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Smith J, Soo D, Celenza A. Triage-initiated intranasal fentanyl for hip fractures in an Emergency Department - Results from introduction of an analgesic guideline. Int Emerg Nurs 2024; 74:101445. [PMID: 38579496 DOI: 10.1016/j.ienj.2024.101445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Pain relief is a priority for patients with hip fractures who present to Emergency Departments (EDs). Intranasal fentanyl (INF) is an ideal option for nurse initiated analgesia as it does not require intravenous access and can expedite care prior to examination by a physician. LOCAL PROBLEM Pain relief in patients with hip fractures is delayed during episodes of ED crowding. METHODS A retrospective medical record review was conducted following introduction of an INF guideline in an adult ED in 2018. Patients were included over a 4-month period during which the guideline was introduced. Historical and concurrent control groups receiving usual care were compared to patients receiving INF. INTERVENTIONS This quality improvement initiative investigated whether an INF analgesia at triage guideline would decrease time to analgesic administration in adults with hip fracture in ED. RESULTS This study included 112 patients diagnosed with fractured hips of which 16 patients received INF. Background characteristics were similar between groups. Mean time to analgesic administration (53 v 110 minutes), time to x-ray (46 v 75 minutes), and ED length of stay (234 v 298 minutes) were significantly decreased in the intervention group. Inadequate documentation was a limiting factor in determining improved efficacy of analgesia. CONCLUSION Use of triage-initiated INF significantly decreased time to analgesic administration, time to imaging and overall length of stay in ED.
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Affiliation(s)
- Jennifer Smith
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - Danny Soo
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - Antonio Celenza
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia; Division of Emergency Medicine, University of Western Australia, Stirling Highway, Nedlands, Western Australia, Australia.
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2
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Elder NM, Heavey SF, Tyler KR. Emergency Department Pain Management in the Older Adult. Clin Geriatr Med 2023; 39:619-634. [PMID: 37798068 DOI: 10.1016/j.cger.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Pain assessment and management in older adults is complex and requires evaluation and consideration of the type of pain, the acuity of the condition, comorbidities, and medications. Many older adults do not receive appropriate therapy for painful conditions in the emergency department (ED). This brief review article is focused on pharmacologic agents, drug-drug interactions, drug-disease interactions, and approaches in the management of painful conditions seen in older adults in the emergency department. Recommendations for specific painful conditions such as fragility fractures are discussed.
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Affiliation(s)
- Natalie M Elder
- University of Vermont, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Sean F Heavey
- University of California Davis, 4150 V Street, Sacramento, CA 95817, USA
| | - Katren R Tyler
- University of California Davis, 4150 V Street, Sacramento, CA 95817, USA.
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3
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Graham B, Smith JE, Barham F, Latour JM. Involving patients and caregivers to develop items for a new patient-reported experience measure for older adults attending the emergency department. Findings from a nominal group technique study. Health Expect 2023; 26:2040-2049. [PMID: 37391897 PMCID: PMC10485325 DOI: 10.1111/hex.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/11/2023] [Accepted: 06/17/2023] [Indexed: 07/02/2023] Open
Abstract
CONTEXT Patient experience is an important component of high-quality care and is linked to improved clinical outcomes across a range of different conditions. Patient-reported experience measures (PREMs) are psychometrically validated instruments designed to identify where strengths and vulnerabilities in care exist. Currently, there is no validated instrument available to measure patient experience among people aged over 65 years attending the emergency department (ED). OBJECTIVE This paper aims to describe the process of generating, refining and prioritising candidate items for inclusion in a new PREM measuring older adults' experiences in ED (PREM-ED 65). DESIGN One hundred and thirty-six draft items were generated via a systematic review, interviews with patients and focus groups with ED staff exploring older adults' experiences in the ED. A 1-day multiple stakeholder workshop was then convened to refine and prioritise these items. The workshop entailed a modified nominal groups technique exercise comprised of three discrete parts-(i) item familiarisation and comprehension assessment, (ii) initial voting and (iii) final adjudication. SETTING AND PARTICIPANTS Twenty-nine participants attended the stakeholder workshop, conducted in a nonhealthcare setting (Buckfast Abbey). The average age of participants was 65.6 years. Self-reported prior experiences of emergency care among the participants included attending the ED as a patient (n = 16, 55.2%); accompanying person (n = 11, 37.9%) and/or as a healthcare provider (n = 7, 24.1%). RESULTS Participants were allocated time to familiarise themselves with the draft items, suggest any improvements to the item structure or content, and suggest new items. Two additional items were proposed by participants, yielding a total of 138 items for prioritisation. Initial prioritisation deemed most items 'critically important' (priority 7-9 out of 9, n = 104, 75.4%). Of these, 70 items demonstrated suitable inter-rater agreement (mean average deviation from the median < 1.04) and were recommended for automatic inclusion. Participants then undertook final adjudication to include or exclude the remaining items, using forced choice voting. A further 29 items were included. Thirty-nine items did not meet the criteria for inclusion. CONCLUSIONS This study has generated a list of 99 prioritised candidate items for inclusion in the draft PREM-ED 65 instrument. These items highlight areas of patient experience that are particularly important to older adults accessing emergency care. This may be of direct interest to those looking to improve the patient experience for older adults in the ED. For the final stage of development, psychometric validation amongst a real-world population of ED patients is now planned. PATIENT AND PUBLIC CONTRIBUTION Initial item generation was informed using qualitative research, including interviews with patients in the ED. The opinions of patients and members of the public were integral to achieving outcomes from the prioritisation meeting. The lay chair of the Royal College of Emergency Medicine participated in the meeting and reviewed the results of this study.
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Affiliation(s)
- Blair Graham
- School of Nursing and Midwifery, Faculty of HealthUniversity of PlymouthPlymouthUK
- Department of Emergency MedicineUniversity Hospitals Plymouth NHS TrustPlymouthUK
| | - Jason E. Smith
- Department of Emergency MedicineUniversity Hospitals Plymouth NHS TrustPlymouthUK
| | - Ffion Barham
- Department of Emergency MedicineUniversity Hospitals Plymouth NHS TrustPlymouthUK
| | - Jos M. Latour
- School of Nursing and Midwifery, Faculty of HealthUniversity of PlymouthPlymouthUK
- School of Nursing, Midwifery and Paramedicine, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
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Keskpaik T, Talving P, Kirsimägi Ü, Mihnovitš V, Ruul A, Starkopf J. Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators. Eur J Trauma Emerg Surg 2023; 49:1375-1381. [PMID: 36995396 DOI: 10.1007/s00068-023-02263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. OBJECTIVES The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals. METHODS This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. RESULTS Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35-105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034). CONCLUSION Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.
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Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Anni Ruul
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Kolli S, Friedman BW, Latev A, Chang AK, Naeem F, Feliciano C, Afrifa F, Walker C, Izzo A, Irizarry E. A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain. Ann Emerg Med 2022; 80:432-439. [PMID: 35965162 PMCID: PMC9588558 DOI: 10.1016/j.annemergmed.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE We conducted a randomized study to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids. METHODS This randomized comparative effectiveness study with 162 participants was conducted in 2 urban emergency departments (EDs). The primary outcome was an improvement in a 0 to 10 pain scale from baseline to 60 minutes later. Secondary outcomes included the need for additional analgesic medication and adverse events that were attributable to the investigational medication. The minimum clinically important difference was an improvement of 1.3 on the 0 to 10 pain scale. RESULTS The median baseline pain score was 10 (interquartile range 8 to 10) in both the groups. By 60 minutes, patients taking acetaminophen improved by 3.6 (standard deviation 2.9) on the 0 to 10 pain scale, whereas patients taking hydromorphone improved by 4.6 (standard deviation 3.3) (95% confidence interval [CI] for the difference of 1.0 was 0.1 to 2.0). Additional analgesic medications were required for 37 (46%) of 81 patients taking acetaminophen and 31 (38%) of 81 patients taking hydromorphone (95% CI for the rounded difference of 7% was -8% to 23%). Adverse events were reported by 6 (7%) of 81 patients taking acetaminophen and 10 (12%) of 81 patients taking hydromorphone (95% CI for the difference of 5% was -4% to 14%) and included dizziness, drowsiness, headache, and nausea. CONCLUSION Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.
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Affiliation(s)
- Shilpa Kolli
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Alex Latev
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Andrew K Chang
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Farnia Naeem
- Department of Emergency Medicine, Mount Sinai Health System, New York, NY
| | - Carmen Feliciano
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | | | - Christopher Walker
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Al Izzo
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
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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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7
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Althagafi SM, Hughes JA. Identifying the relationship between patient-reported outcomes and treatment with opiates in the adult emergency department - A cross-sectional study. Int Emerg Nurs 2022; 62:101152. [PMID: 35245729 DOI: 10.1016/j.ienj.2022.101152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/09/2022] [Accepted: 01/31/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Suhair M Althagafi
- School of Nursing, Queensland University of Technology, Brisbane, Australia; College of Nursing, Umm AlQura University, Makkah, Saudi Arabia
| | - James A Hughes
- School of Nursing, Queensland University of Technology, Brisbane, Australia.
