
- Department of Emergency Medicine, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY
| | - Kriti Gogia
- Department of Emergency Medicine, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY
| | | | | |
Collapse
|
11
|
Santos MBD, Toscano CM, Batista REA, Bohomol E. Assessment of the implementation of a nurse-initiated pain management protocol in the emergency department. Rev Bras Enferm 2021; 74:e20201303. [PMID: 34161508 DOI: 10.1590/0034-7167-2020-1303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/03/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES to assess the implementation of a nurse-initiated pain management protocol for patients triaged as semi-urgent, and its impact in pain intensity, in the Emergency Department. METHODS a prospective cohort study for adult patients with pain who had been triaged as semi-urgent and admitted to the hospital's Emergency Department. Patients who received the intervention (pain-management protocol with analgesic administration) were compared to those who were managed using the conventional approach (physician evaluation prior to analgesic administration). RESULTS of the 185 patients included, 55 (30%) received the intervention, and 130 (70%) were managed conventionally. Patients in the intervention group were more likely to have taken pain medication in the 4 hours prior to admission, and reported higher levels of pain at admission and more significant reductions in pain level. CONCLUSIONS despite low protocol adherence, the intervention resulted in higher reported pain relief.
Collapse
Affiliation(s)
| | | | | | - Elena Bohomol
- Universidade Federal de São Paulo. São Paulo, São Paulo, Brazil
| |
Collapse
|
12
|
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.
Collapse
|
13
|
Leiman D, Jové M, Spahn GR, Palmer P. Patient and Healthcare Professional Satisfaction Ratings and Safety Profile of Sufentanil Sublingual Tablets for Treatment of Acute Pain: A Pooled Demographic Analysis. J Pain Res 2021; 14:805-813. [PMID: 33790642 PMCID: PMC8006952 DOI: 10.2147/jpr.s291359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Objective This analysis reports the healthcare professional global assessment (HPGA) and patient global assessment (PGA) scores and the adverse event (AE) profile by age, body mass index (BMI), sex, and race from the three Phase III registration studies for sufentanil sublingual tablet (SST) 30 mcg. Methods Global assessments and treatment-related AEs were analyzed from patients treated with SST 30 mcg for moderate-to-severe acute pain following surgery or in the emergency department (ED). Pooled data were analyzed across patient demographic subgroups. Results A total of 283 patients were included in the HPGA/PGA analyses. The majority underwent abdominal surgery, with the remaining patients undergoing orthopedic or “other” types of surgery. Overall, SST 30 mcg was highly rated by both healthcare professionals and patients across the demographic subgroups. A total of 323 patients were included in the safety evaluation. The majority of patients did not experience any SST-related AEs; however, those that did experienced common opioid-related side effects such as nausea, headache, dizziness, and vomiting. No patients experienced unexpected AEs or required the use of naloxone. Conclusion SST 30 mcg was highly rated and well tolerated across demographic subgroups with the majority of patients not experiencing any adverse event related to SST 30 mcg. These findings support the use of sublingual sufentanil in all adult patients, regardless of age, BMI, sex, or race for the treatment of moderate-to-severe acute pain.
Collapse
Affiliation(s)
- David Leiman
- HD Research, Houston, TX, USA.,University of Texas at Houston, Department of Surgery, Houston, TX, USA
| | - Maurice Jové
- Atlanta Bone and Joint Specialists, Atlanta, GA, USA
| | - Gail Rosen Spahn
- Medical Affairs, AcelRx Pharmaceuticals, Inc, Redwood City, CA, USA
| | - Pamela Palmer
- Medical Affairs, AcelRx Pharmaceuticals, Inc, Redwood City, CA, USA
| |
Collapse
|
14
|
Brichko L, Gaddam R, Roman C, O’Reilly G, Luckhoff C, Jennings P, Smit DV, Cameron P, Mitra B. Rapid Administration of Methoxyflurane to Patients in the Emergency Department (RAMPED) Study: A Randomized Controlled Trial of Methoxyflurane Versus Standard Care. Acad Emerg Med 2021; 28:164-171. [PMID: 32989888 DOI: 10.1111/acem.14144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/04/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective was to evaluate the effectiveness of methoxyflurane versus standard care for the initial management of severe pain among adult emergency department (ED) patients. METHODS This randomized parallel-group open-label phase IV trial of methoxyflurane was conducted in a tertiary hospital ED setting in Australia. Inclusion criteria required adult patients to have an initial pain score ≥ 8 on the 11-point Numerical Rating Scale (NRS). Patients were randomized 1:1 to receive either inhaled methoxyflurane (3 mL) or standard analgesic treatment at ED triage. The primary outcome was the proportion of patients achieving clinically substantial pain reduction, defined as a ≥50% drop in the pain score at 30 minutes. Secondary outcomes included the pain score at multiple time points (15, 30, 60, 90 minutes) and the difference in the proportion of patients achieving a >2-point reduction on the NRS. RESULTS There were 120 patients randomized and analyzed between September 4, 2019, and January 16, 2020. The primary outcome was achieved in six (10%) patients in the methoxyflurane arm and three (5%) in the standard care arm (p = 0.49). A higher proportion of patients in the methoxyflurane arm reported a >2-point drop on the NRS at all time points (17% vs. 5% at 15 minutes, 25% vs. 9% at 30 minutes, 30% vs. 10% at 60 minutes, and 33% vs. 13% at 90 minutes). Methoxyflurane use was also associated with lower median pain scores at all time points. CONCLUSION Initial management with inhaled methoxyflurane in the ED did not achieve the prespecified substantial reduction in pain, but was associated with clinically significant lower pain scores compared to standard therapy.
