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Martin-Gill C, Brown KM, Cash RE, Haupt RM, Potts BT, Richards CT, Patterson PD. 2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2023; 27:131-143. [PMID: 36369826 DOI: 10.1080/10903127.2022.2143603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel. OBJECTIVES We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel. METHODS We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing. CONCLUSIONS This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.
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Affiliation(s)
- Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel M Haupt
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Benjamin T Potts
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Powell JR, Browne LR, Guild K, Shah MI, Crowe RP, Lindbeck G, Braithwaite S, Lang ES, Panchal AR. Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods. PREHOSP EMERG CARE 2023; 27:154-161. [PMID: 34928783 DOI: 10.1080/10903127.2021.2018074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Emergency Medical Services (EMS) clinicians commonly encounter patients with acute pain. A new set of evidence-based guidelines (EBG) was developed to assist in the prehospital management of pain. Our objective was to describe the methods used to develop these evidence-based guidelines for prehospital pain management. METHODS The EBG development process was supported by a previous systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) covering nine different population, intervention, comparison, and outcome (PICO) questions. A technical expert panel (TEP) was formed and added an additional pediatric-specific PICO question. Identified evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into Summary of Findings tables. The TEP then utilized a rigorous systematic method, including the PanelVoice function, for recommendation development which was applied to generate Evidence to Decision Tables (EtD). This process involved review of the Summary of Findings tables, asynchronous member judging, and facilitated panel discussion to generate final consensus-based recommendations. RESULTS The work product described above was completed by the TEP panel from September 2020 to April 2021. For these recommendations, the overall certainty of evidence was very low or low, data for decisions on cost effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, one strong and seven conditional recommendations were made, with two PICO questions lacking sufficient evidence to generate a recommendation. CONCLUSION We describe a protocol that leveraged established EBG development techniques, the GRADE framework in conjunction with a previous AHRQ systematic review to develop treatment recommendations for prehospital pain management. This process allowed for mitigation of many confounders due to the use of virtual and electronic communication. Our approach may inform future guideline development and increase transparency in the prehospital recommendations development processes.
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Affiliation(s)
- Jonathan R Powell
- National Registry of Emergency Medical Technicians, Columbus, Ohio.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio
| | - Lorin R Browne
- Medical College of Wisconsin, Milwaukee County EMS, Milwaukee, Wisconsin
| | - Kyle Guild
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Manish I Shah
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, and the Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Sabina Braithwaite
- Missouri Department of Health and Senior Services, and the Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Eddy S Lang
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio.,Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Lindbeck G, Shah MI, Braithwaite S, Powell JR, Panchal AR, Browne LR, Lang ES, Burton B, Coughenour J, Crowe RP, Degn H, Hedges M, Gasper J, Guild K, Mattera C, Nasca S, Taillac P, Warth M. Evidence-Based Guidelines for Prehospital Pain Management: Recommendations. PREHOSP EMERG CARE 2023; 27:144-153. [PMID: 34928760 DOI: 10.1080/10903127.2021.2018073] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.
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Affiliation(s)
- George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, and the Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Manish I Shah
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sabina Braithwaite
- Missouri Department of Health and Senior Services, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Jonathan R Powell
- National Registry of Emergency Medical Technicians (NREMT), Columbus, Ohio, USA
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians (NREMT), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lorin R Browne
- Milwaukee County EMS, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eddy S Lang
- Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
| | - Brooke Burton
- Falck Ambulance Northern California, Petaluma, California, USA
| | - Jeffrey Coughenour
- iFrank Mitchell, Jr., MD, Trauma Center, University of Missouri Healthcare, Columbia, Missouri, USA
| | | | - Hannah Degn
- National Association of State EMS Officials (NASEMSO)
| | - Mary Hedges
- National Association of State EMS Officials (NASEMSO)
| | - James Gasper
- California Department of Health Care Services, Sacramento, California, USA
| | - Kyle Guild
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | | | - Peter Taillac
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mark Warth
- Colorado Springs Fire Department, Colorado Springs, Colorado, USA
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Harris MI, Adelgais KM, Linakis SW, Magill CF, Brazauskas R, Shah MI, Nishijima DK, Lowe GS, Chadha K, Chang TP, Lerner EB, Leonard JC, Schwartz HP, Gaither JB, Studnek JR, Browne LR. Impact of Prehospital Pain Management on Emergency Department Management of Injured Children. PREHOSP EMERG CARE 2023; 27:1-9. [PMID: 34734787 DOI: 10.1080/10903127.2021.2000683] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS. METHODS This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions. RESULTS We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care. CONCLUSIONS We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.