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8
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Baril L, Nguyen E, Dufresne-Santerre L, Émond V, Émond M, Berthelot S, Gagnon AP, Nadeau A, Carmichael PH, Mercier E. Pain induced by investigations and procedures commonly administered to older adults in the emergency department: a prospective cohort study. Emerg Med J 2021; 38:825-829. [PMID: 34344731 DOI: 10.1136/emermed-2020-210535] [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: 08/24/2020] [Accepted: 07/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aimed to assess the level of pain induced by common interventions performed in older adults consulting to the ED. METHODS We conducted a prospective multicentre observational cohort study in two academic EDs (Quebec City, Canada) between June 2018 and December 2019. A convenience sample of well-oriented and haemodynamically stable older adults (≥65 years old) who underwent at least two interventions during their ED stay was recruited. The level of pain was assessed using an 11-point Numerous Rating Scale (NRS) and is presented using median and IQR or categorised as no pain (0), mild (1-3), moderate (4-6) or severe pain (7-10). RESULTS A total of 318 patients were included. The mean age was 77.8±8.0 years old and 54.4% were female . The number of pain assessments per intervention ranged between 22 (urinary catheterisation) and 240 (intravenous catheter). All imaging investigations (X-rays, CT and bedside ultrasound) were associated with a median level of pain of 0. The median level of pain for other interventions was as follows: blood samplings (n=231, NRS 1 (IQR 0-3)), intravenous catheters (n=240, NRS 2 (IQR 0-4)), urinary catheterisations (n=22, NRS 4.5 (IQR 2-6)), cervical collars (n=50, NRS 5 (IQR 0-8)) and immobilisation mattresses (n=34, NRS 5 (IQR 0-8)). Urinary catheterisations (63.8%), cervical collars (56.0%) and immobilisation mattresses (52.9%) frequently induced moderate or severe pain. CONCLUSIONS Most interventions administered to older adults in the ED are associated with no or low pain intensity. However, urinary catheterisation and spinal motion restriction devices are frequently associated with moderate or severe pain.
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Affiliation(s)
- Laurence Baril
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Elisabeth Nguyen
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | | | - Virginie Émond
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Marcel Émond
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada.,Emergency Department, CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Simon Berthelot
- Emergency Department, CHU de Québec - Université Laval, Quebec City, Quebec, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Ann-Pier Gagnon
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Alexandra Nadeau
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada.,VITAM - Centre de recherche en santé durable de l'Université Laval, Quebec City, Quebec, Canada
| | | | - Eric Mercier
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada .,VITAM - Centre de recherche en santé durable de l'Université Laval, Quebec City, Quebec, Canada
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Gawthorne J, Stevens J, Faux SG, Leung J, McInnes E, Fasugba O, Mcelduff B, Middleton S. Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department. J Clin Nurs 2021; 30:3611-3622. [PMID: 34109694 DOI: 10.1111/jocn.15883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors. BACKGROUND The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors. DESIGN A prospective cohort study. METHODS The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013-December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies. RESULTS Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group. CONCLUSION Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture. RELEVANCE TO CLINICAL PRACTICE Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.
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Affiliation(s)
- Julie Gawthorne
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Darlinghurst, NSW, Australia
| | - Jennifer Stevens
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Steven G Faux
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Julie Leung
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Darlinghurst, NSW, Australia
| | - Oyebola Fasugba
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Darlinghurst, NSW, Australia
| | - Benjamin Mcelduff
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Darlinghurst, NSW, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Darlinghurst, NSW, Australia
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10
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Chang AK, Edwards RR, Morrison RS, Argoff C, Ata A, Holt C, Bijur PE. Disparities in Acute Pain Treatment by Cognitive Status in Older Adults With Hip Fracture. J Gerontol A Biol Sci Med Sci 2021; 75:2003-2007. [PMID: 31560758 DOI: 10.1093/gerona/glz216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We examined the disparities in emergency department (ED) pain treatment based on cognitive status in older adults with an acute hip fracture. METHODS Observational study in an academic ED in the Bronx, New York. One hundred forty-four adults aged 65 years and older with acute hip fracture were administered the Telephone Interview for Cognitive Status (TICS) while in the ED. The primary outcome was receipt of any parenteral analgesic. The risk factor of interest was cognitive impairment (TICS ≤ 25). Secondary outcomes included receipt of any opioid, receipt of any analgesic, total dose of analgesics in intravenous morphine equivalent units (MEQ), and time to receiving first analgesic. RESULTS Of the 87 (60%) study patients who were cognitively impaired, 60% received a parenteral analgesic compared to 79% of the 57 cognitively unimpaired patients (RR 0.76 [95% CI 0.61, 0.94]). The effect of cognitive impairment on receiving any opioids (RR: 0.81, 95% CI 0.67, 0.98) and any analgesic (RR: 0.85; 95% CI: 0.71, 1.01) was similar. The median analgesic dose in cognitively impaired patients was significantly lower than in cognitively unimpaired patients (4 MEQ vs 8 MEQ, p = .003). CONCLUSION Among older adults presenting to the ED with acute hip fracture, cognitive impairment was independently associated with lower likelihood of receiving analgesia and lower amount of opioid analgesia.
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Affiliation(s)
- Andrew K Chang
- Department of Emergency Medicine, Albany Medical College, New York
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Charles Argoff
- Department of Neurology, Albany Medical College, New York
| | - Ashar Ata
- Department of Emergency Medicine, Albany Medical College, New York
| | - Christian Holt
- Department of Emergency Medicine, Albany Medical College, New York
| | - Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York
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11
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Gonzalez B, Gonzalez SR, Rojo M, Mhyre J. Neuraxial Analgesia in Pregnant Hispanic Women: An Assessment of Their Beliefs and Expectations. Int J Womens Health 2021; 13:87-94. [PMID: 33488125 PMCID: PMC7814237 DOI: 10.2147/ijwh.s270711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background The presence of racial/ethnic disparities in the use of neuraxial labor analgesia for childbirth has been previously described. The purpose of this study was to assess the childbirth pain management beliefs among a small sample of pregnant Hispanic women and to evaluate the Spanish translation accuracy of the Childbirth Pain Scale (CPBS). Methods To collect data, we interviewed 20 pregnant Spanish-speaking women using an interview guide, a demographic datasheet, and the CPBS a 15-item survey. Interviews were transcribed verbatim, translated, and uploaded to ethnograph v6. Descriptive statistics and thematic analysis were used to analyze the data. Results Most of the participants were from Mexico (n=16) and Central America (n=4), mean age was 28.3, and all (n=20) spoke Spanish as their primary language. In this sample, 80% of nulliparous and 100% of multiparous women saw pain as having a positive role in delivery. Four major themes emerged from the data: Theme 1: Normalcy of childbirth pain (pain is good), Theme 2: Availability and role of pain medication, Theme 3: Naturalistic strategies to endure pain, and Theme 4: Fear of the unknown/childbirth process. In this sample, 18 of 20 women stated they did not want epidural analgesia unless medically indicated. During labor and delivery 100% of nulliparous and 25% of multiparas chose to receive epidural analgesia. No changes were requested by the participants regarding the translation of the CPBS. Conclusion Childbirth pain was seen as a valuable component of the birthing process. The majority of participants believed pain medication should be avoided unless medically necessary. These results suggest that racial/ethnic disparities in the use of epidural analgesia may partially reflect patient beliefs and preferences. It is crucial to be aware of these differences to optimize shared decision-making for women in this vulnerable patient population.
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Affiliation(s)
- Basilia Gonzalez
- Department of Family Medicine, Lifelong Medical Care, Richmond, CA, USA
| | - Santiago R Gonzalez
- Division of Plastic & Reconstructive Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Martha Rojo
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jill Mhyre
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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12
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Amado JP, Vasquez R, Huari R, Rimache L, Lizonde R. Impact of Applying Palliative Care on Symptoms and Survival of Patients with Advanced Chronic Disease Admitted to the Emergency Department. Indian J Palliat Care 2020; 26:332-337. [PMID: 33311875 PMCID: PMC7725180 DOI: 10.4103/ijpc.ijpc_195_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/26/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: In the emergency department, there is a need to provide palliative care; however, they are not usually administered. The present study evaluates the evolution of the intensity of the symptoms when applying palliative care, in adult patients with advanced chronic disease admitted to the emergency room, and compares survival between those who receive this care and those who do not. Materials and Methods: A clinical intervention study was conducted including patients older than 18 years with advanced chronic disease admitted to the emergency room with an indication of palliative support according to the Supportive and Palliative Care Indicators Tool 2015. Three hundred and seven patients were studied (74 in the intervention group and 233 in the group not intervened). In the intervention group, the intensity of pre- and postintervention symptoms was compared (Wilcoxon test). The survival of both the groups were then compared (logrank test). Results: There was a significant decrease in pain and dyspnea at 24 and 48 h postintervention (P < 0.01), respectively, while drowsiness increased significantly at 24 h (P < 0.01) but did not change at 48 h (P = 0.38). Excluding patients with better functional status, there was less survival at 3 months in the intervention group (P = 0.01). Conclusions: Dyspnea and pain decreased with the application of palliative care but not drowsiness. Survival in the intervention group was lower than in the nonintervention group. However, the reason for providing palliative care is to relieve suffering at the end of life.
