Long-Bone Fracture Pain Management in the Emergency Department

Racial Disparities in Opioid Prescribing in the United States from 2011 to 2021: A Systematic Review and Meta-Analysis

Background

This meta-analysis is an update to a seminal meta-analysis on racial/ethnic disparities in pain treatment in the United States (US) published in 2012. Since then, literature has accumulated on the topic and important policy changes were made.

Objective

Examining racial/ethnic disparities in pain management and investigating key moderators of the association between race/ethnicity and pain outcomes in the US.

Methods

We performed a systematic search of publications (between January 2011 and February 2021) from the Scopus database. Search terms included: race, racial, racialized, ethnic, ethnicity, minority, minorities, minoritized, pain treatment, pain management, and analgesia. All studies were observational, examining differences in receipt of pain prescription medication in various settings, across racial or ethnic categories in US adult patient populations. Two binary analgesic outcomes were extracted: 1) prescription of "any" analgesia, and 2) prescription of "opioid" analgesia. We analyzed these outcomes in two populations: 1) Black patients, with White patients as a reference; and 2) Hispanic patients, with non-Hispanic White patients as a reference.

Results

The meta-analysis included twelve studies, and the systematic review included forty-three studies. Meta-analysis showed that, compared to White patients, Black patients were less likely to receive opioid analgesia (OR 0.83, 95% CI [0.73-0.94]). Compared to non-Hispanic White patients, Hispanic patients were less likely to receive opioid analgesia (OR 0.80, 95% CI [0.72-0.88]).

Conclusion

Despite a decade's gap, the findings indicate persistent disparities in prescription of, and access to opioid analgesics for pain among Black and Hispanic populations in the US.

Standardized Management of Sickle Cell Disease Patients and the Effects on Care Utilization and Costs

An individualized management program for patients with sickle cell disease (SCD) was created to reduce health care utilization and cost. The program was implemented to standardize the management of patients with SCD. SCD encounters from January 2010 to December 2020 were reviewed for analysis. Preintervention utilization of inpatient, emergency room, and outpatient settings was compared to postintervention. There were 7114 encounters analyzed. Outpatient encounters increased from 36.5% to 70.9%; inpatient encounters decreased from 38.6% to 20.3%; and emergency department visits decreased from 20.3% to 8.8%. The number of high inpatient utilizers decreased 8.4% and the number of individuals who received any emergency care decreased 11.9%. When comparing average charges per time period, the median charge per encounter decreased by $1838 postintervention compared to preintervention. This newly implemented SCD program demonstrated success through shifting the care of the SCD patient to the outpatient setting rather than the emergency department or inpatient hospitalizations.

Comparison of analgesic efficacy of ibuprofen and dexketoprofen in pain management of long bone fractures: a prospective, randomized, double-blind study

INTRODUCTION

Long bone fractures (LBF) often cause severe pain, impacting patients' quality of life. This prospective, randomized, double-blind study aimed to compare the analgesic efficacy of dexketoprofen (Dex) and ibuprofen (Ibu) in LBF patients in the emergency department.

METHODS

Conducted between August 10, 2023, and January 17, 2024, the study included 100 eligible patients randomized into Dex and Ibu groups. Visual analog scale (VAS) scores were measured at baseline and at 30, 60, and 120 min. DeltaVAS (ΔVAS) values and ΔVAS percentages (ΔVAS%) were calculated. Primary endpoints were ΔVAS scores (ΔVAS 30-60-120) and ΔVAS% for comparative analysis.

RESULTS

Statistical analysis showed no significant difference in ΔVAS30 (p = 0.359). However, ΔVAS60 exhibited a significant difference (p = 0.027), as did ΔVAS120 (p = < 0.001). ΔVAS%30 showed no significance (p = 0.224), but ΔVAS%60 and ΔVAS%120 were clinically and statistically significant (p = 0.017 and p = < 0.001, respectively).

CONCLUSION

Ibuprofen 800 mg demonstrated superior analgesic efficacy at 60 and 120 min compared to Dex in long bone fractures. These findings suggest ibuprofen's potential as an effective pain management option in emergency departments.