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Affiliation(s)
- M I Harris
- Department of Pediatrics, Northwell Hofstra School of Medicine, New Hyde Park, New York
| | - K M Adelgais
- Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - S W Linakis
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - C F Magill
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina
| | - R Brazauskas
- Department of Institute for Health Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - M I Shah
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - D K Nishijima
- Department of Emergency Medicine, University of California - Davis, Sacramento, California
| | - G S Lowe
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - K Chadha
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - T P Chang
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - E B Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - J C Leonard
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - H P Schwartz
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J B Gaither
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - J R Studnek
- Mecklenburg EMS Agency, Charlotte, North Carolina
| | - L R Browne
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Nishijima DK, Tancredi DJ, Adelgais KM, Chadha K, Chang TP, Harris MI, Leonard JC, Lerner EB, Linakis SW, Lowe GS, Magill CF, Schwartz HP, Shah MI, Browne LR. Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children. J Emerg Med 2023; 64:55-61. [PMID: 36641254 DOI: 10.1016/j.jemermed.2022.10.011] [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: 06/28/2022] [Revised: 09/04/2022] [Accepted: 10/11/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Treatment with analgesics for injured children is often not provided or delayed during prehospital transport. OBJECTIVE Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children. METHODS We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids. RESULTS We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids. CONCLUSIONS There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis, Sacramento, California.
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Kathleen M Adelgais
- Departments of Pediatrics and Emergency Medicine, University of Colorado, Aurora, Colorado
| | - Kunal Chadha
- Department of Pediatrics, University of Buffalo, Buffalo, New York
| | - Todd P Chang
- Children's Hospital of Los Angeles and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Matthew I Harris
- Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine - Hofstra University, New Hyde Park, New York
| | - Julie C Leonard
- Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - E Brooke Lerner
- Departments of Emegency Medicine and Pediatrics, University of Buffalo, Buffalo, New York
| | - Seth W Linakis
- Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Geoffrey S Lowe
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Christyn F Magill
- Children's Hospital of Los Angeles and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina
| | - Hamilton P Schwartz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Manish I Shah
- Department of Pediatrics, Division of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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6
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Dalton MK, Semco RS, Ordoobadi AJ, Goralnick E, Chovanes J, Salim A, Jarman MP. Opioid administration in the prehospital setting for patients sustaining traumatic injuries: An evaluation of national emergency medical services data. Injury 2022; 53:2923-2929. [PMID: 35437168 PMCID: PMC10018388 DOI: 10.1016/j.injury.2022.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Despite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States. METHODS We used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation. RESULTS We identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5-10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p<0.001), and had a median reduction in pain score of 3 points (IQR 1-5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9-14), and 21.4% of those with minor (ISS 1-8) injuries (p<0.001). CONCLUSION The use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States; Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, United States.
| | - Robert S Semco
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
| | - Alexander J Ordoobadi
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
| | - Eric Goralnick
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States.
| | - John Chovanes
- Division of Trauma, Department of Surgery, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States; Section of Military, Diplomatic, and Field Affairs, Cooper University Hospital, Camden, NJ, United States.
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
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Chumpitazi CE, Chang C, Atanelov Z, Dietrich AM, Lam SH, Rose E, Ruttan T, Shahid S, Stoner MJ, Sulton C, Saidinejad M. Managing acute pain in children presenting to the emergency department without opioids. J Am Coll Emerg Physicians Open 2022; 3:e12664. [PMID: 35310402 PMCID: PMC8918119 DOI: 10.1002/emp2.12664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/12/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023] Open
Abstract
Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non‐pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.