Collapse
Affiliation(s)
- Lisa Brichko
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- School of Public Health & Preventive Medicine Monash MelbourneAustralia
- Emergency Department Cabrini Hospital MelbourneAustralia
| | - Ravali Gaddam
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- Central Clinical School Monash MelbourneAustralia
| | - Cristina Roman
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- Pharmacy Department Alfred Health MelbourneAustralia
- Centre for Medication Use and Safety Faculty of Pharmacy and Pharmaceutical Sciences Monash MelbourneAustralia
| | - Gerard O’Reilly
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- School of Public Health & Preventive Medicine Monash MelbourneAustralia
- and National Trauma and Research Institute Alfred Health MelbourneAustralia
| | - Carl Luckhoff
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
| | - Paul Jennings
- School of Public Health & Preventive Medicine Monash MelbourneAustralia
- and Ambulance Victoria Melbourne Australia
- and Department of Paramedicine Monash University MelbourneAustralia
| | - De Villiers Smit
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- School of Public Health & Preventive Medicine Monash MelbourneAustralia
- and National Trauma and Research Institute Alfred Health MelbourneAustralia
| | - Peter Cameron
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- School of Public Health & Preventive Medicine Monash MelbourneAustralia
| | - Biswadev Mitra
- From Emergency and Trauma Centre Alfred Health MelbourneAustralia
- School of Public Health & Preventive Medicine Monash MelbourneAustralia
- and National Trauma and Research Institute Alfred Health MelbourneAustralia
| |
Collapse
|
15
|
Fabbri A, Borobia AM, Ricard-Hibon A, Coffey F, Caumont-Prim A, Montestruc F, Soldi A, Traseira Lugilde S, Dickerson S. Low-Dose Methoxyflurane versus Standard of Care Analgesics for Emergency Trauma Pain: A Systematic Review and Meta-Analysis of Pooled Data. J Pain Res 2021; 14:93-105. [PMID: 33505170 PMCID: PMC7829133 DOI: 10.2147/jpr.s292521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Undertreatment of trauma-related pain is common in the pre-hospital and hospital settings owing to barriers to the use of traditional standard of care analgesics. Low-dose methoxyflurane is an inhaled non-opioid analgesic with a rapid onset of pain relief that is approved for emergency relief of moderate-to-severe trauma-related pain in adults. This analysis was performed to compare the efficacy and safety of low-dose methoxyflurane with standard of care analgesics in adults with trauma-related pain. Methods A meta-analysis was performed on pooled data from randomized controlled trials identified via a systematic review. The primary endpoint was the pain intensity difference between baseline and various time intervals (5, 10, 15, 20, and 30 minutes) after initiation of treatment. Results The pain intensity difference was statistically superior with low-dose methoxyflurane compared with standard of care analgesics (overall estimated treatment effect=11.88, 95% CI=9.75–14.00; P<0.0001). The superiority of low-dose methoxyflurane was demonstrated at 5 minutes after treatment initiation and was maintained across all timepoints. Significantly more patients treated with methoxyflurane achieved response criteria of pain intensity ≤30 mm on a visual analog scale, and relative reductions in pain intensity of ≥30% and ≥50%, compared with patients who received standard of care analgesics. The median time to pain relief was shorter with methoxyflurane than with standard of care analgesics. The findings were consistent in a subgroup of elderly patients (aged ≥65 years). Conclusion Methoxyflurane can be considered as an alternative to standard of care analgesics in pre-hospital and hospital settings for treatment of adult patients with acute trauma-related pain.