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Affiliation(s)
- Jose P Amado
- Department of Emergency, Rebagliati Hospital, EsSalud, Peru.,Medicine School, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Rolando Vasquez
- Department of Emergency, Rebagliati Hospital, EsSalud, Peru.,Medicine School, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Roberto Huari
- Department of Emergency, Rebagliati Hospital, EsSalud, Peru
| | | | - Rosa Lizonde
- Department of Emergency, Rebagliati Hospital, EsSalud, Peru
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13
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Comparison of ibuprofen and piroxicam gel in the treatment of trauma pain: A randomized double-blind trial of geriatric population. Am J Emerg Med 2020; 38:2110-2115. [PMID: 33041145 DOI: 10.1016/j.ajem.2020.08.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study aimed to compare the analgesic efficacy of topical ibuprofen and topical piroxicam for acute musculoskeletal injuries. METHODS In this prospective, randomized, controlled, double-blinded study, geriatric patients were assigned to groups to receive either topical ibuprofen (n = 70) or topical piroxicam (n = 69). The first dose of gel was applied in the emergency department and the remaining doses were self-administered at home by the patients thrice daily for 72 h. For each patient, the initial baseline visual analog scale (VAS) score (V 0) was compared with the VAS scores at the 60 min (V1), 120 min (V2), 24 h (V3) and 72 h (V4) time points. The decreases in VAS scores, clinical effectiveness of the treatments, and incidence of adverse events were evaluated. RESULTS In the topical ibuprofen group, the VAS scores were significantly lower at each measurement time point compared to baseline (p < .001). The results were as follows: V0 -V: 1.08, 95% CI: 0.56-1.61; V0 -V2: 1.09, 95% CI: 0.49-1.69; V0 -V3: 1.44, 95% CI: 0.81-2.07; V0 -V4: 1.59, 95% CI: 0.91-2.26. The mean percentage decrease in the VAS scores in the topical ibuprofen group was significantly higher than that in the topical piroxicam group (p < .001). The clinical effect of treatment was found to be significantly higher for the ibuprofen gel group (p < .001). There was no substantial difference in treatment-related adverse events between the groups (p > .05). CONCLUSION Ibuprofen gel, which is a safe treatment option for geriatric patients, is more clinically effective than piroxicam gel. Response to Reviewers.
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14
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Benzing AC, Bell C, Derazin M, Mack R, MacIntosh T. Disparities in Opioid Pain Management for Long Bone Fractures. J Racial Ethn Health Disparities 2020; 7:740-745. [PMID: 32378160 DOI: 10.1007/s40615-020-00701-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/29/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022]
Abstract
An expanding body of evidence has established that racial disparities exist in the US healthcare system, manifesting in poorer health outcomes for members of the non-white population. This study examines whether disparities exist in the type of analgesia ordered for long bone fractures and the time to medication administration in a community teaching hospital serving a large Hispanic population. We reviewed de-identified data of 115 patients from the emergency department of a community Level II Trauma Center in central Florida with diagnosed long bone fractures and examined the clinical and demographic variables associated with the type of analgesic administered and factors associated with delays in medication administration. We found that women reported higher pain scores than men, but there was no difference in the type of pain medication administered. There was no difference in pain scores between white and non-white patients; however, white patients were more likely to receive opiates for their long bone fractures compared with non-white patients (70 vs 50%, p < 0.0001). Opioid pain medications were prescribed significantly more often to adult and elderly patients compared with pediatric patients who were more likely to receive acetaminophen compared with both other patient groups (p < 0.001). In summary, we found that pain score was not associated with the class of pain medication administered, but that race and age were. This study questions the utility of the pain score for acute injuries and raises concerns about the role of physician bias in analgesia administration.
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Affiliation(s)
| | - C Bell
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - M Derazin
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - R Mack
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - T MacIntosh
- UCF/HCA Emergency Medicine Residency of Greater Orlando, Osceola Regional Medical Center, Kissimmee, FL, USA.
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15
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de Vries M, Gravel J, Horn D, McLeod S, Varner C. Comparative efficacy of opioids for older adults presenting to the emergency department with acute pain: Systematic review. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e538-e543. [PMID: 31831503 PMCID: PMC6907377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To systematically review the literature for studies comparing the efficacy of opioid analgesics for older adults (≥ 65 years) presenting to the emergency department (ED) with acute pain. DATA SOURCES The Cochrane Library, MEDLINE, EMBASE, Web of Science, and CINAHL were searched up to August or September 2017. Reference lists were searched for potential articles and ClinicalTrials.gov was searched for unpublished trials. STUDY SELECTION Randomized controlled trials (RCTs) were sought that compared the efficacy of 2 or more opioid analgesics for acute pain in older patients (≥ 65 years) in the ED. Two reviewers independently screened abstracts, assessed study quality, and extracted data. SYNTHESIS After screening titles and abstracts of 1315 citations, the full texts of 63 studies were reviewed and 1 RCT met the inclusion criteria. This study randomized older adult patients presenting to an urban academic ED with acute, severe pain to receive a single dose of either 0.0075 mg/kg intravenous hydromorphone or 0.05 mg/kg intravenous morphine. This study found no clinical or statistical difference between the 2 treatments. CONCLUSION The lack of published research in this area demonstrates a considerable gap in knowledge of the comparative efficacy of opioid analgesics in the growing older adult patient population. Physicians are often uncertain in their choice of analgesia, potentially contributing to the undertreatment of pain. It is clear that well designed RCTs are urgently needed.
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Affiliation(s)
- Maaike de Vries
- Doctoral student at the Institute of Health Policy, Management and Evaluation at the University of Toronto in Ontario.
| | - Jonathan Gravel
- Emergency medicine resident in the Department of Medicine and the Department of Family Medicine at McMaster University in Hamilton, Ont
| | - Daphne Horn
- Lead, Library Services, at Scarborough Health Network in Ontario
| | - Shelley McLeod
- Research Director at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health Systems and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto
| | - Catherine Varner
- Emergency physician at Mount Sinai Hospital, Clinician Investigator at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health Systems, and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto
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16
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Anderson GL, Mattson AE, Brown CS, Cabrera D, Mara KC, Bellolio MF. Safety of parenteral ketorolac use for analgesia in geriatric emergency department patients. Am J Emerg Med 2019; 38:727-730. [PMID: 31201117 DOI: 10.1016/j.ajem.2019.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/10/2019] [Accepted: 06/04/2019] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess the safety of a single dose of parenteral ketorolac for analgesia management in geriatric emergency department (ED) patients. METHODS This was a retrospective study of all administrations of parenteral ketorolac to adults ≥65 years of age and matched controls. The primary outcome was the occurrence of any of the following adverse events within 30 days of the ED visit: gastrointestinal bleeding, intracranial bleeding, acute decompensated heart failure, acute coronary syndrome, dialysis, transfusion, and death. The secondary outcome was the occurrence of an increase in serum creatinine of ≥1.5 times baseline within 7 and 30 days of the ED visit. RESULTS There were 480 patients included in the final analysis, of which 120 received ketorolac (3: 1 matching). The primary outcome occurred in 14 of 360 patients who did not receive ketorolac and 2 of 120 ketorolac patients (3.9% vs 1.7%, p = 0.38; OR 2.39, 95% CI 0.54-10.66). There was no occurrence of dialysis or death in either group. The secondary outcome occurred in 1 of 13 and 1 of 23 ketorolac patients with both a baseline serum creatinine and a measure within 7 and 30 days, respectively, but did not occur in patients who did not receive ketorolac (7 days: 7.7% vs 0.0%, p = 0.29; 30 days: 4.4% vs 0.0%, p = 0.22). CONCLUSION The use of single doses of parenteral ketorolac for analgesia management was not associated with an increased incidence of adverse cardiovascular, gastrointestinal, or renal adverse outcomes in a select group of older adults.
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Affiliation(s)
| | | | | | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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17
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Chang AK, Bijur PE, Ata A, Campbell C, Pearlman S, White D, Chertoff A, Restivo A, Gallagher EJ. Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain. Acad Emerg Med 2019; 26:402-409. [PMID: 30118582 DOI: 10.1111/acem.13556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain. METHODS This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes. RESULTS Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups. CONCLUSION In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.
