Pain relief in major trauma patients: an Israeli perspective

Analgesia and Sedation of Pediatric Patients with Major Trauma in Pre-Hospital and Emergency Department Settings-A Narrative Review

Children who sustain major injuries are at risk of receiving insufficient pain relief and sedation, which can have physical and psychological repercussions. Heightened emotional distress can increase the likelihood of developing symptoms of post-traumatic stress. Providing sufficient analgesia and sedation for children with major trauma presents specific challenges, given the potential for drug-related adverse events, particularly in non-intubated patients. The current literature suggests that a relatively low percentage of pediatric patients receive adequate analgesia in pre-hospital and emergency department settings following major trauma. There are only sparse data on the safety of the provision of analgesia and sedation in children with major trauma in the pre-hospital and ED settings. The few studies that examined sedation protocols in this context highlight the importance of physician training and competency in managing pediatric airways. There is a pressing need for prospective studies that focus upon pediatric major trauma in the pre-hospital and emergency department setting to evaluate the benefits and risks of administering analgesia and sedation to these patients. The aim of this narrative review was to offer an updated overview of analgesia and sedation management in children with major trauma in pre-hospital and ED settings.

The Influence of Gender Bias: Is Pain Management in the Field Affected by Health Care Provider's Gender?

INTRODUCTION

Appropriate pain management indicates the quality of casualty care in trauma. Gender bias in pain management focused so far on the patient. Studies regarding provider gender are scarce and have conflicting results, especially in the military and prehospital settings.

STUDY OBJECTIVE

The purpose of this study is to investigate the effect of health care providers' gender on pain management approaches among prehospital trauma casualties treated by the Israel Defense Forces (IDF) medical teams.

METHODS

This retrospective cohort study included all trauma casualties treated by IDF senior providers from 2015-2020. Casualties with a pain score of zero, age under 18 years, or treated with endotracheal intubation were excluded. Groups were divided according to the senior provider's gender: only females, males, or both female and male. A multivariate analysis was performed to assess the odds ratio of receiving an analgesic, depending on the presence of a female senior provider, adjusting for potential confounders. A subgroup analysis was performed for "delta-pain," defined as the difference in pain score during treatment.

RESULTS

A total of 976 casualties were included, of whom 835 (85.6%) were male. Mean pain scores (SD) for the female only, male only, and both genders providers were 6.4 (SD = 2.9), 6.4 (SD = 3.0), and 6.9 (SD = 2.8), respectively (P = .257). There was no significant difference between females, males, or both female and male groups in analgesic treatment, overall and per specific agent. This remained true also in the multivariate model. Delta-pain difference between groups was also not significant. Less than two-thirds of casualties in this study were treated for pain among all study groups.

CONCLUSION

This study found no association between IDF Medical Corps providers' gender and pain management in prehospital trauma patients. Further studies regarding disparities in acute pain treatment are advised.

Trends in prehospital pain management following the introduction of new clinical practice guidelines

BACKGROUND

Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF.

METHODS

All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided.

RESULT

Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001).

CONCLUSION

Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Improvement in physician pain perception with using pain scales

BACKGROUND AND AIMS

Acute pain is the most common reason for visits to the emergency department (ED). The underuse of analgesics occurs in a large proportion of ED patients. The physician's accurate assessment of patients' pain is a key element to improved pain management. The purpose of this study was to assess if physicians' perception of pain can improve with looking at the pain score of the patient marked on VAS.

STUDY DESIGN

This was a single-center, cross-sectional prospective observational study, that took place in an academic ED.

METHODS

All adult ED patients presenting with a painful condition were enrolled to the study. In the first phase of the study, the physician rated his/her opinion about the patient's pain on a 100 mm VAS, in a blinded fashion to the patient's pain score. In the second phase, the physician rated his/her opinion after looking at the pain scale marked by patient.

RESULTS

587 patients (295, in first and 292, in second phase) were enrolled. The groups were not statistically different for demographic data. The physician's perception of pain was lower than the patient's pain score at both phases of the study. Insight of the patient's pain score on VAS increased the physician's pain perception significantly (p = 0.03). During the second phase, physicians ordered significantly more analgesic medications to the patients (p = 0.03).

CONCLUSION

The physicians' perception of the patients' pain differs significantly from the pain that the patient is experiencing. VAS helps to bring the physicians impression of pain perception to the level of pain that the patient is actually experiencing and resulted in ordering more analgesics to the patients. Implementation of a pain assessment tool can raise the physician's perception of the pain and may improve pain management practices and patient satisfaction.