Collapse
Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Alberto M Borobia
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
| | - Agnes Ricard-Hibon
- Emergency Department SAMU-SMUR 95, CHG Pontoise-Beaumont/Oise, Pontoise, France
| | - Frank Coffey
- DREEAM: Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | | | | | | |
Collapse
|
16
|
Sin B, Sikorska G, YauLin J, Bonitto RA, Motov SM. Comparing Nonopioids Versus Opioids for Acute Pain in the Emergency Department: A Literature Review. Am J Ther 2021; 28:e52-e86. [DOI: 10.1097/mjt.0000000000001098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
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: 3] [Impact Index Per Article: 0.8] [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.
Collapse
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
| |
Collapse
|
18
|
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.
Collapse
|
19
|
Longacre CF, Nyman JA, Visscher SL, Borah BJ, Cheville AL. Cost-effectiveness of the Collaborative Care to Preserve Performance in Cancer (COPE) trial tele-rehabilitation interventions for patients with advanced cancers. Cancer Med 2020; 9:2723-2731. [PMID: 32090502 PMCID: PMC7163089 DOI: 10.1002/cam4.2837] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/15/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this analysis was to determine the cost‐effectiveness of a Collaborative Care Model (CCM)‐based, centralized telecare approach to delivering rehabilitation services to late‐stage cancer patients experiencing functional limitations. Methods Data for this analysis came from the Collaborative Care to Preserve Performance in Cancer (COPE) trial, a randomized control trial of 516 patients assigned to: (a) a control group (arm A), (b) tele‐rehabilitation (arm B), and (c) tele‐rehabilitation plus pharmacological pain management (arm C). Patient quality of life was measured using the EQ‐5D‐3L at baseline, 3‐month, and 6‐month follow‐up. Direct intervention costs were measured from the experience of the trial. Participants’ hospitalization data were obtained from their medical records, and costs associated with these encounters were estimated from unit cost data and hospital‐associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients for whom comprehensive cost capture was possible. Results In the intervention‐only model, tele‐rehabilitation (arm B) was found to be the dominant strategy, with an incremental cost‐effectiveness ratio (ICER) of $15 494/QALY. At the $100 000 willingness‐to‐pay threshold, this tele‐rehabilitation was the cost‐effective strategy in 95.4% of simulations. It was found to be cost saving compared to enhanced usual care once the downstream hospitalization costs were taken into account. In the total cost analysis, total inpatient hospitalization costs were significantly lower in both tele‐rehabilitation (arm B) and tele‐rehabilitation plus pain management (arm C) compared to control (arm A), (P = .048). Conclusion The delivery of a CCM‐based, centralized tele‐rehabilitation intervention to patients with advanced stage cancer is highly cost‐effective. Clinicians and care teams working with this vulnerable population should consider incorporating such interventions into their patient care plans.
Collapse
Affiliation(s)
- Colleen F Longacre
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - John A Nyman
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Sue L Visscher
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Bijan J Borah
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
20
|
Miner JR. Sublingual analgesia: a promising proposal for the treatment of pain. Expert Opin Drug Deliv 2020; 17:123-126. [PMID: 31933384 DOI: 10.1080/17425247.2020.1714588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- James R Miner
- Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.,Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
21
|
The Use of a Nurse-Initiated Pain Protocol in the Emergency Department for Patients with Musculoskeletal Injury: A Pre-Post Intervention Study. Pain Manag Nurs 2019; 20:639-648. [DOI: 10.1016/j.pmn.2019.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/10/2019] [Accepted: 02/23/2019] [Indexed: 11/21/2022]
|
22
|
Pooled Dosing and Efficacy Analysis of the Sufentanil Sublingual Tablet 30 mcg Across Demographic Subgroups for the Management of Moderate-to-Severe Acute Pain. J Perianesth Nurs 2019; 35:22-28. [PMID: 31732448 DOI: 10.1016/j.jopan.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/12/2019] [Accepted: 08/25/2019] [Indexed: 11/23/2022]
Abstract
PURPOSE To aid nurses in dosing sufentanil sublingual tablet (SST) 30 mcg administered via a single-dose applicator, dosing requirements and efficacy of SST 30 mcg were analyzed across age, sex, race, and body mass index subgroups. DESIGN Patient characteristics were pooled from three postoperative studies (two placebo-controlled and one open-label) and one open-label emergency department study. Drug dosing and efficacy data were pooled from the postoperative studies. METHODS Efficacy was assessed through summed pain intensity difference to baseline during 12 hours across subgroups. FINDINGS Mean (standard deviation) drug doses administered from 0 to 12 hours was 3.9 (2.0) for SST 30 mcg and was less frequent for older (≥65 years) versus younger patients. The summed pain intensity difference to baseline during 12 hours was superior with SST 30 mcg versus placebo across all subgroups. CONCLUSIONS SST 30 mcg is a sublingual opioid analgesic with efficacy across demographic subgroups.