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Affiliation(s)
- Corrie E. Chumpitazi
- Department of Pediatrics Division of Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Cindy Chang
- Department of Pediatrics, Division of Emergency Medicine Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Zaza Atanelov
- North Florida Regional Medical Center Emergency Department HCA/University of Central Florida College of Medicine Consortium Florida USA
| | - Ann M. Dietrich
- Department of Pediatrics and Emergency Medicine University of South Carolina College of Medicine Greenville North Carolina USA
| | - Samuel Hiu‐Fung Lam
- Department of Emergency Medicine Sutter Medical Center Sacramento Sacramento California USA
| | - Emily Rose
- Keck School of Medicine of the University of Southern California Los Angeles California USA
| | - Tim Ruttan
- Dell Children's Medical Center, Department of Pediatrics The University of Texas at Austin Dell Medical School, US Acute Care Solutions Austin Texas USA
| | - Sam Shahid
- American College of Emergency Physicians Irving Texas USA
| | - Michael J. Stoner
- Nationwide Children's Hospital The Ohio State University College of Medicine Columbus Ohio USA
| | - Carmen Sulton
- Emory University School of Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Mohsen Saidinejad
- Department of Emergency Medicine Harbor UCLA Medical Center Torrance California USA
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8
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Pain Management in Pediatric Trauma. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00216-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Mosca CG, Stein C, Lawrence H. South African pre-hospital emergency care personnel's lived experiences of managing paediatric emergencies: A qualitative research design utilising one-on-one interviews. Health SA 2021; 26:1558. [PMID: 34394964 PMCID: PMC8335770 DOI: 10.4102/hsag.v26i0.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/21/2021] [Indexed: 11/28/2022] Open
Abstract
Background The phenomenon of managing paediatric emergencies in the pre-hospital environment within the South African setting is poorly understood with specific regard to what emergency care personnel are experiencing when managing paediatric emergencies. Aim The aim of this study was to explore and describe the lived experiences of emergency care personnel in managing paediatric patients in the pre-hospital environment and to understand the meaning and the significance of these experiences. Setting All participants were purposively sampled from emergency medical services agencies operating within the Johannesburg metropolitan city area. Methods This study followed a qualitative, exploratory, descriptive, phenomenological design, whereby participants purposively sampled within the Johannesburg metropolitan city voluntarily consented to one-on-one interviews (n = 10). Results Three main themes, with 11 contributing categories, were identified and contextualised with available literature. Emerging from the main themes was an overall sense that managing paediatric emergencies is a negative experience, coloured with feelings of inadequacy, stress, anxiety and even fear. Conclusions The findings of this study provided new insights into what South African EMS are experiencing when managing paediatric emergencies, which enables future research efforts to identify research and practice gaps that are relevant to paediatric pre-hospital emergency care, and that are specific to the South African environment. Contribution This research provides preliminary insight into the lived experiences of prehospital personnel managing paediatric emergencies as well as emerging recommendations for the improvement of the prehospital care of paediatric patients.
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Affiliation(s)
- Colin G Mosca
- Department of Emergency Medical Care, Faculty of Health Science, University of Johannesburg, Johannesburg, South Africa
| | - Christopher Stein
- Department of Emergency Medical Care, Faculty of Health Science, University of Johannesburg, Johannesburg, South Africa
| | - Heather Lawrence
- Department of Allied Health Professions, Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
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Kothari K, Zuger C, Desai N, Leonard J, Alletag M, Balakas A, Binney M, Caffrey S, Kotas J, Mahar P, Roswell K, Adelgais KM. Effect of Repetitive Simulation Training on Emergency Medical Services Team Performance in Simulated Pediatric Medical Emergencies. AEM EDUCATION AND TRAINING 2021; 5:e10537. [PMID: 34099990 PMCID: PMC8166302 DOI: 10.1002/aet2.10537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Emergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care. METHODS This was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T0), 1-month-old with hypoglycemia (T1), and 4-year-old clonidine ingestion (T2). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T0 to T2. RESULTS A total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T0, T1, and T2, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T0 to T2 (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02). CONCLUSION Serial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.