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Affiliation(s)
- Andrew K. Chang
- Department of Emergency Medicine Albany Medical College AlbanyNY
| | - Polly E. Bijur
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Ashar Ata
- Department of Emergency Medicine Albany Medical College AlbanyNY
| | - Caron Campbell
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Scott Pearlman
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Deborah White
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Andrew Chertoff
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - Andrew Restivo
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
| | - E. John Gallagher
- Department of Emergency Medicine Albert Einstein College of Medicine Bronx NY
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Prehospital intravenous fentanyl administered by ambulance personnel: a cluster-randomised comparison of two treatment protocols. Scand J Trauma Resusc Emerg Med 2019; 27:11. [PMID: 30732618 PMCID: PMC6367789 DOI: 10.1186/s13049-019-0588-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background Prehospital acute pain is a frequent symptom that is often inadequately managed. The concerns of opioid induced side effects are well-founded. To ensure patient safety, ambulance personnel are therefore provided with treatment protocols with dosing restrictions, however, with the concomitant risk of insufficient pain treatment of the patients. The aim of this study was to investigate the impact of a liberal intravenous fentanyl treatment protocol on efficacy and safety measures. Methods A two-armed, cluster-randomised trial was conducted in the Central Denmark Region over a 1-year period. Ambulance stations (stratified according to size) were randomised to follow either a liberal treatment protocol (3 μg/kg) or a standard treatment protocol (2 μg/kg). The primary outcome was the proportion of patients with sufficient pan relief (numeric rating scale (NRS, 0–10) < 3) at hospital arrival. Secondary outcomes included abnormal vital parameters as proxy measures of safety. A multi-level mixed effect logistic regression model was applied. Results In total, 5278 patients were included. Ambulance personnel following the liberal protocol administered higher doses of fentanyl [117.7 μg (95% CI 116.7–118.6)] than ambulance personnel following the standard protocol [111.5 μg (95% CI 110.7–112.4), P = 0.0001]. The number of patient with sufficient pain relief at hospital arrival was higher in the liberal treatment group than the standard treatment group [44.0% (95% CI 41.8–46.1) vs. 37.4% (95% CI 35.2–39.6), adjusted odds ratio 1.47 (95% CI 1.17–1.84)]. The relative decrease in NRS scores during transport was less evident [adjusted odds ratio 1.18 (95% CI 0.95–1.48)]. The occurrences of abnormal vital parameters were similar in both groups. Conclusions Liberalising an intravenous fentanyl treatment protocol applied by ambulance personnel slightly increased the number of patients with sufficient pain relief at hospital arrival without compromising patient safety. Future efforts of training ambulance personnel are needed to further improve protocol adherence and quality of treatment. Trial registration ClinicalTrials.gov (NCT02914678). Date of registration: 26th September, 2016.
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19
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Pasiorowski A, Olson K, Ghosh S, Ray L. Oligoanalgesia in Adult Colles Fracture Patients Admitted to the Emergency Department. Clin Nurs Res 2018; 30:23-31. [PMID: 30585090 DOI: 10.1177/1054773818820175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pain is a complex symptom to assess properly and it is often poorly managed in the Emergency Department. The majority of research has focused on exploring oligoanalgesia in samples of patients with heterogeneous injuries. The occurrence of oligoanalgesia in a homogeneous injury, such as Colles fracture, has yet to be explored. A retrospective chart review was conducted to determine the incidence of oligoanalgesia in adults with Colles fractures admitted to two urban Emergency Departments in Western Canada. Data were collected from one hundred fifty charts from a 5-year period (2009-2014). Age and gender predicted of pain assessment (p = .019), but were not significantly associated with receipt of an opioid or pain reassessment. Pain reassessment was only completed in 47% of patients who received an initial pain assessment; this was significantly different from current best practice standards (p = .0002).
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Affiliation(s)
| | | | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Lynne Ray
- University of Alberta, Edmonton, Canada
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20
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Ringer T, Dougherty M, McQuown C, Melady D, Ouchi K, Southerland LT, Hogan TM. White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults. AEM EDUCATION AND TRAINING 2018; 2:S5-S16. [PMID: 30607374 PMCID: PMC6304282 DOI: 10.1002/aet2.10205] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/02/2018] [Indexed: 05/21/2023]
Abstract
Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.
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Affiliation(s)
- Thom Ringer
- Mount Sinai Academic Family Health TeamTorontoOntarioCanada
| | | | - Colleen McQuown
- Northeast Ohio Medical UniversityRootstownOH
- Academic & Community Emergency SpecialistsLLCUniontownOH
| | - Don Melady
- Schwarz/Reisman Emergency Medicine InstituteDepartment of Family and Community MedicineSinai Health SystemUniversity of TorontoTorontoOntarioCanada
| | - Kei Ouchi
- Brigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Lauren T. Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
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21
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Redley B, Baker T. Have you SCAND MMe Please? A framework to prevent harm during acute hospitalisation of older persons: A retrospective audit. J Clin Nurs 2018; 28:560-574. [PMID: 30129081 DOI: 10.1111/jocn.14650] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To test the mnemonic Have you SCAND MMe Please? as a framework to audit nursing care to prevent harms common to older inpatients. BACKGROUND It is not known if acute hospital care comprehensively addresses eight interrelated factors that contribute to preventable harms common in older hospitalised patients. DESIGN Retrospective audit of medical records. METHODS A random selection of 400 medical records of inpatients over 65 years of age with an unplanned admission of longer than 72 hr in acute medical wards at four hospitals in Victoria, Australia, during 2011-12, was examined for frequency of documented evidence of assessments, interventions or new problems related to eight factors contributing to common preventable harms during hospitalisation. RESULTS Assessments of skin integrity (94%-97%), mobility (95%-98%) and pain (93%-97%) were most often documented. Gaps in assessment of continence (4%-31%), nutrition (9%-49%), cognition (delirium, depression and dementia) (10%-24%) were most common. No patient record had evidence of all eight factors being assessed. Almost 80% of records had interventions documented for one or more factors that contribute to preventable harms. In almost 20% of patient records, a new preventable harm was documented during hospitalisation. CONCLUSIONS The mnemonic Have you SCAND MMe Please? brings together eight factors known to contribute to preventable harms common in older hospitalised patients. This framework was useful to identify gaps in assessment and interventions for factors that contribute to preventable harms during acute hospital care. Future research should test if the mnemonic can assist nurses with comprehensive harm prevention during acute hospitalisation. RELEVANCE TO CLINICAL PRACTICE The mnemonic Have you SCAND MMe Please? represents eight factors that contribute to preventable harms common in older hospitalised patients. This framework provides a model for harm prevention to assist nurses to implement comprehensive harm prevention to improve quality of care and safety for older hospitalised patients.
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Affiliation(s)
- Bernice Redley
- School of Nursing and Midwifery, Nursing Research Centre, Monash Health-Deakin Partnership, Deakin University, Burwood, Victoria, Australia
| | - Tim Baker
- Centre for Rural Emergency Medicine, Deakin University, Warrnambool, Victoria, Australia
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22
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Deng LX, Patel K, Miaskowski C, Maravilla I, Schear S, Garrigues S, Thompson N, Auerbach AD, Ritchie CS. Prevalence and Characteristics of Moderate to Severe Pain among Hospitalized Older Adults. J Am Geriatr Soc 2018; 66:1744-1751. [PMID: 30095854 DOI: 10.1111/jgs.15459] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the prevalence, characteristics, and management of pain in older hospitalized medical patients. DESIGN Medical record aggregate review. SETTING Tertiary care hospital. PARTICIPANTS Individuals aged 65 and older admitted to the medicine service between November 28, 2014, and May 28, 2015. MEASUREMENTS Demographic characteristics, comorbidity burden, pain characteristics, and analgesics during index hospitalization were assessed in individuals with moderate to severe pain (≥4 on 0-10 Numeric Pain Rating Scale). RESULTS Of 1,267 patients admitted to the medicine service, 248 (20%) had moderate to severe pain on admission (mean age 75 ± 8, 57% female, 50% white). During hospitalization, most participants received opioids (80%) and acetaminophen (74%), and few received nonsteroidal antiinflammatory drugs (9%). Participants with chronic pain had less reduction in pain intensity score from admission to discharge than those without a history of chronic pain (mean change score 3.7 vs 4.9, p=.002) and were more likely to receive opioids, adjuvant analgesics, and other analgesics (all p<.05). CONCLUSION Twenty percent of older adults admitted to a general medicine service had moderate to severe pain. Further research about optimal pain management in hospitalized older adults, particularly those with chronic pain, is necessary to improve care in this population.
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Affiliation(s)
- Lisa X Deng
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Christine Miaskowski
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California
| | - Ingrid Maravilla
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Sarah Schear
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Sarah Garrigues
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Nicole Thompson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
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23
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Gleason LJ, Escue ED, Hogan TM. Older Adult Emergency Department Pain Management Strategies. Clin Geriatr Med 2018; 34:491-504. [PMID: 30031429 DOI: 10.1016/j.cger.2018.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Older adults frequently present to the emergency department (ED) with pain, which is often underrecognized and undertreated. There is high variability of pain management and prescribing practices by ED providers. This article focuses on treatment of older adults in the ED who present with pain and addresses special considerations for this population. Social supports and follow-up must be considered in discharge treatment recommendations.
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Affiliation(s)
- Lauren J Gleason
- Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637, USA
| | - Emily D Escue
- Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637, USA
| | - Teresita M Hogan
- Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC6098, Chicago, IL 60637, USA; Section of Emergency Medicine, L-550A (MC 5068), 5841 S, Maryland Avenue, Chicago, IL 60637, USA.