Collapse
|
23
|
Segura-Grau E, Afonso A. Clinical ultrasound in the management of polytraumatized patients in the daily practice of the anesthesiologist. ACTA ACUST UNITED AC 2019; 66:434-438. [PMID: 31466799 DOI: 10.1016/j.redar.2019.06.005] [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: 02/15/2019] [Revised: 06/04/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022]
Abstract
Ultrasound has an important role in the diagnosis and prognosis of polytrauma patients. We describe a case of a 52-year-old man with hemodynamic instability and multiple injuries. Abdominal ultrasound evaluation was positive for hemoperitoneum, so an exploratory laparotomy was performed. During the intraoperative period, lung ultrasound was used to exclude traumatic lung injury. In the right lung, lung ultrasound suggested the presence of pneumothorax, and in the left a subpleural consolidation. Subsequently, a computed tomography was performed, confirming the sonographic findings. On the fourth admission day, he underwent surgical correction of a left hip fracture. A type 2 quadratus lumborum block (ultrasound-guided) was performed before surgical incision. The procedure was uneventful. The patient remained hemodynamically stable, without indirect signs of pain. This case shows that ultrasound-guided examination plays a crucial role in the management of polytrauma patients. It was a fundamental diagnostic tool in the initial evaluation, and was also used during surgery.
Collapse
Affiliation(s)
- E Segura-Grau
- Servicio de Anestesiología, Centro Hospitalar Tondela-Viseu, Viseu, Portugal.
| | - A Afonso
- Servicio de Anestesiología, Instituto Português de Oncologia do Porto-Francisco Gentil, Porto, Portugal
| |
Collapse
|
24
|
Blancher M, Maignan M, Clapé C, Quesada JL, Collomb-Muret R, Albasini F, Ageron FX, Fey S, Wuyts A, Banihachemi JJ, Bertrand B, Lehmann A, Bollart C, Debaty G, Briot R, Viglino D. Intranasal sufentanil versus intravenous morphine for acute severe trauma pain: A double-blind randomized non-inferiority study. PLoS Med 2019; 16:e1002849. [PMID: 31310600 PMCID: PMC6634380 DOI: 10.1371/journal.pmed.1002849] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/07/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intravenous morphine (IVM) is the most common strong analgesic used in trauma, but is associated with a clear time limitation related to the need to obtain an access route. The intranasal (IN) route provides easy administration with a fast peak action time due to high vascularization and the absence of first-pass metabolism. We aimed to determine whether IN sufentanil (INS) for patients presenting to an emergency department with acute severe traumatic pain results in a reduction in pain intensity non-inferior to IVM. METHODS AND FINDINGS In a prospective, randomized, multicenter non-inferiority trial conducted in the emergency departments of 6 hospitals across France, patients were randomized 1:1 to INS titration (0.3 μg/kg and additional doses of 0.15 μg/kg at 10 minutes and 20 minutes if numerical pain rating scale [NRS] > 3) and intravenous placebo, or to IVM (0.1 mg/kg and additional doses of 0.05 mg/kg at 10 minutes and 20 minutes if NRS > 3) and IN placebo. Patients, clinical staff, and research staff were blinded to the treatment allocation. The primary endpoint was the total decrease on NRS at 30 minutes after first administration. The prespecified non-inferiority margin was -1.3 on the NRS. The primary outcome was analyzed per protocol. Adverse events were prospectively recorded during 4 hours. Among the 194 patients enrolled in the emergency department cohort between November 4, 2013, and April 10, 2016, 157 were randomized, and the protocol was correctly administered in 136 (69 IVM group, 67 INS group, per protocol population, 76% men, median age 40 [IQR 29 to 54] years). The mean difference between NRS at first administration and NRS at 30 minutes was -4.1 (97.5% CI -4.6 to -3.6) in the IVM group and -5.2 (97.5% CI -5.7 to -4.6) in the INS group. Non-inferiority was demonstrated (p < 0.001 with 1-sided mean-equivalence t test), as the lower 97.5% confidence interval of 0.29 (97.5% CI 0.29 to 1.93) was above the prespecified margin of -1.3. INS was superior to IVM (intention to treat analysis: p = 0.034), but without a clinically significant difference in mean NRS between groups. Six severe adverse events were observed in the INS group and 2 in the IVM group (number needed to harm: 17), including an apparent imbalance for hypoxemia (3 in the INS group versus 1 in the IVM group) and for bradypnea (2 in the INS group versus 0 in the IVM group). The main limitation of the study was that the choice of concomitant analgesics, when they were used, was left to the discretion of the physician in charge, and co-analgesia was more often used in the IVM group. Moreover, the size of the study did not allow us to conclude with certainty about the safety of INS in emergency settings. CONCLUSIONS We confirm the non-inferiority of INS compared to IVM for pain reduction at 30 minutes after administration in patients with severe traumatic pain presenting to an emergency department. The IN route, with no need to obtain a venous route, may allow early and effective analgesia in emergency settings and in difficult situations. Confirmation of the safety profile of INS will require further larger studies. TRIAL REGISTRATION ClinicalTrials.gov NCT02095366. EudraCT 2013-001665-16.