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Affiliation(s)
- Kathryn Kothari
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
- theDenver Health and Hospital AuthorityDenverCOUSA
| | - Chelsea Zuger
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Neil Desai
- theEmergency DepartmentBritish Columbia Children’s HospitalVancouverBritish ColumbiaCanada
| | - Jan Leonard
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Michelle Alletag
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Ashley Balakas
- theEmergency Medical Services Education and Outreach ProgramChildren’s Hospital ColoradoAuroraCOUSA
| | - Mike Binney
- theWest Metro Fire Protection DistrictLakewoodCOUSA
| | - Sean Caffrey
- and theEMS DivisionCrested Butte Fire Protection AuthorityCrested ButteCOUSA
| | - Jason Kotas
- theEmergency Medical Services Education and Outreach ProgramChildren’s Hospital ColoradoAuroraCOUSA
| | - Patrick Mahar
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kelley Roswell
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
| | - Kathleen M. Adelgais
- From theDepartment of PediatricsSection of Pediatric Emergency MedicineUniversity of Colorado School of MedicineAuroraCOUSA
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11
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Groulx M, Nadeau A, Émond M, Harrisson J, Blanchard PG, Eramian D, Mercier E. Continuous flow insufflation of oxygen compared with manual ventilation during out-of-hospital cardiac arrest: A survey of the paramedics. SAGE Open Med 2021; 9:20503121211018105. [PMID: 34262761 PMCID: PMC8252405 DOI: 10.1177/20503121211018105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/26/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: In 2018, a continuous flow insufflation of oxygen (CFIO) device (b-card™, Vygon (USA)) placed on a supraglottic airway (SGA) became the standard of care to ventilate patients during adult out-of-hospital cardiac arrest (OHCA) care in Quebec–Capitale-Nationale region, Canada. This study aims to assess the paramedics’ perception as well as the disadvantages and the benefits relative to the use of CFIO during OHCA management. Methods: An invitation to complete an online survey (Survey Monkey™) was sent to all 560 paramedics who are working in our region. The survey included 22 questions of which 9 aimed to compare the traditional manual ventilation with a bag to the CFIO using a 5-point Likert-type scale. Results: A total of 244 paramedics completed the survey, of which 189 (77.5%) had used the CFIO device during an OHCA at least once. Most respondents felt that the intervention was faster (70.2%) and easier (86.5%) with the CFIO device compared with manual ventilation. CFIO was also associated with perceived increased patient safety (64.4%) as well as paramedic safety during the evacuation (88.9%) and the ambulance transport (88.9%). Paramedics reported that physical (48.1%) and cognitive (52.9%) fatigue were also improved with CFIO. The main reported barriers were the bending of the external SGA tube and the loss of capnography values. Conclusion: The use of CFIO during adult OHCA care allows a simplified approach and was perceived as safer for the patient and the paramedics compared with manual ventilation. Its impact on patient-centred outcomes needs to be assessed.
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Affiliation(s)
- Mathieu Groulx
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.,Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Alexandra Nadeau
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Québec, QC, Canada
| | - Marcel Émond
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.,Faculté de médecine, Université Laval, Québec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Québec, QC, Canada.,Département de médecine d'urgence, CHU de Québec, Québec, QC, Canada
| | - Jessica Harrisson
- Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) de la Capitale-Nationale, Québec, QC, Canada
| | - Pierre-Gilles Blanchard
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.,Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Douglas Eramian
- Département de médecine d'urgence, CHU de Québec, Québec, QC, Canada.,Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) de la Capitale-Nationale, Québec, QC, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.,Faculté de médecine, Université Laval, Québec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Québec, QC, Canada.,Département de médecine d'urgence, CHU de Québec, Québec, QC, Canada.,Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) de la Capitale-Nationale, Québec, QC, Canada
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12
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Zia A, MacDonald R, Moore S, Ducharme J, Vaillancourt C. Assessment of Pain Management During Interfacility Air Medical Transport of Intubated Patients. Air Med J 2019; 38:421-425. [PMID: 31843153 DOI: 10.1016/j.amj.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 07/23/2019] [Accepted: 09/03/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system. METHODS This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management. RESULTS Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care. CONCLUSION Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.