Acute pain in the emergency department: Effect of an educational intervention

BACKGROUND AND AIMS

Pain management is often inadequate in emergency departments (ED) despite the availability of effective analgesics. Interventions to change professional behavior may therefore help to improve the management of pain within the ED. We hypothesized that a 2-h educational intervention combining e-learning and simulation would result in improved pain treatment of ED patients with pain.

METHODS

Data were collected at the ED of Horsens Regional Hospital during a 3-week study period in March 2015. Pain intensity (NRS, 0-10) and analgesic administration were recorded 24h a day for all patients who were admitted to the ED during the first and third study weeks. Fifty-three ED nurses and 14 ED residents participated in the educational intervention, which took place in the second study week.

RESULTS

In total, 247 of 796 patients had pain >3 on the NRS at the admission to the ED and were included in the data analysis. The theoretical knowledge of pain management among nurses and residents increased as assessed by a multiple choice test performed before and after the educational intervention (P=0.001), but no change in clinical practice could be observed: The administration for analgesics [OR: 1.79 (0.97-3.33)] and for opioids [2.02 (0.79-5.18)] were similar before and after the educational intervention, as was the rate of clinically meaningful pain reduction (NRS >2) during the ED stay [OR: 0.81 (CI 0.45-1.44)].

CONCLUSIONS

Conduction of a 2-h educational intervention combining interactive case-based e-learning with simulation-based training in an ED setting was feasible with a high participation rate of nurses and residents. Their knowledge of pain management increased after completion of the program, but transfer of the new knowledge into clinical practice could not be found. Future research should explore the effects of repeated education of healthcare providers on pain management.

IMPLICATIONS

It is essential for nurses and residents in emergency departments to have the basic theoretical and practical skills to treat acute pain properly. A modern approach including e-learning and simulation lead to increased knowledge of acute pain management. Further studies are needed to show how this increased knowledge is transferred into clinical practice.

Effect of System-Wide Interventions on the Assessment and Treatment of Pain by Emergency Medical Services Providers

BACKGROUND

An estimated 20% of patients arriving by ambulance to the emergency department are in moderate to severe pain. However, the management of pain in the prehospital setting has been shown to be inadequate. Untreated pain may have negative physiologic and psychological consequences. The prehospital community has acknowledged this inadequacy and made treatment of pain a priority.

OBJECTIVES

To determine if system-wide pain management improvement efforts (i.e. education and protocol implementation) improve the assessment of pain and treatment with opioid medications in the prehospital setting and to determine if improvements are maintained over time.

METHODS

This was a retrospective before and after study of a countywide prehospital patient care database. The study population included all adult patients transported by EMS between February 2004 and February 2012 with a working assessment of trauma or burn. EMS patient care records were searched for documentation of pain scores and opioid administration. Four time periods were examined: 1) before interventions, 2) after pediatric specific pain management education, 3) after pain management protocol implementation, and 4) maintenance phase. Frequencies and 95% confidence intervals were calculated for all patients meeting the inclusion criteria in each time period and Chi-square was used to compare frequencies between time periods.

RESULTS

15,228 adult patients transported by EMS during the study period met the inclusion criteria. Subject demographics were similar between the four time periods. Pain score documentation improved between the time periods but was not maintained over time (13% [95%CI 12-15%] to 32% [95%CI 31-34%] to 29% [95 CI 27-30%] to 19% [95%CI 18-21%]). Opioid administration also improved between the time periods and was maintained over time (7% [95%CI 6-8%] to 18% [95%CI 16-19%] to 24% [95%CI 22-25%] to 23% [95% CI 22-24%]).

CONCLUSIONS

In adult patients both pediatric-focused education and pain protocol implementation improved the administration of opioid pain medications. Documentation and assessment of pain scores was less affected by specific pain management improvement efforts.

A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain

While acute musculoskeletal pain is a frequent complaint, its management is often neglected. An implementation of a nurse-initiated pain protocol based on the algorithm of a Dutch pain management guideline in the emergency department might improve this. A pre-post intervention study was performed as part of the prospective PROTACT follow-up study. During the pre- (15 months, n = 504) and post-period (6 months, n = 156) patients' self-reported pain intensity and pain treatment were registered. Analgesic provision in patients with moderate to severe pain (NRS ≥4) improved from 46.8% to 68.0%. Over 10% of the patients refused analgesics, resulting into an actual analgesic administration increase from 36.3% to 46.1%. Median time to analgesic decreased from 10 to 7 min (P < 0.05), whereas time to opioids decreased from 37 to 15 min (P < 0.01). Mean pain relief significantly increased to 1.56 NRS-points, in patients who received analgesic treatment even up to 2.02 points. The protocol appeared to lead to an increase in analgesic administration, shorter time to analgesics and a higher clinically relevant pain relief. Despite improvements, suffering moderate to severe pain at ED discharge was still common. Protocol adherence needs to be studied in order to optimize pain management.