Comparing intravenous lidocaine and pethidine for pain management in emergency department patients with femoral bone fracture: a randomized controlled trial

BACKGROUND

Intravenous lidocaine has shown promise as an effective analgesic in various clinical settings, but its utility for pain management in emergency departments, especially for bone fractures, remains relatively understudied.

OBJECTIVE

This study compared intravenous lidocaine to pethidine for femoral bone fracture pain management.

METHODS

This double-blind, randomized, controlled clinical trial was conducted in the emergency department of AJA University of Medical Sciences affiliated hospitals. Patients aged 18-70 years-old with femoral bone fracture and experiencing severe pain, defined as a numerical rating scale (NRS) of pain ≥ 7, were included in the study. One group received intravenous pethidine (25 mg), while the other group received intravenous lidocaine (3 mg/kg, not exceeding 200 mg), infused with 250 ml saline over 20 min. Pain levels were evaluated before treatment administration (0 min) and at 10, 20, 30, 40, 50, and 60 min after treatment administration using the NRS.

RESULTS

Seventy-two patients were enrolled in the study. Demographic characteristics and pain scores were similar between the two groups. The mean pain scores upon arrival for the lidocaine and pethidine groups were 8.50 ± 1 and 8.0 ± 1, respectively; after one hour, they were 4.0 ± 1 and 4.0 ± 1, respectively. While there was a statistically significant reduction in pain in both groups after one hour, there were no clinically or statistically significant differences between the two groups (p = 0.262). Pethidine had a higher incidence of adverse events, though not statistically significant. Additionally, females required more rescue analgesics.

CONCLUSION

The administration of intravenous lidocaine is beneficial for managing pain in femoral bone fractures, suggesting that lidocaine could be a potent alternative to opioids.

TRIAL REGISTRATION

IRCT20231213060355N1 ( https://irct.behdasht.gov.ir/trial/74624 ) (30/12/2023).

An exploratory study of acute analgesia in tibial shaft fractures: a comparison between Māori and Non-Māori

BACKGROUND

Published research suggests Indigenous peoples are less likely to receive analgesia in acute pain settings however there is limited data on the indigenous New Zealand Māori population. The aim of this exploratory pilot study was to compare management between Māori and non-Māori for acute fracture pain in a regional trauma centre.

METHODS

A retrospective review was undertaken for 120 patients with isolated tibial shaft fractures presenting at a tertiary level trauma center between 2015 and 2020. Outcome measures reflected the patient journey including type of analgesia charted pre-hospital, in the ED and on the ward.

RESULTS

Out of 104 matched patients, 48 (46%) were Māori and 65% were male. Fewer Māori received pre-hospital analgesia compared with non-Māori (odds ratio 0.29, p = 0.006). Pain scores were similar on arrival to ED (6.1 ± 3.5 versus 5.4 ± 2.7, p = 0.2). Once at hospital, there were similar rates of prescribed analgesia (paracetamol, NSAIDs, synthetics, or opioids) both in ED and the ward. Time to analgesia were also similar for both groups (72 ± 71 min versus 65 ± 63 min, P > 0.9).

DISCUSSION

We found differences in pre-hospital administration of analgesia between Māori and non-Māori patients with tibial shaft fractures. However once in hospital although there was a trend towards lower prescribing for Māori, there were no significant differences. Exploring the reasons underpinning this difference and the development of robust analgesic guidelines for tibial shaft fractures may help in reducing this inequity in care, particularly in the pre-hospital setting.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care

BACKGROUND

Disparities in trauma outcomes and care are well established for adults, but the extent to which similar disparities are observed in pediatric trauma patients requires further investigation. The objective of this study was to evaluate the unique contributions of social determinants (race, gender, insurance status, community distress, rurality/urbanicity) on trauma outcomes after controlling for specific injury-related risk factors.

STUDY DESIGN

All pediatric (age < 18) trauma patients admitted to a single level 1 trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed (n = 14,398). Primary outcomes were receipt of opioids in the emergency department, post-discharge rehabilitation referrals, and mortality. Multivariate logistic regressions evaluated demographic, socioeconomic, and injury characteristics. Multilevel logistic regressions evaluated area-level indicators, which were derived from abstracted home addresses.