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Belland L, Rivera-Reyes L, Hwang U. Using music to reduce anxiety among older adults in the emergency department: a randomized pilot study. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2018; 15:450-455. [PMID: 29103414 DOI: 10.1016/s2095-4964(17)60341-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND An emergency department (ED) visit may be distressing and anxiety-provoking for older adults (age > 65 years). No studies have specifically evaluated the effect of music listening on anxiety in older adults in the ED. OBJECTIVE The objective of this pilot study was to evaluate the effect of music listening on anxiety levels in older ED patients. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS This was a randomized pilot study in the geriatric ED of an urban academic tertiary medical center. This was a sample of English-speaking adults (age > 65 years) who were not deaf (n = 35). Subjects consented to participate and were randomized to receive up to 60 min of music listening with routine care, while the control group received routine care with no music. Subjects in the music treatment group received headphones and an electronic tablet with pre-downloaded music, and were allowed to choose from 5 selections. MAIN OUTCOME MEASURES The primary outcome was change in anxiety levels, measured by the state-trait anxiety inventory (STAI), at enrollment and 1 h later. RESULTS A total of 35 participants were enrolled: 74% were female, 40% were white, and 40% were black; of these, 32 subjects completed the study protocol. When comparing control (n = 18) against intervention subjects (n = 17), there were no significant differences in enrollment STAI scores (43.00 ± 15.00 vs. 40.30 ± 12.80, P = 0.57). STAI scores 1 hour after enrollment (after the music intervention) were significantly reduced in the intervention subjects compared to the control subjects (with reduction of 10.00 ± 12.29 vs. 1.88 ± 7.97, P = 0.03). CONCLUSION These pilot results suggest that music listening may be an effective tool for reducing anxiety among older adults in the ED.
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Affiliation(s)
- Laura Belland
- Center for Family Medicine, NewYork-Presbyterian/Columbia University Medical Center, New York, NY 10032, USA
| | - Laura Rivera-Reyes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, New York, NY 10029, USA
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Marra EM, Mazer-Amirshahi M, Mullins P, Pines JM. Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015). West J Emerg Med 2018; 19:678-688. [PMID: 30013704 PMCID: PMC6040900 DOI: 10.5811/westjem.2018.5.37853] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/04/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION We assess trends in opioid administration and prescribing from 2005-2015 in older adults in United States (U.S.) emergency departments (ED). METHODS We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18-64, 65-74, 75-84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored. RESULTS Opioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18-64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18-64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to <65. However, this age-related disparity in prescribing narrowed over the study period. There were shifts in the specific types of opioids administered and prescribed in adult encounters ≥ 65 years over the study period, with the most notable being a 76% increase in hydromorphone administration comparing 2005-06 to 2014-15. CONCLUSION From 2005-15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005-11 and then declined from 2012-15, more so among visits in the 18-64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects.
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Affiliation(s)
- Erin M Marra
- Aventura Hospital and Medical Center, Department of Emergency Medicine, Aventura, Florida
| | - Maryann Mazer-Amirshahi
- MedStar Washington Hospital Center, Department of Emergency Medicine, Washington, District of Columbia
| | - Peter Mullins
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jesse M Pines
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
- The George Washington University, Department of Emergency Medicine, Washington, District of Columbia
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Miner JR, Rafique Z, Minkowitz HS, DiDonato KP, Palmer PP. Sufentanil sublingual tablet 30 mcg for moderate-to-severe acute pain in the ED. Am J Emerg Med 2018; 36:954-961. [DOI: 10.1016/j.ajem.2017.10.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022] Open
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Allione A, Pivetta E, Pizzolato E, Lorenzati B, Pomero F, Barutta L, Lauria G, Tartaglino B. Determinants of inappropriate acute pain management in old people unable to communicate verbally in the emergency department. Turk J Emerg Med 2017; 17:160-164. [PMID: 29464223 PMCID: PMC5812916 DOI: 10.1016/j.tjem.2017.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 07/30/2017] [Accepted: 08/10/2017] [Indexed: 12/01/2022] Open
Abstract
Objectives Poor pain management is relevant among individuals unable to communicate verbally (UCV). Analgesia may be due to three determinants: patients' status, physician's characteristics and pain etiology. Our aim is to investigate the association between prescription of ED pain treatment and these determinants. Materials and Methods An observational prospective study including UCV patients was conducted. Severity of pain was evaluated by ALGOPLUS Scale and a score P ≥ 2 out of 5 on the pain scale was retained as the threshold for the presence of acute pain in elderly UCV patients. Results Our data showed that only 31,9% of UCV patients received a pharmacological treatment. The presence of the caregiver would influence the rate of therapy administration [OR 6,19 (95% CI 2,6–14,75)]. The presence of leg pain [OR 0,32 (95% CI 0,12–0,86)] and head pain [OR 0,29 (95% CI 0,10–0,84)] were less likely associated to receive analgesia. Pain related to trauma [OR 4.82 (95% CI 1.17 to 19.78)] and youngest physicians [OR 1.08 (95% CI 1.001 to 1.18)] were variables associated with the administration of drugs opiates. Discussion Older UCV patients presenting to the ED with pain are at high risk of inadequate analgesia. Providers should always suspect presence of pain and an increasing need for behavioural pain evaluation is necessary for a complete assessment. Conclusions Presence of a caregiver influences a more appropriate pain management in these patients. Staff training on pain management could result in better assessment, treatment, and interaction with caregivers.
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Affiliation(s)
- Attilio Allione
- Emergency Medicine Unit, S. Croce and Carle General Hospital, Cuneo, Italy
| | - Emanuele Pivetta
- Cancer Epidemiology Unit, CPO Piemonte, CeRMS, University of Turin, Italy
| | - Elisa Pizzolato
- Emergency Medicine Unit, S. Croce and Carle General Hospital, Cuneo, Italy
| | | | - Fulvio Pomero
- Internal Medicine Unit, Santa Croce and Carle General Hospital, Cuneo, Italy
| | - Letizia Barutta
- Emergency Medicine Unit, S. Croce and Carle General Hospital, Cuneo, Italy
| | - Giuseppe Lauria
- Emergency Medicine Unit, S. Croce and Carle General Hospital, Cuneo, Italy
| | - Bruno Tartaglino
- Emergency Medicine Unit, S. Croce and Carle General Hospital, Cuneo, Italy
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Patel PM, Goodman LF, Knepel SA, Miller CC, Azimi A, Phillips G, Gustin JL, Hartman A. Evaluation of Emergency Department Management of Opioid-Tolerant Cancer Patients With Acute Pain. J Pain Symptom Manage 2017; 54:501-507. [PMID: 28729010 DOI: 10.1016/j.jpainsymman.2017.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/29/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT There are no previously published studies examining opioid doses administered to opioid-tolerant cancer patients during emergency department (ED) encounters. OBJECTIVES To determine if opioid-tolerant cancer patients presenting with acute pain exacerbations receive adequate initial doses of as needed (PRN) opioids during ED encounters based on home oral morphine equivalent (OME) use. METHODS We performed a retrospective cohort study of opioid-tolerant cancer patients who received opioids in our ED over a two-year period. The percentage of patients who received an adequate initial dose of PRN opioid (defined as ≥10% of total 24-hour ambulatory OME) was evaluated. Logistic regression was used to establish the relationship between 24-hour ambulatory OME and initial ED OME to assess whether higher home usage was associated with higher likelihood of being undertreated. RESULTS Out of 216 patients, 61.1% of patients received an adequate initial PRN dose of opioids in the ED. Of patients taking <200 OMEs per day at home, 77.4% received an adequate initial dose; however, only 3.2% of patients taking >400 OMEs per day at home received an adequate dose. Patients with ambulatory 24-hour OME greater than 400 had 99% lower odds of receiving an adequate initial dose of PRN opioid in the ED compared to patients with ambulatory 24-hour OME less than 100 (OR <0.01, CI 0.00-0.02, P < 0.001). CONCLUSIONS Patients with daily home use less than 200 OMEs generally received adequate initial PRN opioid doses during their ED visit. However, patients with higher home opioid usage were at increased likelihood of being undertreated.