A simplified way for the urgent treatment of somatic pain in patients admitted to the emergency room: the SUPER algorithm

Somatic pain is one of the most frequent symptoms reported by patients presenting to the emergency department (ED), but, in spite of this, it is very often underestimated and under-treated. Moreover, pain-killers prescriptions are usually related to the medical examination, leading to a delay in its administration, thus worsening the patient's quality of life. With our study, we want to define and validate a systematic and homogeneous approach to analgesic drugs administration, testing a new therapeutic algorithm in terms of earliness, safety, and efficacy. 442 consecutive patients who accessed our ED for any kind of somatic pain were enrolled, and then randomly divided into two groups: group A follow the normal process of access to pain-control drugs, and group B follow our SUPER algorithm for early administration of drugs to relieve pain directly from triage. We excluded from the study, patients with abdominal pain referred to the surgeon, patients with headache, recent history of trauma, history of drug allergies, and life-threatening conditions or lack of cooperation. Drugs used in the study were those available in our ED, such as paracetamol, paracetamol/codeine, ketorolac-tromethamine, and tramadol-hydrochloride. Pain level, risk factors, indication, and contraindication of each drug were taken into account in our SUPER algorithm for a rapid and safe administration of it. The Verbal Numeric Scale (VNS) and the Visual Analog Scale (VAS) were used to verify the patient's health and perception of it. Only 59 patient from group A (27.1 %) received analgesic therapy (at the time of the medical examination) compared to 181 patients (100 %) of group B (p < 0.001). Group B patients, received analgesic therapy 76 min before group A subjects (p < 0.01), resulting in a significant lower VNS (7.31 ± 1.68 vs 4.75 ± 2.3; p < 0.001), and a superior VAS after discharge (54.43 ± 22.16 vs 61.30 ± 19.13; p < 0.001) compared to group A subjects. No significant differences concerning side effects were observed between group A and group B patients. Early administration of a pain-control therapy directly from triage is safe and effective, and significantly improves patients perceptions of their own health.

Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions

Objectives:

Traditionally, patients have to wait until assessed by a physician for opioid analgesia to be administered, which contributes to delays to analgesia. Western Hospital developed a protocol enabling nurses to initiate opioid analgesia prior to medical assessment for selected conditions. The aim of this study was to determine the impact of this protocol on time to first opioid dose in patients presenting to the emergency department (ED) with renal or biliary colic.

Methods:

This was an explicit medical record review of all adult patients with an ED discharge diagnosis of renal or biliary colic presenting to a metropolitan teaching hospital ED. Patients were identified via the ED data management system. Data collected included demographics, condition, triage category, time of presentation, whether analgesia was nurse-initiated or not, and interval from arrival to first opioid analgesic dose. The narcotic drug register for the relevant period was also searched to cross-check whether opiates were doctor- or nurse-initiated.

Results:

There were 58 presentations in the nurse-initiated opioid analgesia group and 99 in the non-nurse-initiated analgesia group. Groups were reasonably well matched for gender, triage category and time of presentation, but there was a higher proportion of biliary colic in the non-nurse-initiated analgesia group. Median time to first analgesic dose was 31 minutes in the nurse-initiated group and 57 minutes in the non-nurse-initiated analgesia group (effect size, 26 minutes; 95% confidence interval 16-36 min;p&lt; 0.0001]. There were no major adverse events in either group.

Conclusion:

A nurse-initiated opioid analgesia protocol reduces delays to opioid analgesia for patients with renal and biliary colic.

Prehospital Pain and Analgesic Therapy in Elderly Patients with Hip Fractures

INTRODUCTION

As a part of aging, hip fractures are becoming more common. The connection between increased pain and a poor outcome has previously been shown. Therefore, even in prehospital situations, analgesic therapy appears to be reasonable. We established a prospective study with 153 patients to evaluate the patients' pain levels during the prehospital phase of treatment and prehospital analgesic therapy.