RESULTS

Analyses adjusting for demographic and injury characteristics revealed that Black children (n = 6255) had significantly lower odds (OR = 0.87) of being prescribed opioid medications in the emergency department compared to White children (n = 5883). Children living in more distressed and rural communities had greater odds of receiving opioid medications. Girls had significantly lower odds (OR = 0.61) of being referred for rehabilitation services than boys. Post hoc analyses revealed that Black girls had the lowest odds of receiving rehabilitation referrals compared to Black boys and White children.

CONCLUSION

Results highlight the need to examine both main and interactive effects of social determinants on trauma care and outcomes. Findings reinforce and expand into the pediatric population the growing notion that traumatic injury care is not immune to disparities.

Racial and Ethnic Disparity in Prehospital Pain Management for Trauma Patients

BACKGROUND

Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear whether these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic use by emergency medical services (EMS) in trauma patients.

STUDY DESIGN

Retrospective chart review of adult trauma patients aged 18 to 89 years old transported by EMS to our American College of Surgeons-verified level 1 trauma center from 2014 to 2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration.

RESULTS

A total of 2,476 patients were transported by EMS (47% White and 53% REM). White patients were older on average (46 years vs 38 years; p < 0.001) and had higher rates of blunt trauma (76% vs 60%; p < 0.001). There were no differences in Injury Severity Score (21 vs 20; p = 0.22). Although REM patients reported higher subjective pain rating (7.2 vs 6.6; p = 0.002), they were less likely to get prehospital pain medication (24% vs 35%; p < 0.001), and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (adjusted odds ratio [95% CI], 0.67 [0.47 to 0.96]; p = 0.03).

CONCLUSIONS

Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

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.

Door-To-Triage Time in a Canadian Tertiary-Care Center

BACKGROUND

The interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional.

OBJECTIVE

We sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada.

METHODS

Data were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period. Demographic information, arrival time (door time), triage time, and Canadian Triage and Acuity Score (CTAS) were collected. DTT was compared across variables using Kruskal-Wallis one-way analysis of variance.

RESULTS

Seven hundred and seventy-five patients were included in the study, representing 82.9% of ambulatory patients. DTT was variable (1-86 min) with a median of 12 min (interquartile range [IQR] 6-21 min). Patients in the 5^th percentile with the longest DTT waited a median of 54 min (IQR 48-63 min). DTT varied across days of the week (p < 0.01); the longest wait was on Monday (median 22 [IQR 11-43] min) and the shortest on Sunday (median 8 [IQR 5-12] min). There was no relationship between DTT and CTAS (p = 0.12).

CONCLUSIONS

DTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.

Disparities in Opioid Pain Management for Long Bone Fractures

An expanding body of evidence has established that racial disparities exist in the US healthcare system, manifesting in poorer health outcomes for members of the non-white population. This study examines whether disparities exist in the type of analgesia ordered for long bone fractures and the time to medication administration in a community teaching hospital serving a large Hispanic population. We reviewed de-identified data of 115 patients from the emergency department of a community Level II Trauma Center in central Florida with diagnosed long bone fractures and examined the clinical and demographic variables associated with the type of analgesic administered and factors associated with delays in medication administration. We found that women reported higher pain scores than men, but there was no difference in the type of pain medication administered. There was no difference in pain scores between white and non-white patients; however, white patients were more likely to receive opiates for their long bone fractures compared with non-white patients (70 vs 50%, p < 0.0001). Opioid pain medications were prescribed significantly more often to adult and elderly patients compared with pediatric patients who were more likely to receive acetaminophen compared with both other patient groups (p < 0.001). In summary, we found that pain score was not associated with the class of pain medication administered, but that race and age were. This study questions the utility of the pain score for acute injuries and raises concerns about the role of physician bias in analgesia administration.

Both Race and Insurance Type Independently Predict the Selection of Oral Opioids Prescribed to Cancer Outpatients

BACKGROUND

Previous research suggests that racial disparities in patients' reported analgesic adverse effects are partially mediated by the type of opioid prescribed to African Americans despite the presence of certain comorbidities, such as renal disease.

AIMS

We aimed to identify independent predictors of the type of opioid prescribed to cancer outpatients and determine if race and chronic kidney disease independently predict prescription type, adjusting for relevant sociodemographic and clinical confounders.