Collapse
Affiliation(s)
- Marc Blancher
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
- * E-mail:
| | - Maxime Maignan
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France
| | - Cyrielle Clapé
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Quesada
- Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Roselyne Collomb-Muret
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - François Albasini
- Emergency Department and Mobile Intensive Care Unit, Saint-Jean-de-Maurienne Hospital, Saint-Jean-de-Maurienne France
| | | | - Stephanie Fey
- Emergency Department and Mobile Intensive Care Unit, Metropole Savoie Hospital, Chambery, France
| | - Audrey Wuyts
- Emergency Department, Albertville–Moutiers Hospital, Moutiers, France
| | - Jean-Jacques Banihachemi
- Emergency Trauma Unit, Department of Orthopedic Surgery and Sport Traumatology, Hôpital Sud, Grenoble Alpes University Hospital, Grenoble, France
| | - Barthelemy Bertrand
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Audrey Lehmann
- Pharmacy Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Claire Bollart
- Clinical and Innovation Research Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Guillaume Debaty
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
- CNRS TIMC-IMAG Laboratory, UMR 5525, University Grenoble Alpes, Grenoble, France
| | - Raphaël Briot
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
- CNRS TIMC-IMAG Laboratory, UMR 5525, University Grenoble Alpes, Grenoble, France
| | - Damien Viglino
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France
| |
Collapse
|
25
|
Miller AC, Khan AM, Castro Bigalli AA, Sewell KA, King AR, Ghadermarzi S, Mao Y, Zehtabchi S. Neuroleptanalgesia for acute abdominal pain: a systematic review. J Pain Res 2019; 12:787-801. [PMID: 30881092 PMCID: PMC6396833 DOI: 10.2147/jpr.s187798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Acute abdominal pain (AAP) comprises up to 10% of all emergency department (ED) visits. Current pain management practice is moving toward multi-modal analgesia regimens that decrease opioid use. OBJECTIVE This project sought to determine whether, in patients with AAP (population), does administration of butyrophenone antipsychotics (intervention) compared to placebo, usual care, or opiates alone (comparisons) improve analgesia or decrease opiate consumption (outcomes)? METHODS A structured search was performed in Cochrane CENTRAL, CINAHL, Database of Abstracts of Reviews of Effects, Directory of Open Access Journals, Embase, IEEE-Xplorer, Latin American and Caribbean Health Sciences Literature, Magiran, PubMed, Scientific Information Database, Scopus, TÜBİTAK ULAKBİM, and Web of Science. Clinical trial registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Australian New Zealand Clinical Trials Registry), relevant bibliographies, and conference proceedings were also searched. Searches were not limited by date, language, or publication status. Studies eligible for inclusion were prospective randomized clinical trials enrolling patients (age ≥18 years) with AAP treated in acute care environments (ED, intensive care unit, postoperative). The butyrophenone must have been administered either intravenously or intra-muscularly. Comparison groups included placebo, opiate only, corticosteroids, non-steroidal anti-inflammatory drugs, or acetaminophen. RESULTS We identified 7,217 references. Six studies met inclusion criteria. One study assessed ED patients with AAP associated with gastroparesis, whereas five studies assessed patients with postoperative AAP: abdominal hysterectomy (n=4), sleeve gastrectomy (n=1). Three of four studies found improvements in pain intensity with butyrophenone use. Three of five studies reported no change in postoperative opiate consumption, while two reported a decrease. One ED study reported no change in patient satisfaction, while one postoperative study reported improved satisfaction scores. Both extrapyramidal side effects (n=3) and sedation (n=3) were reported as unchanged. CONCLUSION Based on available evidence, we cannot draw a conclusion on the efficacy or benefit of neuroleptanalgesia in the management of patients with AAP. However, preliminary data suggest that it may improve analgesia and decrease opiate consumption.