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Affiliation(s)
- Pina M Patel
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Lauren F Goodman
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States; Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States.
| | - Sheri A Knepel
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Charles C Miller
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Asma Azimi
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Gary Phillips
- The Ohio State University Center for Biostatistics, Columbus, Ohio, United States
| | - Jillian L Gustin
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Amber Hartman
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States; Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
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Consensus multidisciplinaire d’experts en douleur et gériatrie : utilisation des antalgiques dans la prise en charge de la douleur de la personne âgée (hors anesthésie). ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.douler.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Chen KH, Hsieh HM, Chen CM, Chiu HC, Lee IC. The Long-Term Trends of the Association Between Falls Among the Elderly in Taiwan and their Utilization of Medical Facilities. INT J GERONTOL 2017. [DOI: 10.1016/j.ijge.2016.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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The frequency of analgesic drug use and causes in 65 years old and above; A family medicine unit experience. JOURNAL OF SURGERY AND MEDICINE 2017. [DOI: 10.28982/josam.339263] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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de Almeida Tavares JP, Sa-Couto P, Boltz M, Capezuti E. Portuguese Older Adults Presenting at the Emergency Department: Predictive Validity of the Identification of Seniors at Risk (ISAR) Tool. J Gerontol Nurs 2017; 43:1-7. [PMID: 28399314 DOI: 10.3928/00989134-20170405-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/02/2017] [Indexed: 11/20/2022]
Abstract
Following an emergency department (ED) visit, older adults are more likely to experience poorer outcomes than younger adults. It is crucial to identify older patients using a validated tool. One of the most studied tools is the Identification of Seniors at Risk (ISAR), which is used to identify older adults at risk of adverse outcomes after ED admission. The purpose of the current study was to examine the sensitivity, specificity, and interrater reliability of the Portuguese version of the ISAR when considering early (30 days) and late (180 days) outcomes. Four hundred two older adults presenting in EDs from January 2013 to August 2014 were prospectively enrolled and surveyed. The ISAR threshold (cutoff =2) presented a better compromise between sensitivity (81.8% to 88.7%) and specificity (14.7% to 28.1%) when compared to cutoffs =1 or =3, respectively. Interrater reliability results were very good (0.81 to 0.94). Overall, the Portuguese ISAR appears worthwhile for screening older adults at risk in EDs. [Journal of Gerontological Nursing, xx(x), xx-xx.].
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Gorawara-Bhat R, Wong A, Dale W, Hogan T. Nurses' perceptions of pain management for older-patients in the Emergency Department: A qualitative study. PATIENT EDUCATION AND COUNSELING 2017; 100:231-241. [PMID: 27591825 DOI: 10.1016/j.pec.2016.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES 1) Identify themes arising from nurses' perceptions of assessing older-patients' pain; 2) use themes to guide development of optimal interventions to improve quality of pain assessment in the emergency department (ED). METHODS Nurse interviews (n=20) were conducted until theme saturation. They were transcribed, coded, and analyzed using qualitative methodology. RESULTS Two major themes-nurse 'challenges' and 'strategies' to overcome challenges, and their subthemes - classified as 'patient-related' or 'system-related,' were salient in nurses' perceptions. Strategies nurses reported for managing challenges were based in their own professional lived experiences. DISCUSSION AND CONCLUSION A 2×2 framework was developed to conceptualize challenges, strategies, subthemes and their classifications, yielding 4 typologies comprising challenge types matched with appropriate strategy types. While emergent challenges and strategies are corroborated in the literature, the present study is the first to develop a scheme of typologies beneficial for guiding the development of optimal interventions to improve the quality of assessing pain in older-patients. PRACTICE IMPLICATIONS The typology framework can guide the development of pain assessment tools and the needed combinations for assessing multidimensional pain in older-patients. Using the present findings, a new clinical intervention was shown to significantly improve pain management for older-patients in the ED.
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Affiliation(s)
| | - Alexandra Wong
- Section of Geriatrics and Palliative Medicine, Chicago, IL, USA
| | - William Dale
- Section of Geriatrics and Palliative Medicine, Chicago, IL, USA
| | - Teresita Hogan
- Section of Geriatrics and Palliative Medicine, Chicago, IL, USA; Section of Emergency Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Cornelius R, Herr KA, Gordon DB, Kretzer K, Butcher HK. Evidence-Based Practice Guideline : Acute Pain Management in Older Adults. J Gerontol Nurs 2017; 43:18-27. [DOI: 10.3928/00989134-20170111-08] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Friesgaard KD, Christensen EF, Kirkegaard H, Bendtsen MD, Jensen FB, Nikolajsen L. Prehospital intravenous fentanyl to patients with hip fracture: an observational cohort study of risk factors for analgesic non-treatment. Scand J Trauma Resusc Emerg Med 2017; 25:5. [PMID: 28103892 PMCID: PMC5244577 DOI: 10.1186/s13049-017-0348-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with proximal femoral neck fracture have a high short-term mortality, a high risk of postoperative complications, and impaired quality of life. One of the challenges related to the prehospital treatment of these patients is to administer systemic opioids fast and properly. Effective analgesic prehospital treatment ought be initiated rapidly in order to alleviate the stress that follows acute pain, to facilitate transportation, and to improve quality of care. The objectives of this study were to explore the prevalence of prehospital administration of intravenous fentanyl to patients with proximal femoral neck fracture in the ambulances and to assess risk factors for analgesic non-treatment. METHODS This was a register-based observational cohort study of patients with proximal femoral neck fracture from the North Denmark Region transported by ambulance. The patients were identified via the Danish Interdisciplinary Hip Fracture Registry over a 3-year period from 1 July 2011 to 30 June 2014. This hospital registry contains data on several patient characteristics used for the risk factor analysis. Data on prehospital treatment (intravenous fentanyl) and patient monitoring were registered in an electronic prehospital patient record. A modified Poisson regression with robust standard errors was carried out with intravenous fentanyl as the primary binary outcome and the following explanatory variables: age, sex, Charlson Comorbidity Index score, housing, body mass index, type of fracture, fracture displacement, prior consultation with general practitioner, dispatch triage level, and time with ambulance personnel. RESULTS In total, 2,140 patients with proximal femoral neck fracture were transported by ambulance, of which 584 (27.3%, 95% CI: 25.4-29.2) were treated with intravenous fentanyl. Risk factors for non-treatment were: older age, male sex (RR 0.77, 95% CI: 0.64-0.91), institutional housing (RR 0.72, 95% CI: 0.56-0.92), medial fracture (RR 0.74, 95% CI: 0.60-0.92), short time with ambulance personnel, Charlson Comorbidity Index score > 1, year of fracture (2011), low levels of urgency at dispatch, and if seen by general practitioners prior to transport. DISCUSSION Education of ambulance personnel in assessing and treating patients with hip fracture seems to be required. Also, future studies should consider alternative or supportive pain treatment options with suitable analgesic effects and side effects. CONCLUSIONS Few patients with proximal femoral neck fracture were treated with intravenous fentanyl, and several risk factors were associated with prehospital analgesic non-treatment. Future prospective studies should explore covariates of socioeconomic, cultural, and psychological origin to provide further insight into the multifactorial causes of non-treatment of acute pain.
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Affiliation(s)
- Kristian D Friesgaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus N, Denmark. .,Department of Anesthesiology, Regional Hospital of Horsens, Horsens, Denmark.
| | - Erika F Christensen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark.,Department of Anesthesiology and Intensive Care, Emergency Clinic Aalborg University Hospital, Aalborg, Denmark
| | - Hans Kirkegaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus N, Denmark
| | - Mette D Bendtsen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Flemming B Jensen
- Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Lone Nikolajsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Hogan TM, Richmond NL, Carpenter CR, Biese K, Hwang U, Shah MN, Escobedo M, Berman A, Broder JS, Platts-Mills TF. Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda. Acad Emerg Med 2016; 23:1386-1393. [PMID: 27561819 DOI: 10.1111/acem.13074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/01/2016] [Accepted: 08/23/2016] [Indexed: 12/20/2022]
Abstract
Older emergency department patients have high rates of serious illness and injury, are at high risk for side effects and adverse events from treatments and diagnostic tests, and in many cases, have nuanced goals of care in which pursuing the most aggressive approach is not desired. Although some forms of shared decision making (SDM) are commonly practiced by emergency physicians caring for older adults, broader use of SDM in this setting is limited by a lack of knowledge of the types of patients and conditions for which SDM is most helpful and the approaches and tools that can best facilitate this process. We describe a research agenda to generate new knowledge to optimize the use of SDM during the emergency care of older adults.
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Affiliation(s)
| | - Natalie L. Richmond
- School of Medicine; University of North Carolina at Chapel Hill; Chapel Hill NC
| | | | - Kevin Biese
- Department of Emergency Medicine; University of North Carolina at Chapel Hill; Chapel Hill NC
| | - Ula Hwang
- Icahn School of Medicine at Mount Sinai; New York NY
| | - Manish N. Shah
- Department of Emergency Medicine; University of Wisconsin; Madison WI
| | | | - Amy Berman
- John A. Hartford Foundation; New York NY
| | | | - Timothy F. Platts-Mills
- Department of Emergency Medicine and the Department of Anesthesiology; University of North Carolina at Chapel Hill; Chapel Hill NC
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Hogan TM, Howell MD, Cursio JF, Wong A, Dale W. Improving Pain Relief in Elder Patients (I-PREP): An Emergency Department Education and Quality Intervention. J Am Geriatr Soc 2016; 64:2566-2571. [PMID: 27806183 DOI: 10.1111/jgs.14377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the effectiveness of a novel combined education and quality improvement (QI) program for management of pain in older adults in the emergency department (ED). DESIGN Controlled pre/postintervention examination. SETTING An academic urban ED seeing 60,000 adult visits annually. PARTICIPANTS Individuals aged 65 and older experiencing moderate to severe pain. INTERVENTION Linked standardized education and continuous QI for multidisciplinary staff in an urban, academic ED from January 2012 to January 2014. MEASUREMENTS Pain intensity, percentage receiving and time to pain assessment and reassessment, percentage receiving and time to delivery of analgesic. RESULTS The percentage of participants with final pain score of 4 or less (out of 10) increased 47.5% (95% confidence interval (CI) = 41.8-53.2%). Median decrease in pain intensity improved significantly, from 0.0 to 5.0 points (P < .001). Median final pain score decreased from 7.0 to 4.0 points (P < .001). The percentage of participants with any pain improvement increased 43.7% (95% CI = 37.1-50.3%, P < .001). Pain reassessments increased significantly (from 51.9% to 82.5%, P < .001). The percentage receiving analgesics increased significantly (from 64.1% to 84.8%, P < .001). After the intervention, participants had 3.1 (95% CI = 2.1-4.4, P < .001) greater odds of receiving analgesics and 4.7 (95% CI = 3.5-6.5, P < .001) greater odds of documented pain reassessment. CONCLUSION The I-PREP intervention substantially improved pain management in older adults in the ED with moderate to severe musculoskeletal or abdominal pain. Significant reductions in pain intensity were achieved, the timing of pain assessments and reassessments was improved, and analgesics were delivered faster. Tightly linking education to targeted QI improved pain management of older adults in the ED.