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Affiliation(s)
- Ayesha Zia
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Russell MacDonald
- Ornge, Mississauga, Onatrio, Canada; Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sean Moore
- Ornge, Mississauga, Onatrio, Canada; Division of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - James Ducharme
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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13
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Abstract
Introduction: Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. Studies have identified a number of barriers to pre-hospital pain management in children which include the route of analgesia administration. The aim of this review is to critically evaluate the pre-hospital literature, exploring the safety and efficacy of intranasal (IN) analgesics for children suffering pain. Methods: We performed a rapid evidence review, searching from inception to 17 December 2018, CINAHL, MEDLINE and Google Scholar. We included studies of children < 18 years suffering pain who were administered any IN analgesic in the pre-hospital setting. Our outcomes were effective pain management, defined as a pain score reduction of ≥ 2 out of 10, safety and rates of analgesia administration. Screening and risk of bias assessments were performed in duplicate. We performed a narrative synthesis. Results: From 310 articles screened, 23 received a full-text review resulting in 10 articles included. No interventional studies were found. Most papers reported on the use of intranasal fentanyl (INF) (n = 8) with one reporting IN ketamine and the other IN S-ketamine. Narrative synthesis showed that INF appeared safe and effective at reducing pain; however, its ability to increase analgesia administration rates was unclear. The effectiveness, safety and ability of IN ketamine and S-ketamine to increase analgesia administration rates were unclear. There was no evidence for IN diamorphine for children in this setting. Conclusion: Interventional studies are needed to determine with a higher confidence the effectiveness and safety of IN analgesics (fentanyl, ketamine, S-ketamine, diamorphine) for children in the pre-hospital setting.
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Affiliation(s)
| | - Richard Pilbery
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-5797-9788
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14
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Effects of the Introduction of Intranasal Fentanyl on Reduction of Pain Severity Score in Children: An Interrupted Time-Series Analysis. Pediatr Emerg Care 2019; 35:749-754. [PMID: 29200141 DOI: 10.1097/pec.0000000000001376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Children are at risk of inadequate analgesia due to paramedics' inexperience in assessing children and challenges in administering analgesics when the patient is distressed and uncooperative. This study reports on the outcome of a change to practice guidelines that added intranasal fentanyl and intramuscular morphine within a large statewide ambulance service. METHODS This retrospective study included patients younger than 15 years treated by paramedics between January 2008 and December 2011. The primary outcome of interest was the proportion of patients having a 2/10 or greater reduction in pain severity score using an 11-point Verbal Numeric Rating Scale before and after the intervention. Segmented regression analysis was used to estimate the effect of the intervention over time. A multiple regression model calculated odds ratios with 95% confidence intervals. RESULTS A total of 92,378 children were transported by paramedics during the study period, with 9833 cases included in the analysis. The median age was 11 years; 61.6% were male. Before the intervention, 88.1% (n = 3114) of children receiving analgesia had a reduction of pain severity of 2 or more points, with 94.2% (n = 5933) achieving this benchmark after intervention (P < 0.0001). The odds of a reduction in pain of 2 or more points increased by 1.01 per month immediately before the intervention and 2.33 after intervention (<0.0001). CONCLUSIONS This large study of a system-wide clinical practice guideline change has demonstrated a significant improvement in the outcome of interest. However, a proportion of children with moderate to severe pain did not receive analgesia.
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Abstract
Introduction: Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England. Methods: This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10). Results: A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1–12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia. Conclusion: Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.
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Affiliation(s)
- Richard Pilbery
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-5797-9788
| | - Jamie Miles
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-1080-768X
| | - Fiona Bell
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0003-4503-1903
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16
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Carey JM, Studnek JR, Browne LR, Ostermayer DG, Grawey T, Schroter S, Lerner EB, Shah MI. Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study. PREHOSP EMERG CARE 2019; 23:870-881. [PMID: 30917730 DOI: 10.1080/10903127.2019.1595234] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background: Seizures have the potential to cause significant morbidity and mortality, and are a common reason emergency medical services (EMS) are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation. Objective: The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems. Methods: This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in 3 different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews. Results: Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability. Conclusions: Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.