METHODS

We performed a prospective study on 153 patients the age of 60 years or older in a University hospital setting between 2010 and 2011 who suffered hip fracture. Analgesics given and the type of medical staff that was involved were documented. Pain was measured using the NRS upon initial contact of the medical staff and upon admission to our emergency department.

RESULTS

Initial pain level evaluated by EMS (emergency medical service) was 6.8 (SD = 2.7). Twenty-two percent of the patients reported an NRS of 10 as the highest value following their injury. Forty-three of 153 patients (28%) received analgesics. The mean initial pain score for those 43 patients who did receive pain medication was 7.0 (SD = 2.6). However, this score dropped to a mean of 2.8 (SD = 1.4) upon hospital arrival (P < 0.001). The patients who did not receive pain medication had an initial pain score of 4.5 (SD = 1.9). Upon admission to the hospital, this score decreased to a mean of 4.0 (SD = 1.7, P = 0.092).

CONCLUSION

Only a minority of patients with hip fractures received prehospital analgesia. The administration of prehospital analgesia was associated with significant pain relief.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction.

Facilitators and barriers in pain management for trauma patients in the chain of emergency care

INTRODUCTION

The aim of the study is to give insight into facilitators and barriers in pain management in trauma patients in the chain of emergency care in the Netherlands.

PATIENTS AND METHODS

A qualitative approach was adopted with the use of the implementation Model of Change of Clinical Practice. The chain of emergency care concerned prehospital Emergency Medical Services (EMS) and Emergency Departments (EDs). We included two EMS ambulance services and three EDs and conducted five focus groups and 10 individual interviews. Stakeholders and managers of organisations were interviewed individually. Focus group participants were selected based on availability and general characteristics. Transcripts of the audio recordings and field notes were analysed in consecutive steps, based on thematic content analysis. Each step was independently performed by the researchers, and was discussed afterwards. We analysed differences and similarities supported by software for qualitative analysis MaxQDA.

RESULTS

This study identified five concepts as facilitators and barriers in pain management for trauma patients in the chain of emergency care. We described the concepts of knowledge, attitude, professional communication, organisational aspects and patient input, illustrated with quotes from the interviews and focus group sessions. Furthermore, we identified whether the themes occurred in the chain of care. Knowledge deficits, attitude problems and patient input were similar for the EMS and ED settings, despite the different positions, backgrounds and educational levels of respondents. In the chain of care a lack of professional communication and organisational feedback occurred as new themes, and were specifically related to the organisational structure of the prehospital EMS and EDs.

CONCLUSION

Identified organisational aspects stressed the importance of organisational embedding of improvement of pain management. However, change of clinical practice requires a comprehensive approach focused at all five concepts. We think a shift in attitudes is needed, together with constant surveillance and feedback to emergency care providers. Implementation efforts need to be aimed at the identified barriers and facilitators, tailored to the chain of emergency care and the multi-professional group of emergency care providers.

Pain management in emergency departments: a review of present protocols in The Netherlands

This descriptive study presents availability and content of acute pain protocols in emergency departments (EDs) in The Netherlands. Current acute pain protocols were collected and an a priori list of questions was used for analysis. Findings were compared with current international standards. Sixty-six of the 108 EDs responded. Fifty-six percent of the protocols did not address adults and 35% did not address children. Protocols were rather conservative and showed poor multidisciplinary approach. Seventy-three percent required a diagnosis before pain relief. Six percent did not include opioids, 36% did not allow intravenous opioids and only 49% allowed direct administration of opioids in severe pain. Pain measurement was included in 55% and in only 5% a target score was defined. Nonpharmacological approaches were mentioned in 6%. Acute pain protocols are lacking in many EDs. Most protocols did not apply current standards. We exposed an area with space for leadership.

Does a pain scale improve pain assessment in the pediatric emergency department?

OBJECTIVE

Pain management in children requires rapid and sensitive assessment. The Wong-Baker FACES pain scale (WBFPS) is a widely accepted, validated tool to assess pain in children. Our objective was to determine whether incorporation of the WBFPS into the emergency medical record (EMR) improves pain documentation in the pediatric emergency department. We also examined whether this intervention improves the management of children who present with pain.

METHODS

The WBFPS was incorporated into the EMR in an urban tertiary care pediatric emergency department. We performed a review of EMRs for patients aged 3 to 20 years at 30 days before and 30 days after the intervention. All physicians were trained to use the WBFPS. We excluded patients younger than 3 years or who were unable to perform the assessment. We compare rates of pain score documentation for the preintervention (PRE) and postintervention (POST) groups and times from triage to analgesia administration using Fisher exact test.