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Affiliation(s)
- Teresita M Hogan
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois.,Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois
| | - Michael D Howell
- Center for Pulmonary and Critical Care, University of Chicago, Chicago, Illinois.,Center for Healthcare Delivery Science, University of Chicago, Chicago, Illinois
| | - John F Cursio
- Center for Quality, University of Chicago, Chicago, Illinois
| | - Alexandra Wong
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois
| | - William Dale
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois
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Taylor DM, Chen J, Khan M, Lee M, Rajee M, Yeoh M, Richardson JR, Ugoni AM. Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department. Emerg Med J 2016; 34:13-19. [PMID: 27789567 DOI: 10.1136/emermed-2016-206044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the patient and clinical variables associated with administration of any analgesia, nurse-initiated analgesia (NIA, prescribed and administered by a nurse) and early analgesia (within 30 min of presentation). METHODS We undertook a retrospective cohort study of patients who presented to a metropolitan ED in Melbourne, Australia, during July and August, 2013. The ED has an established NIA programme. Patients were included if they were aged 18 years or more and presented with a painful complaint. The study sample was randomly selected from a list of all eligible patients. Data were extracted electronically from the ED records and by explicit extraction from the medical record. Logistic regression models were constructed to assess associations with the three binary study end points. RESULTS 1289 patients were enrolled. Patients were less likely to receive any analgesia if they presented 08:00-15:59 hours (OR 0.67, 95% CI 0.46 to 0.98) or 16:00-24:00 hours (OR 0.55, 95% CI 0.37 to 0.80) were triage category 5 (OR 0.20, 95% CI 0.08 to 0.49) or required an interpreter (OR 0.34, 95% CI 0.14 to 0.86). Patients were less likely to receive NIA or early analgesia if they were aged 56 years or more (OR 0.70 and 0.63; OR 0.57 and 0.21, respectively) or if they had received ambulance analgesia (OR 0.59, 95% CI 0.36 to 0.95; OR 0.38, 95% CI 0.20 to 0.74, respectively). CONCLUSIONS Patients who present during the daytime, have a triage category of 5 or require an interpreter are less likely to receive analgesia. Older patients and those who received ambulance analgesia are less likely to receive NIA or early analgesia.
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Affiliation(s)
- David McD Taylor
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Chen
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Munad Khan
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Marina Lee
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Mani Rajee
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Yeoh
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Joanna R Richardson
- Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Antony M Ugoni
- Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
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Moustafa F, Macian N, Giron F, Schmidt J, Pereira B, Pickering G. Intervention Study with Algoplus®: A Pain Behavioral Scale for Older Patients in the Emergency Department. Pain Pract 2016; 17:655-662. [DOI: 10.1111/papr.12498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/04/2016] [Accepted: 07/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Nicolas Macian
- CHU Clermont-Ferrand; Clinical Pharmacology Department; Clermont-Ferrand France
| | - Fatiha Giron
- CHU Clermont-Ferrand; Clinical Pharmacology Department; Clermont-Ferrand France
| | | | - Bruno Pereira
- CHU Clermont-Ferrand; Biostatistics Unit; Clermont-Ferrand France
| | - Gisèle Pickering
- CHU Clermont-Ferrand; Clinical Pharmacology Department; Clermont-Ferrand France
- Inserm 1107 and 1405; Clermont-Ferrand France
- Pharmacology Department; Medical Faculty; Clermont University; Clermont-Ferrand France
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Ko A, Harada MY, Smith EJ, Scheipe M, Alban RF, Melo N, Margulies DR, Ley EJ. Pain Assessment and Control in the Injured Elderly. Am Surg 2016. [DOI: 10.1177/000313481608201001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y. Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J.T. Smith
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Scheipe
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Roberts ES, Belland L, Rivera-Reyes L, Hwang U. The effect of surgical consult in the treatment of abdominal pain in older adults in the ED. Am J Emerg Med 2016; 34:1524-7. [PMID: 27241564 DOI: 10.1016/j.ajem.2016.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/09/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective was to determine whether need for surgical consult contributes to delayed or reduced analgesic administration in older adults presenting to the emergency department with abdominal pain. METHODS Secondary data analyses from a prospective cohort study consisting of adults ≥65 years in age presenting to the emergency department with a chief concern of abdominal pain from November 1, 2012, through October 31, 2014, were performed. Measurements included administration of analgesics, time to administration, type given, and pain score reduction. Covariates for adjusted analyses included age, sex, race/ethnicity, and Emergency Severity Index. RESULTS A total of 3522 patients were included, of which 281 (8.7%) received any consult. Consult patients were less likely to receive any analgesic medication (53.0%) compared with nonconsult patients (62.5%) (relative risk = 0.80; 95% confidence interval, 0.70-0.91). However, among those patients receiving analgesic medications, there were no differences in likelihood of receiving an opioid, time to administration, or pain score reduction. When analyzing patients who received a surgical consult (n = 154, 4.4%), these associations were notably stronger. Surgical consult patients had a lower rate of analgesic administration (46.8%) compared with nonconsult patients (62.4%) (relative risk = 0.75; 95% confidence interval, 0.63- 0.89). Again, no differences were found in likelihood of receiving any opioid, time to administration, or pain score reduction. CONCLUSION Need for abdominal surgical consult is associated with decreased administration of analgesics in older patients, possibly indicating a continued need to improve management in this setting. This difference, however, did not impact pain score reductions.
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Affiliation(s)
- Eleanor S Roberts
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1062, New York, NY, 10029.
| | - Laura Belland
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1062, New York, NY, 10029; Center for Family and Community Medicine, Columbia University Medical Center, 610 W 158th St, New York, NY, 10032
| | - Laura Rivera-Reyes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1062, New York, NY, 10029
| | - Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1062, New York, NY, 10029; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatrics Research, Education and Clinical Center, James J Peters VAMC, Bronx, NY
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Genes N, Kim MS, Thum FL, Rivera L, Beato R, Song C, Soriano J, Kannry J, Baumlin K, Hwang U. Usability Evaluation of a Clinical Decision Support System for Geriatric ED Pain Treatment. Appl Clin Inform 2016; 7:128-42. [PMID: 27081412 DOI: 10.4338/aci-2015-08-ra-0108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older adults are at risk for inadequate emergency department (ED) pain care. Unrelieved acute pain is associated with poor outcomes. Clinical decision support systems (CDSS) hold promise to improve patient care, but CDSS quality varies widely, particularly when usability evaluation is not employed. OBJECTIVE To conduct an iterative usability and redesign process of a novel geriatric abdominal pain care CDSS. We hypothesized this process would result in the creation of more usable and favorable pain care interventions. METHODS Thirteen emergency physicians familiar with the Electronic Health Record (EHR) in use at the study site were recruited. Over a 10-week period, 17 1-hour usability test sessions were conducted across 3 rounds of testing. Participants were given 3 patient scenarios and provided simulated clinical care using the EHR, while interacting with the CDSS interventions. Quantitative System Usability Scores (SUS), favorability scores and qualitative narrative feedback were collected for each session. Using a multi-step review process by an interdisciplinary team, positive and negative usability issues in effectiveness, efficiency, and satisfaction were considered, prioritized and incorporated in the iterative redesign process of the CDSS. Video analysis was used to determine the appropriateness of the CDS appearances during simulated clinical care. RESULTS Over the 3 rounds of usability evaluations and subsequent redesign processes, mean SUS progressively improved from 74.8 to 81.2 to 88.9; mean favorability scores improved from 3.23 to 4.29 (1 worst, 5 best). Video analysis revealed that, in the course of the iterative redesign processes, rates of physicians' acknowledgment of CDS interventions increased, however most rates of desired actions by physicians (such as more frequent pain score updates) decreased. CONCLUSION The iterative usability redesign process was instrumental in improving the usability of the CDSS; if implemented in practice, it could improve geriatric pain care. The usability evaluation process led to improved acknowledgement and favorability. Incorporating usability testing when designing CDSS interventions for studies may be effective to enhance clinician use.