DESIGN

We conducted a secondary analysis of a 3-month observational study.

SETTING

Outpatient oncology clinics of an academic medical center.

PARTICIPANTS/SUBJECTS

Patients were older than 18 years of age, self-identified as African American or White, and had an analgesic prescription for cancer pain.

METHODS

Cancer patients (N = 241) were recruited from outpatient oncology clinics within a large mid-Atlantic healthcare system.

RESULTS

Consistent with published literature, most patients (75.5%) were prescribed either morphine or oxycodone preparations as oral opioid therapy for cancer pain. When compared with Whites, African Americans were significantly more likely to be prescribed morphine (33% vs 14%) and less likely to be prescribed oxycodone (38% vs 64%) (p < .001). The estimated odds for African Americans to receive morphine were 2.573 times that for Whites (95% confidence interval 1.077-6.134) after controlling for insurance type, income, and pain levels. In addition, the presence of private health insurance was negatively associated with the prescription of morphine and positively associated with prescription of oxycodone in separate multivariable models. The presence of chronic kidney disease did not predict type of analgesic prescribed.

CONCLUSIONS

Both race and insurance type independently predict type of opioid selection for cancer outpatients. Larger clinical studies are needed to fully understand the sources and clinical consequences of racial differences in opioid selection for cancer pain.

Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review

OBJECTIVE

This review aims to quantify the effect of minority status on analgesia use for acute pain management in US Emergency Department (ED) settings.

METHODS

We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology to perform a review of studies from 1990 to 2018 comparing racial and ethnic differences in the administration of analgesia for acute pain. Studies were included if they measured analgesia use in white patients compared to a racial minority in the ED and studies were excluded if they focused primarily on chronic pain, case reports and survey studies. Following data abstraction, a meta-analysis was performed using fixed and random-effect models to determine primary outcome of analgesia administration stratified by racial and ethnic classification.

RESULTS

763 articles were screened for eligibility and fourteen studies met inclusion criteria for qualitative synthesis. The total study population included 7070 non-Hispanic White patients, 1538 Hispanic, 3125 Black, and 50.3% female. Black patients were less likely than white to receive analgesia for acute pain: OR 0.60 [95%-CI, 0.43-0.83, random effects model]. Hispanics were also less likely to receive analgesia: OR 0.75 [95%-CI, 0.52-1.09].

CONCLUSION

This study demonstrates the presence of racial disparities in analgesia use for the management of acute pain in US EDs. Further research is needed to examine patient reported outcomes in addition to the presence of disparities in other groups besides Black and Hispanic.

TRIAL REGISTRATION

Registration number CRD42018104697 in PROSPERO.

Administration of Tramadol or Buprenorphine via the drinking water for post-operative analgesia in a mouse-osteotomy model

Adequate analgesia is essential whenever pain might occur in animal experiments. Unfortunately, the selection of suitable analgesics for mice in bone-linked models is limited. Here, we evaluated two analgesics – Tramadol [0.1 mg/ml (T_low) vs. 1 mg/ml (T_high)] and Buprenorphine (Bup; 0.009 mg/ml) – after a pre-surgical injection of Buprenorphine, in a mouse-osteotomy model. The aim of this study was to verify the efficacy of these opioids in alleviating pain-related behaviors, to provide evidence for adequate dosages and to examine potential side effects. High concentrations of Tramadol affected water intake, drinking frequency, food intake and body weight negatively in the first 2–3 days post-osteotomy, while home cage activity was comparable between all groups. General wellbeing parameters were strongly influenced by anesthesia and analgesics. Model-specific pain parameters did not indicate more effective pain relief at high concentrations of Tramadol. In addition, ex vivo high-resolution micro computed tomography (µCT) analysis and histology analyzing bone healing outcomes showed no differences between analgesic groups with respect to newly formed mineralized bone, cartilage and vessels. Our results show that high concentrations of Tramadol do not improve pain relief compared to low dosage Tramadol and Buprenorphine, but rather negatively affect animal wellbeing.