Collapse
Affiliation(s)
- Andrew C Miller
- Department of Emergency Medicine, Vidant Medical Center, Brody School of Medicine, East Carolina University, Greenville, NC, USA,
- The MORZAK Collaborative, Orlando, FL, USA,
| | | | | | - Kerry A Sewell
- William E. Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Alexandra R King
- Division of Emergency Medicine and Toxicology, Department of Pharmacy, Vidant Medical Center, Greenville, NC, USA
| | - Shadi Ghadermarzi
- Department of Internal Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Yuxuan Mao
- Department of Internal Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| |
Collapse
|
26
|
Assessment of Acute Pain Management and Associated Factors among Emergency Surgical Patients in Gondar University Specialized Hospital Emergency Department, Northwest Ethiopia, 2018: Institutional Based Cross-Sectional Study. PAIN RESEARCH AND TREATMENT 2019; 2018:5636039. [PMID: 30631598 PMCID: PMC6304567 DOI: 10.1155/2018/5636039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 10/12/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022]
Abstract
Background Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients. Patients and Methods After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department. Results A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery. Conclusion The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice.
Collapse
|
27
|
Maignan M, Termoz-Masson N, Viglino D. Retour d’expérience sur l’utilisation du méthoxyflurane aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’oligoanalgésie chez le patient traumatisé aux urgences est une situation fréquente du fait de la complexité de la prise en charge de la douleur. L’une des solutions les mieux décrites à ce problème est l’utilisation d’analgésiques dès l’admission du patient. Ce type de protocole est à privilégier notamment en cas de filière de prise en charge rapide au sein des urgences. Le méthoxyflurane est un éther halogéné volatil utilisé en médecine. Son inhalation produit une analgésie supérieure au placebo. Du fait de sa rapidité d’action, de sa facilité d’emploi et de ses propriétés antalgiques, le méthoxyflurane doit faire partie de l’arsenal des thérapeutiques antalgiques aux urgences. Aux urgences du CHU de Grenoble-Alpes, nous privilégions l’utilisation du méthoxyflurane au sein d’un protocole d’analgésie multimodale du patient adulte traumatisé. Dans cette indication, le méthoxyflurane permet d’amorcer l’analgésie et de faire le pont jusqu’à ce que les autres thérapeutiques soient efficaces.
Collapse
|
28
|
Porter KM, Dayan AD, Dickerson S, Middleton PM. The role of inhaled methoxyflurane in acute pain management. Open Access Emerg Med 2018; 10:149-164. [PMID: 30410414 PMCID: PMC6200081 DOI: 10.2147/oaem.s181222] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methoxyflurane is an inhaled analgesic administered via a disposable inhaler which has been used in Australia for over 40 years for the management of pain associated with trauma and for medical procedures in children and adults. Now available in 16 countries worldwide, it is licensed in Europe for moderate to severe pain associated with trauma in conscious adults, although additional applications are being made to widen the range of approved indications. Considering these ongoing developments, we reviewed the available evidence on clinical usage and safety of inhaled analgesic methoxyflurane in trauma pain and in medical procedures in both adults and children. Published data on methoxyflurane in trauma and procedural pain show it to be effective, well tolerated, and highly rated by patients, providing rapid onset of analgesia. Methoxyflurane has a well-established safety profile; adverse events are usually brief and self-limiting, and no clinically significant effects on vital signs or consciousness levels have been reported. Nephrotoxicity previously associated with methoxyflurane at high anesthetic doses is not reported with low analgesic doses. Although two large retrospective comparative studies in the prehospital setting showed inhaled analgesic methoxyflurane to be less effective than intravenous morphine and intranasal fentanyl, this should be balanced against the administration, supervision times, and safety profile of these agents. Given the limitations of currently available analgesic agents in the prehospital and emergency department settings, the ease of use and portability of methoxyflurane combined with its rapid onset of effective pain relief and favorable safety profile make it a useful nonopioid option for pain management. Except for the STOP! study, which formed the basis for approval in trauma pain in Europe, and a few smaller randomized controlled trials (RCTs), much of the available data are observational or retrospective, and further RCTs are currently underway to provide more robust data.