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17
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Hartshorn S, Dissmann P, Coffey F, Lomax M. Low-dose methoxyflurane analgesia in adolescent patients with moderate-to-severe trauma pain: a subgroup analysis of the STOP! study. J Pain Res 2019; 12:689-700. [PMID: 30863141 PMCID: PMC6388743 DOI: 10.2147/jpr.s188675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The undertreatment of acute pain presents a significant challenge in the Emergency Department. This post hoc subgroup analysis of a previously reported randomized controlled UK study reports the efficacy and safety of low-dose methoxyflurane analgesia in treating adolescent patients with moderate-to-severe trauma pain. Patients and methods Three hundred patients (96 in the adolescent subgroup) aged ≥12 years requiring analgesia for acute trauma pain (pain score of 4-7 on the Numerical Rating Scale) at triage were randomized 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline), both administered using a Penthrox® inhaler. The patient could request rescue medication (paracetamol/opioids) at any time. The primary endpoint was the change from baseline in visual analog scale (VAS) pain intensity. Results Mean VAS pain score for the adolescent subgroup at baseline was ~ 61 mm. Adjusted mean change in VAS pain intensity from baseline to 5, 10, 15, and 20 minutes was -24.5, -28.1, -31.6, and -31.7 mm for methoxyflurane and -14.6, -18.8, -19.2, and -23.7 mm for placebo, with a statistically significant treatment effect in favor of methoxyflurane overall across all four time points (-9.9 mm; 95% CI: -17.4, -2.4 mm; P=0.0104). Median time to first pain relief was significantly shorter with methoxyflurane (1 minute) than placebo (3 minutes, P<0.0001). Pain relief was reported within 1-10 inhalations in 95.7% of methoxyflurane-treated patients and 64.6% of placebo-treated patients. Rescue medication was requested by two (4.3%) methoxyflurane-treated patients and three (6.3%) placebo-treated patients. Over 95% of patients, physicians, and nurses rated methoxyflurane treatment as "Excellent", "Very Good" or "Good" compared with between 64% and 68% for placebo. The incidence of adverse events was higher with methoxyflurane (51%) than placebo (42%), mostly comprising mild/transient dizziness and headache. Conclusion This subgroup analysis shows that low-dose inhaled methoxyflurane is a rapid-acting and effective analgesic in adolescent patients presenting with moderate-to-severe trauma pain. Trial registration Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.
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Affiliation(s)
- Stuart Hartshorn
- Emergency Department, Birmingham Children's Hospital, Birmingham, UK,
| | - Patrick Dissmann
- Academic Department of Emergency Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Frank Coffey
- DREEAM: Department of Research and Education in Emergency Medicine, Acute Medicine and Major Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Lomax
- Data Management & Statistics, Mundipharma Research Limited, Cambridge, UK
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Adelgais KM, Hansen M, Lerner EB, Donofrio JJ, Yadav K, Brown K, Liu YT, Denslow P, Denninghoff K, Ishimine P, Olson LM. Establishing the Key Outcomes for Pediatric Emergency Medical Services Research. Acad Emerg Med 2018; 25:1345-1354. [PMID: 30312993 DOI: 10.1111/acem.13637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.
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Affiliation(s)
| | - Kathleen M. Adelgais
- Department of Pediatrics Section of Pediatric Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Matthew Hansen
- Department of Emergency Medicine Oregon Health Sciences University PortlandOR
| | - E. Brooke Lerner
- Departments of Emergency Medicine and Pediatrics Medical College of Wisconsin Milwaukee WI
| | - J. Joelle Donofrio
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | - Kathleen Brown
- Department of Emergency Medicine The George Washington University School of Medicine and Children's National Medical Center Washington DC
| | - Yiju T. Liu
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | | | - Kurt Denninghoff
- Department of Emergency Medicine University of Arizona School of Medicine Tucson AZ
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Lenora M. Olson
- Division of Pediatric Critical Care Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
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Adelgais KM, Sholl JM, Alter R, Gurley KL, Broadwater-Hollifield C, Taillac P. Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States. PREHOSP EMERG CARE 2018; 23:167-178. [PMID: 30118367 DOI: 10.1080/10903127.2018.1495284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. METHODS This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. RESULTS Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. CONCLUSION Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.