Change in Pain Score after Administration of Analgesics for Lower Extremity Fracture Pain during Hospitalization

BACKGROUND

Effective acute pain management following injury is critical to improve short-and long-term patient outcomes. Analgesics can effectively reduce pain intensity, yet half of injury patients report moderate to severe pain during hospitalization.

PURPOSE

The primary aim of this study was to identify the analgesic, different analgesic combinations, or analgesic and adjuvant analgesic combination that generated the largest percent change from pre- to post-analgesic pain score.

DESIGN

This was a descriptive retrospective cohort study of 129 adults admitted with lower extremity fractures to a trauma center.

METHODS

Name, dose, and frequency of analgesics and adjuvant analgesics administered from admission to discharge were collected from medical records. Percent change was calculated from pain scores documented on the 0-10 numeric rating scale.

RESULTS

The analgesic with largest percent change from pre- to post-administration pain score was hydromorphone 2 mg IV (53%) for the emergency department and morphine 4 mg IV (54%) for the in-patient unit. All analgesics administered in the emergency department and ∼50% administered on the in-patient unit produced a minimal (15%) decrease in pain score.

CONCLUSIONS

This study revealed that few analgesics administered in the emergency department and the in-patient unit to patients with lower extremity fractures provide adequate pain relief. In the emergency department, all analgesics administered resulted in at least minimal improvement of pain. On the in-patient unit 13 analgesic doses resulted at least minimal improvement in pain while nine doses did not even reach 20% change in pain. Findings from this study can be used guide the treatment of fracture pain in the hospital.

Analgesics Administered for Pain During Hospitalization Following Lower Extremity Fracture: A Review of the Literature

Effective treatment of acute pain during hospitalization following lower extremity fracture is critical to improve short-term patient outcomes including wound healing, stress response, hospital length of stay, and cost as well as minimizing long-term negative patient outcomes such as delayed return to work, disability, and chronic pain. As many patients report moderate to severe pain during hospitalization, identifying the analgesics that most effectively reduces pain is a priority to improve patient outcomes. The purpose of this review was to examine published studies describing patient response to analgesics administered orally (PO) or intravenously (IV) in the immediate hospitalization following lower extremity fracture. PubMed was queried for articles published through May 2017 that included information on type of study, population, fracture site, pain measurement tool, analgesic, and result. Of 514 articles found, eight met the inclusion criteria. Analgesics administered PO or IV were fentanyl, hydromorphone, morphine, remifentanil, diclofenac, ibuprofen, ketorolac, and etoricoxib. Five of the studies focused on comparisons between one or more analgesics and three studies compared an IV analgesic to a regional anesthetic agent. Two studies compared different nonsteroidal anti-inflammatory drugs (NSAIDs). Bupivacaine, lignocaine, and levobupivacaine administered as regional nerve blocks were superior to controlling pain compared with IV fentanyl and IV hydromorphone. IV morphine provided faster and better pain relief compared with IV ibuprofen. Based on the limited data available, regional nerve blocks provided superior pain relief compared with opioids, and opioids provided superior pain relief compared with NSAIDs. Different NSAIDs provided similar pain relief.

A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town

INTRODUCTION

Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.

METHODS

A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.

RESULTS

A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4).

DISCUSSION

Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.

A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures

Objectives

To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients.

Design

Secondary analysis of retrospective cohort study.

Setting

Five EDs (four academic, one community) in the United States.

Participants

Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]).

Measurements

Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type.

Results

A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P  < 0.001) and higher opioid-doses (parameter estimate = 0.268; 95 CI = 0.239 to 0.297; P  < 0.001). When LBF were examined separately, older-patients had a trend to longer analgesic wait-times (99 [55-163] vs. 76 [35-149] minutes, P  = 0.057), but no other differences in process outcomes were found.

Conclusion

Long bone fractures were associated with more aggressive pain care than SBF. When fracture types were examined separately, older patients did not appear to receive more aggressive pain care. This difference should be accounted for in further research.

Pain management of trauma patients in the emergency department: a study in a public hospital in Iran

BACKGROUND

Pain is a common problem which the patients in emergency departments (ED) face, especially trauma patients under treatment may suffer from physical, psychological and ethical issues. The purpose of this study was to evaluate traumatic pain management in the emergency department at a public hospital in Iran in 2014.