Collapse
Affiliation(s)
- Keith M Porter
- Trauma Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Sara Dickerson
- Medical Affairs, Mundipharma International Limited, Cambridge, UK,
| | - Paul M Middleton
- Emergency Medicine Research Unit, Liverpool Hospital, Sydney, NSW, Australia
- Distributed Research in Emergency and Acute Medicine (DREAM) Collaboration, Sydney, NSW, Australia
| |
Collapse
|
29
|
Miner JR, Rafique Z, Minkowitz HS, DiDonato KP, Palmer PP. Sufentanil sublingual tablet 30 mcg for moderate-to-severe acute pain in the ED. Am J Emerg Med 2018; 36:954-961. [DOI: 10.1016/j.ajem.2017.10.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022] Open
|
30
|
Abstract
Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.
Collapse
|
31
|
Sin B, Wiafe J, Ciaramella C, Valdez L, Motov SM. The use of intranasal analgesia for acute pain control in the emergency department: A literature review. Am J Emerg Med 2018; 36:310-318. [DOI: 10.1016/j.ajem.2017.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022] Open
|
32
|
Roman C, Poole S, Walker C, Smit DV, Dooley MJ. A ‘time and motion’ evaluation of automated dispensing machines in the emergency department. ACTA ACUST UNITED AC 2016; 19:112-7. [DOI: 10.1016/j.aenj.2016.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/14/2016] [Accepted: 01/22/2016] [Indexed: 01/09/2023]
|
33
|
Pierik JGJ, Berben SA, IJzerman MJ, Gaakeer MI, van Eenennaam FL, van Vugt AB, Doggen CJM. A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain. Int Emerg Nurs 2016; 27:3-10. [PMID: 26968352 DOI: 10.1016/j.ienj.2016.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 11/16/2022]
Abstract
While acute musculoskeletal pain is a frequent complaint, its management is often neglected. An implementation of a nurse-initiated pain protocol based on the algorithm of a Dutch pain management guideline in the emergency department might improve this. A pre-post intervention study was performed as part of the prospective PROTACT follow-up study. During the pre- (15 months, n = 504) and post-period (6 months, n = 156) patients' self-reported pain intensity and pain treatment were registered. Analgesic provision in patients with moderate to severe pain (NRS ≥4) improved from 46.8% to 68.0%. Over 10% of the patients refused analgesics, resulting into an actual analgesic administration increase from 36.3% to 46.1%. Median time to analgesic decreased from 10 to 7 min (P < 0.05), whereas time to opioids decreased from 37 to 15 min (P < 0.01). Mean pain relief significantly increased to 1.56 NRS-points, in patients who received analgesic treatment even up to 2.02 points. The protocol appeared to lead to an increase in analgesic administration, shorter time to analgesics and a higher clinically relevant pain relief. Despite improvements, suffering moderate to severe pain at ED discharge was still common. Protocol adherence needs to be studied in order to optimize pain management.
Collapse
Affiliation(s)
- Jorien G J Pierik
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Drienerlolaan 5, P.O. Box 217, 7522 NB, Enschede, Netherlands.
| | - Sivera A Berben
- Regional Emergency Healthcare Network, Radboud University Medical Center, Nijmegen, Netherlands; Faculty of Health and Social Studies, Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, Netherlands
| | - Maarten J IJzerman
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Drienerlolaan 5, P.O. Box 217, 7522 NB, Enschede, Netherlands
| | - Menno I Gaakeer
- Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes, Netherlands
| | - Fred L van Eenennaam
- Ambulance Oost, Hengelo, Netherlands; Anesthesiology, Ziekenhuisgroep Twente, Almelo, Netherlands
| | - Arie B van Vugt
- Emergency Department, Medisch Spectrum Twente, Enschede, Netherlands
| | - Carine J M Doggen
- Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Drienerlolaan 5, P.O. Box 217, 7522 NB, Enschede, Netherlands
| |
Collapse
|
34
|
Abstract
BACKGROUND Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders. OBJECTIVE A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes. RESEARCH DESIGN A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009. SUBJECTS A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included. MEASURES The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity. RESULTS On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357). DISCUSSION In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.