RESULTS

A total of 462 and 372 EMRs were included in the PRE and POST groups, respectively. The groups were similar with respect to age (P = 0.46); there were more males in the POST group (47.2% vs 56.5%, P = 0.008). The rate of pain score documentation was 7.4% (n = 34) in the PRE group and 38.2% (n = 142) in the POST group (P < 0.001). In patients with pain score of 6 or greater, there was no statistical difference in analgesia administration (PRE, 41.7% [10/24] vs POST, 41.8% [28/67]) or time to administer analgesia in minutes (PRE, 80.4%; median, 42 and POST, 100.5%; median, 52.5; P = 0.71).

CONCLUSIONS

Incorporating the WBFPS into the EMR significantly improves pain assessment in children. Despite this, there was neither improvement in analgesia administration nor reduction in time to administer analgesia in children with pain.

Pain prevalence and pain relief in trauma patients in the Accident & Emergency department

BACKGROUND

Acute pain in the A&E department (ED) has been described as a problem, however insight into the problem for trauma patients is lacking.

OBJECTIVE

This study describes the prevalence of pain, the pain intensity and the effect of conventional pain treatment in trauma patients in the ED.

METHODS

In a prospective cohort study of 450 trauma patients, pain was measured on admission and at discharge, using standardized and validated pain instruments.

RESULTS

The prevalence of pain was high, both on admission (91%) and at discharge (86%). Two thirds of the trauma patients reported moderate or severe pain at discharge. Few patients received pharmacological or non-pharmacological pain relieving treatment during their stay in the ED. Pain decreased in 37% of the patients, did not change at all in 46%, or had increased in 17% of the patients at discharge from the ED. The most effective pain treatment given was a combination of injury treatment and supplementary pharmacological interventions, however this treatment was given to a small group of patients.

CONCLUSIONS

Acute pain in trauma patients is a significant problem in the ED's. Pain itself does not seem to be treated systematically and sufficiently, anywhere in the cycle of injury treatment in the ED.

Analgesic Use in Intubated Patients during Acute Resuscitation

BACKGROUND

Pain relief can often be overlooked during a busy trauma resuscitation, especially in patients who are intubated. We sought to investigate qualitative and quantitative aspects of analgesic use in intubated patients during the acute phase of resuscitation.

METHODS

We evaluated a retrospective cohort of consecutive adult patients who were intubated during the acute trauma resuscitation (first 6 hours) from January 2001 to May 2002 at a Level I trauma center in the United States. Patient demographics, injuries, vital signs, medications, trauma bay procedures, and disposition status were analyzed. Analgesia was recorded as the type of analgesic, route of administration, elapsed time to receive the first analgesic, total dosage, and time intervals between two successive doses. Fisher's exact test, chi test, and ANOVA were used to analyze data.

RESULTS

A total of 120 patients were included. Sixty-one (51%) patients received analgesia during their stay in the emergency department. Using logistic regression analysis, patients who more likely to receive analgesia were those who did not require immediate surgical operation and were transferred to the intensive care unit (odds ratio [OR]=3.91; 95% CI=1.75-8.76) and those who were admitted during the hours of 8 am to 6 pm (OR=3.17; CI=1.40-7.16). Among those patients receiving analgesia, 30 (25%) patients received analgesia within 30 minutes upon arrival. The mean time of receiving the first analgesia dose was 57 minutes. The average morphine equivalent dose given to the patients was 15.7 mg. The most frequently given single dose was 100 mug of intravenous fentanyl. Most of the analgesics (37%) were given between 30 to 60 minutes apart.

CONCLUSION

Our findings suggest that patients who are intubated during the acute resuscitation probably receive inadequate analgesia. The inadequacy appears to be in the timing and repetition of administration, rather than the dose. Patients who were transferred early to the intensive care unit were more likely to receive analgesics.

Fentanyl trauma analgesia use in air medical scene transports

This study assessed frequency, safety and efficacy of prehospital fentanyl analgesia during 6 months' adult and pediatric helicopter trauma scene transports (213 doses in 177 patients). We reviewed flight records for pain assessment and analgesia provision, effect, and complications. Analgesia was administered to 46/49 (93.9%) intubated patients. In non-intubated patients, pain assessment was documented in 112 of 128 (87.5%), and analgesia was offered, or there was no pain, in 97/128 (75.8%). Of the 67 non-intubated patients to whom analgesia was administered, post-analgesia pain assessment was documented in 62 (92.5%) and pain improved in 53 (79.1% of 67). Post-analgesia blood pressure dropped below 90 torr in 2/177 cases (1.1%, 95% confidence interval [CI] 0.1-4.0%). Post-analgesia S(p)O(2) did not drop below 90% in any patients (95% CI 0-2.3%). In this study, prehospital providers performed well with respect to pain assessment and treatment. Fentanyl was provided frequently, with good effect and minimal cardiorespiratory consequence.