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Schauer SG, Arana AA, Naylor JF, Hill GJ, April MD. Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan. PREHOSP EMERG CARE 2018; 22:608-613. [DOI: 10.1080/10903127.2018.1428839] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Galinski M, Hoffman L, Bregeaud D, Kamboua M, Ageron FX, Rouanet C, Hubert JC, Istria J, Ruscev M, Tazarourte K, Pevirieri F, Lapostolle F, Adnet F. Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study. PREHOSP EMERG CARE 2018; 22:497-505. [DOI: 10.1080/10903127.2017.1413464] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Nassif A, Ostermayer DG, Hoang KB, Claiborne MK, Camp EA, Shah MI. Implementation of a Prehospital Protocol Change For Asthmatic Children. PREHOSP EMERG CARE 2018; 22:457-465. [PMID: 29351496 DOI: 10.1080/10903127.2017.1408727] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown. OBJECTIVE The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge. METHODS This was a retrospective cohort study of children (2-18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ2 test. RESULTS During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4-6.8) to 4.5 hours (95% CI: 4.2-4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8-7.3) vs. 5.2 hours (95% CI: 4.8-5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor. CONCLUSIONS Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed.
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Martin-Gill C, Higgins JS, Van Dongen HPA, Buysse DJ, Thackery RW, Kupas DF, Becker DS, Dean BE, Lindbeck GH, Guyette FX, Penner JH, Violanti JM, Lang ES, Patterson PD. Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:102-109. [DOI: 10.1080/10903127.2017.1381791] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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24
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Mellion SA, Adelgais K. Prehospital Pediatric Pain Management: Continued Barriers to Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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25
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Hewes HA, Dai M, Mann NC, Baca T, Taillac P. Prehospital Pain Management: Disparity By Age and Race. PREHOSP EMERG CARE 2017; 22:189-197. [PMID: 28956669 DOI: 10.1080/10903127.2017.1367444] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
IMPORTANCE Historically, pain management in the prehospital setting, specifically pediatric pain management, has been inadequate despite many EMS (emergency medical services) transports related to traumatic injury with pain noted as a symptom. The National Emergency Services Information System (NEMSIS) database offers the largest national repository of prehospital data, and can be used to assess current patterns of EMS pain management across the country. OBJECTIVES To analyze prehospital management of pain using NEMSIS data, and to assess if variables such as patient age and/or race/ethnicity are associated with disparity in pain treatment. DESIGN/SETTING/PARTICIPANTS A retrospective descriptive study over a three-year period (2012-2014) of the NEMSIS database for patients evaluated for three potentially painful medical impressions (fracture, burn, penetrating injury) to assess the presence of documented pain as a symptom, and if patients received treatment with analgesic medications. Results were analyzed according to type of pain medication given, age categories, and race/ethnicity of the patients. MAIN OUTCOMES Percentage of EMS transports documenting the three painful impressions that had pain documented as a symptom, received any of the six pain medications, and the disparity in documentation and treatment by age and race/ethnicity. RESULTS There were 276,925 EMS records in the NEMSIS database that met inclusion criteria. Pain was listed as a primary or associated symptom for 29.5% of patients, and the youngest children (0-3 years) were least likely to have pain documented as a symptom (14.6%). Only 15.6% of all activations documented the receipt of prehospital pain medications. Children (<15 years) received pain medication 14.8% [95% CI 14.33, 15.34] of the time versus adults (≥15 years) 15.6% [95% CI 15.48, 15.76, p = 0.004]. Morphine and fentanyl were the most commonly administered medications to all age groups. Black patients were less likely to receive pain medication than other racial groups. CONCLUSIONS Documentation of pain as a symptom and pain treatment continue to be infrequent in the prehospital setting in all age groups, especially young children. There appears to be a racial disparity with Black patients less often treated with analgesics. The broad incorporation of national NEMSIS data suggests that these inadequacies are a widespread challenge deserving further attention.
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