Collapse
|
35
|
Ratneswaran C, Dodd K, Enright K, Dasan S. A multi-faceted approach to increase appropriate analgesia prescribing in the emergency department. BMJ QUALITY IMPROVEMENT REPORTS 2016; 4:bmjquality_uu204091.w3774. [PMID: 26734441 PMCID: PMC4693099 DOI: 10.1136/bmjquality.u204091.w3774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/13/2015] [Accepted: 10/14/2015] [Indexed: 11/25/2022]
Abstract
Pain is the most common presenting complaint within the emergency department. Whilst national RCEM guidelines exist, there tends to be low compliance with its use. A retrospective, cross-sectional audit, over a 24 hour period, was carried out in the emergency department of a tertiary hospital in London on all patients with abdominal pain. Pain score documentation was checked as well as: whether analgesia prescribed was compliant with guidelines, time to prescription, and if pain scores were rechecked within an hour. Cycle 1 (21 patients) showed that only 29% of patients were prescribed analgesia in accordance with guidelines, 38% of pain scores were documented at triage, and only 19% of scores were rechecked at any time. 22% of patients in severe pain were prescribed analgesia within the recommended duration from presentation (20 minutes). New guidelines, adapted from RCEM, were departmentally approved and disseminated to reflect local medication use. Monthly doctor and nurse teaching sessions were established to improve guideline compliance, objective pain score documentation, and encourage results driven performance. A nurse prescriber champion was established to encourage analgesia prescribing competence in addressing delayed administration. Finally, plans to integrate electronic pain scoring with timer prompts for rechecking are in place to help streamline the process. Following these interventions, cycle 2 (n=23) showed 87% of pain scores were documented at triage, 52% were prescribed guideline concordant analgesia, and 40% of severe pain scores were acted upon in time. Cycle 3 (n=33) demonstrated the need for monthly educational intervention to maintain high standards; as in its absence, any improvement returned to baseline.
Collapse
Affiliation(s)
| | - Kevin Dodd
- St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Kevin Enright
- St George's University Hospitals NHS Foundation Trust, United Kingdom
| | - Sunil Dasan
- St George's University Hospitals NHS Foundation Trust, United Kingdom
| |
Collapse
|
36
|
Grissa MH, Boubaker H, Zorgati A, Beltaïef K, Zhani W, Msolli MA, Bzeouich N, Bouida W, Boukef R, Nouira S. Efficacy and safety of nebulized morphine given at 2 different doses compared to IV titrated morphine in trauma pain. Am J Emerg Med 2015; 33:1557-61. [PMID: 26143313 DOI: 10.1016/j.ajem.2015.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 06/04/2015] [Accepted: 06/04/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Our aim was to compare the efficacy and safety of intravenous (IV) titrated morphine with nebulized morphine given at 2 different doses in severe traumatic pain. METHODS In a prospective, randomized, controlled double-blind study, we included 300 patients with severe traumatic pain. They were assigned to 3 groups: Neb10 group received 1 nebulization of 10-mg morphine; Neb20 group received 1 nebulization of 20-mg morphine, repeated every 10 minutes with a maximum of 3 nebulizations; and the IV morphine group received 2-mg IV morphine repeated every 5 minutes until pain relief. Visual analog scale was monitored at baseline, 5, 10, 15, 20, 25, 30, and 60 minutes after the start of drug administration. Treatment success was defined by the percentage of patients in whom visual analog scale decreased greater than or equal to 50% of its baseline value. When this end point was not reached, rescue morphine was administered. Pain resolution time was defined by the elapsed time between the start of the protocol and the reach of treatment success criteria. RESULTS Success rate was significantly better at 97% (95% confidence interval [CI], 93-100) for Neb20 group compared to Neb10 group (81% [95% CI, 73-89]) and IV morphine group (79% [95% CI, 67-84]). The lowest resolution time was observed in Neb20 group (20 minutes [95% CI, 18-21]). Side effects were minor and significantly lower in both nebulization groups compared to IV morphine group. CONCLUSIONS Nebulized morphine using boluses of 10 mg has similar efficacy and better safety than IV titrated morphine in patients with severe posttraumatic pain. Increasing nebulized boluses to 20 mg increases the effectiveness without increasing side effects.
Collapse
Affiliation(s)
- Mohamed Habib Grissa
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Asma Zorgati
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Kaouthar Beltaïef
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Wafa Zhani
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | | | - Nasri Bzeouich
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, Sousse, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia; Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
| |
Collapse
|