Pain management and regional anaesthesia in the trauma patient

PURPOSE OF THE REVIEW

Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. This update reviews recent publications related to pain relief in the trauma patient.

RECENT FINDINGS

Although recent publications suggest that the assessment and treatment of pain in trauma have improved, most studies still document inadequate analgesia. We discuss the use of different analgesia strategies in the prehospital and emergency room settings.

SUMMARY

Educating the emergency room staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma. Peripheral nerve block techniques should be practised by emergency room staff. If simple techniques are chosen, competence can be achieved with short, focused training sessions. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient.

Improving the pattern of work towards emergency medicine at the Emergency Department in Rambam Medical Centre

BACKGROUND

Rambam Medical Centre is a 950-bed referral hospital, containing 34 beds in the Emergency Department (ED). The arrangement of the ED was based on two separate units: trauma and medical. Patient evaluation lasted many hours, with an abuse of consultants, laboratory and imaging services.

OBJECTIVE

To describe the improvement of patient management in our ED by changing working patterns according to emergency medicine guidelines.

METHODS

The trauma and medical units were combined into a one-unit ED, managed by one director and two specialists in emergency medicine. The goal of the ED was defined as the treatment and triage of patients towards discharge or admission in the minimal time needed. New protocols for clinical evaluation, blood and imaging tests, consultation facilities and pain management were implemented according to emergency medicine practice. Once a decision for admission is made, a computerized program assigns the patient to the appropriate ward.

RESULTS

There was a dramatic reduction (44%) in the time needed for patient evaluation. The number of patients waiting more than 4 h and 8 h for admission was reduced significantly (11 versus 38% and 1 versus 24%, respectively). The total number of blood tests was reduced by 45%, and the number of blood and urine cultures by 81 and 87%, respectively. Two years after the change, the ED won first place in patient satisfaction screening.

CONCLUSIONS

By changing work methods according to emergency medicine guidelines, and by using protocols written for emergency medicine, a significant improvement in our duties as an ED was achieved. The backing of the hospital management helped to implement the changes, which led to the functional improvement.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Whether a component of a disease process, the result of acute injury, or a product of a diagnostic or therapeutic procedure, pain should be relieved and stress should be decreased for pediatric patients. Control of pain and stress for children who enter into the emergency medical system, from the prehospital arena to the emergency department, is a vital component of emergency care. Any barriers that prevent appropriate and timely administration of analgesia to the child who requires emergency medical treatment should be eliminated. Although more research and innovation are needed, every opportunity should be taken to use available methods of pain control. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can have a positive effect on providing comfort to children in the emergency setting.

Pain scores improve analgesic administration patterns for trauma patients in the emergency department

OBJECTIVE

To determine the efficacy of pain scores in improving pain management practices for trauma patients in the emergency department (ED).

METHODS

A prospective, observational study of analgesic administration to trauma patients was conducted over a nine-week period following educational intervention and introduction of verbal pain scores (VPSs). All ED nursing and physician staff in an urban Level I trauma center were trained to use the 0-10 VPS. Patients younger than 12 years old, having a Glasgow Coma Scale score (GCS) <8, or requiring intubation were excluded from analysis. Demographics, mechanism of injury, vital signs, pain scores, and analgesic data were extracted from a computerized ED database and patients' records. The staff was blinded to the ongoing study.

RESULTS

There were 150 patients studied (183 consecutive trauma patients seen; 33 patients excluded per criteria). Pain scores were documented for 73% of the patients. Overall, 53% (95% confidence interval [CI] = 45% to 61%) of the patients received analgesics in the ED. Of the patients who had pain scores documented, 60% (95% CI = 51% to 69%) received analgesics, whereas 33% (95% CI = 18% to 47%) of the patients without pain scores received analgesics. No patient with a VPS < 4 received analgesics, whereas 72% of patients with a VPS > 4 and 82% with a VPS > 7 received analgesics. Mean time to analgesic administration was 68 minutes (95% CI = 49 to 87).

CONCLUSIONS

Pain assessment using VPS increased the likelihood of analgesic administration to trauma patients with higher pain scores in the ED.