METHODS

This observational prospective study was conducted on 450 trauma patients admitted to a trauma emergency department. The tool used in this study has three parts: demographic data, data of trauma, and VRS (Verbal Rating Scales) score at a 7-point scale-at the arrival time to 4h later. The statistical analysis was conducted by using Mann-Whitney and Kruskal-Wallis tests, repeated measures, survival analysis, and multiple regression analysis.

RESULTS

The majority of the samples were male (83.3%) with the mean age of 35.2years. The patients mostly suffered from contusions and strains (42.4%). The majority of the patients [274 patients (60.8%)] received no intervention for pain relief and only 60 patients (13.3%) received analgesics. The mean time period of the first analgesic utilization was 41 (±20.4) minutes. Pain in admission, pain assessment, and receiving intervention could explain the 32% of pain reduction. No other variables such as age, sex, education, kind of trauma, and the shift of admission were involved in pain reduction.

CONCLUSIONS

This research study demonstrated that comprehensive, adequate pain management remains an obscure goal within the emergency nursing setting. There is a need to undertake further research and develop educational programs on effective analgesic practice in pain management.

Pain management in the emergency chain: the use and effectiveness of pain management in patients with acute musculoskeletal pain

OBJECTIVE

While acute musculoskeletal pain is a frequent complaint in emergency care, its management is often neglected, placing patients at risk for insufficient pain relief. Our aim is to investigate how often pain management is provided in the prehospital phase and emergency department (ED) and how this affects pain relief. A secondary goal is to identify prognostic factors for clinically relevant pain relief.

DESIGN

This prospective study (PROTACT) includes 697 patients admitted to ED with musculoskeletal extremity injury. Data regarding pain, injury, and pain management were collected using questionnaires and registries.

RESULTS

Although 39.9% of the patients used analgesics in the prehospital phase, most patients arrived at the ED with severe pain. Despite the high pain prevalence in the ED, only 35.7% of the patients received analgesics and 12.5% received adequate analgesic pain management. More than two-third of the patients still had moderate to severe pain at discharge. Clinically relevant pain relief was achieved in only 19.7% of the patients. Pain relief in the ED was higher in patients who received analgesics compared with those who did not. Besides analgesics, the type of injury and pain intensity on admission were associated with pain relief.

CONCLUSIONS

There is still room for improvement of musculoskeletal pain management in the chain of emergency care. A high percentage of patients were discharged with unacceptable pain levels. The use of multimodal pain management or the implementation of a pain management protocol might be useful methods to optimize pain relief. Additional research in these areas is needed.

The relationship between patient age and pain management of acute long-bone fracture in the ED

OBJECTIVE

Certain patient populations may be unable to communicate their needs in the emergency department (ED) setting, and the ability to communicate varies between age groups. We aim to determine if there are differences in pain management of acute long-bone fracture (ALBF) among age groups presenting to the ED.

METHODS

This study was a retrospective chart review of a consecutive sample of subjects over 13 months. Fracture site, subject age, arrival time, whether pain medication was administered, and time to initial administration were recorded. Subjects were categorized into 3 groups based on age: pediatric (<18 years), adult (≥18 and <65 years), and geriatric (≥65 years).

RESULTS

A total of 1255 patients were included in analysis. One hundred seventy-seven (78.0%) pediatric, 364 (86.5%) adult, and 486 (80.1%) geriatric patients received pain medication during their ED stay. Median and average times to initial pain medication administration with 95% confidence intervals were 44 and 52.0 minutes (45.9-58.1), 39 and 53.6 minutes (48.8-58.4), and 55 and 73.2 minutes (68.1-78.3) for pediatric, adult, and geriatric groups, respectively. A single-factor analysis of variance indicated a significant difference between the groups (P<.01). Student t tests revealed significant differences between pediatric and geriatric groups (P<.01) and adult and geriatric groups (P<.01).

CONCLUSIONS

Although most patients presenting to the ED with ALBF were geriatric, these patients were the least likely to have their pain addressed in a timely fashion. Subgroup analysis of pediatric and geriatric populations indicates significant delay, especially for those ages younger than 3 and 85 years and older. We believe that patients within these groups experience the greatest difficulty communicating their needs effectively due to age-related issues.