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Affiliation(s)
- Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Min Soon Kim
- Department of Health Management & Informatics, University of Missouri School of Medicine, Columbia, MO; Informatics Institute, University of Missouri, Columbia, MO
| | - Frederick L Thum
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Laura Rivera
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Rosemary Beato
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Carolyn Song
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Jared Soriano
- Information Technology, Mount Sinai Health System , New York, NY
| | - Joseph Kannry
- Information Technology, Mount Sinai Health System, New York, NY; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kevin Baumlin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Ula Hwang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J Peters VAMC, Bronx, NY
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Dale J, Bjørnsen LP. Assessment of pain in a Norwegian Emergency Department. Scand J Trauma Resusc Emerg Med 2015; 23:86. [PMID: 26514633 PMCID: PMC4625614 DOI: 10.1186/s13049-015-0166-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/21/2015] [Indexed: 12/02/2022] Open
Abstract
Background Although pain management is a fundamental aspect of care in emergency departments (EDs), inadequate treatment of pain is unfortunately common. There are multiple local protocols for pain assessment in the ED. This study evaluated whether the initial assessment and treatment of pain in the ED are in accordance with the in-hospital protocol of the ED at a Norwegian University Hospital. Materials and methods Prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation. The patients’ perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10. Results Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58 %), only 14 % received pain relief. Discussion Assessment and treatment of pain in the ED are inadequate and not in line with the local protocols. A focus on strategies to improve pain treatment in the ED is a necessary aspect of developing optimal acute patient care in Norway in the future.
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Affiliation(s)
- Jostein Dale
- Emergency Department, Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim, Norway
| | - Lars Petter Bjørnsen
- Emergency Department, Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim, Norway.
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Oligoanalgesia in Blunt Geriatric Trauma. J Emerg Med 2015; 48:653-9. [DOI: 10.1016/j.jemermed.2014.12.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/17/2014] [Accepted: 12/21/2014] [Indexed: 11/16/2022]
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Abstract
Undertreatment of pain (oligoanalgesia) in the emergency department is common, and it negatively impacts patient care. Both failure of appropriate pain assessment and the potential for unsafe analgesic use contribute to the problem. As a result, achieving satisfactory analgesia while minimizing side effects remains particularly challenging for emergency physicians, both in the emergency department and after a patient is discharged. Improvements in rapid pain assessment and in evaluation of noncommunicative populations may result in a better estimation of which patients require analgesia and how much pain is present. New formulations of available treatments, such as rapidly absorbed, topical, or intranasal nonsteroidal anti-inflammatory drug formulations or intranasal opioids, may provide effective analgesia with an improved risk-benefit profile. Other pharmacological therapies have been shown to be effective for certain pain modalities, such as the use of antidepressants for musculoskeletal pain, γ-aminobutyric acid agonists for neuropathic and postsurgical pain, antipsychotics for headache, and topical capsaicin for neuropathic pain. Nonpharmacological methods of pain control include the use of electrical stimulation, relaxation therapies, psychosocial/manipulative therapies, and acupuncture. Tailoring of available treatment options to specific pain modalities, as well as improvements in pain assessment, treatment options, and formulations, may improve pain control in the emergency department setting and beyond.
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Affiliation(s)
- Charles V Pollack
- Professor, Department of Emergency Medicine, Perelman School of Medicine of the University of Pennsylvania, and Chairman, Department of Emergency Medicine, Pennsylvania Hospital , Philadelphia, PA , USA
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Bartley EJ, Boissoneault J, Vargovich AM, Wandner PhD LD, Hirsh AT, Lok BC, Heft MW, Robinson ME. The influence of health care professional characteristics on pain management decisions. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:99-111. [PMID: 25339248 PMCID: PMC5555370 DOI: 10.1111/pme.12591] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Evidence suggests that patient characteristics such as sex, race, and age influence the pain management decisions of health care providers. Although this signifies that patient demographics may be important determinants of health care decisions, pain-related care also may be impacted by the personal characteristics of the health care practitioner. However, the extent to which health care provider characteristics affect pain management decisions is unclear, underscoring the need for further research in this area. METHODS A total of 154 health care providers (77 physicians, 77 dentists) viewed video vignettes of virtual human (VH) patients varying in sex, race, and age. Practitioners provided computerized ratings of VH patients' pain intensity and unpleasantness, and also reported their willingness to prescribe non-opioid and opioid analgesics for each patient. Practitioner sex, race, age, and duration of professional experience were included as predictors to determine their impact on pain management decisions. RESULTS When assessing and treating pain, practitioner sex, race, age, and duration of experience were all significantly associated with pain management decisions. Further, the role of these characteristics differed across VH patient sex, race, and age. CONCLUSIONS These findings suggest that pain assessment and treatment decisions may be impacted by the health care providers' demographic characteristics, effects which may contribute to pain management disparities. Future research is warranted to determine whether findings replicate in other health care disciplines and medical conditions, and identify other practitioner characteristics (e.g., culture) that may affect pain management decisions.
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Affiliation(s)
- Emily J. Bartley
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, USA
| | - Jeff Boissoneault
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, USA
| | - Alison M. Vargovich
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Laura D. Wandner PhD
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Adam T. Hirsh
- Oral and Maxillofacial Surgery, University of Florida, Gainesville, Florida, USA
| | - Benjamin C. Lok
- Department of Psychology, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Marc W. Heft
- Computer and Information Science and Engineering, University of Florida, Gainesville, Florida, USA
| | - Michael E. Robinson
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
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Hwang U, Belland LK, Handel DA, Yadav K, Heard K, Rivera-Reyes L, Eisenberg A, Noble MJ, Mekala S, Valley M, Winkel G, Todd KH, Morrison SR. Is all pain is treated equally? A multicenter evaluation of acute pain care by age. Pain 2014; 155:2568-2574. [PMID: 25244947 DOI: 10.1016/j.pain.2014.09.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 09/11/2014] [Accepted: 09/15/2014] [Indexed: 11/29/2022]
Abstract
Pain is highly prevalent in health care settings; however, disparities continue to exist in pain care treatment. Few studies have investigated if differences exist based on patient-related characteristics associated with aging. The objective of this study was to determine if there are differences in acute pain care for older vs younger patients. This was a multicenter, retrospective, cross-sectional observation study of 5 emergency departments across the United States evaluating the 2 most commonly presenting pain conditions for older adults, abdominal and fracture pain. Multivariable adjusted hierarchical modeling was completed. A total of 6,948 visits were reviewed. Older (⩾ 65 years) and oldest (⩾ 85 years) were less likely to receive analgesics compared to younger patients (<65 years), yet older patients had greater reductions in final pain scores. When evaluating pain treatment and final pain scores, differences appeared to be based on type of pain. Older patients with abdominal pain were less likely to receive pain medications, while older patients with fracture were more likely to receive analgesics and opioids compared to younger patients. Differences in pain care for older patients appear to be driven by the type of presenting pain.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY, USA Medical University of South Carolina, Charleston, SC, USA Department of Emergency Medicine, Oregon Health & Science University, Portland, SC, USA Department of Emergency Medicine, George Washington University Medical Center, Washington, DC, USA Department of Emergency Medicine, University of Colorado, Aurora, CO, USA Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Fry M, Arendts G, Chenoweth L, MacGregor C. Cognitive impairment is a risk factor for delayed analgesia in older people with long bone fracture: a multicenter exploratory study. Int Psychogeriatr 2014; 27:1-6. [PMID: 25162158 DOI: 10.1017/s1041610214001732] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT Background: Older people who present to the emergency department (ED) often experience a significant delay to analgesia. This study compares the time to analgesia for cognitively impaired and cognitively intact older people diagnosed with a long bone fracture. Methods: The aim of the study was to determine if cognitive impairment is associated with a delayed analgesic response. A 12-month exploratory study, using patient data, was conducted across four EDs. Medical records of 264 patients with long bone fractures were randomly selected. Results: The majority of patients waited longer than 60 minutes for analgesia. The median time to analgesia was longer for the cognitively impaired (149 minutes) compared with cognitively intact (72 minutes; Mann-Whitney U test: p < 0.001). Conclusions: This study suggests that cognitive impairment is a significant risk factor for delayed analgesia response in the ED.
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Affiliation(s)
- Margaret Fry
- Research and Practice Development,Northern Sydney Local Health District,St Leonards,NSW,Australia
| | - Glenn Arendts
- School of Primary,Aboriginal and Rural Health Care,University of Western Australia,Crawley,WA,Australia
| | - Lynn Chenoweth
- Aged and Extended Care Nursing,University of Technology,Sydney,NSW,Australia
| | - Casimir MacGregor
- Research and Practice Development,Northern Sydney Local Health District,St Leonards,NSW,Australia
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Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients. Drugs Aging 2014; 30:747-54. [PMID: 23846749 DOI: 10.1007/s40266-013-0103-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. METHODS This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. RESULTS 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. CONCLUSIONS Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 min.
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Morrissey MB, Viola D, Shi Q. Relationship between pain and chronic illness among seriously ill older adults: expanding role for palliative social work. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2014; 10:8-33. [PMID: 24628140 DOI: 10.1080/15524256.2013.877861] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Confronting the issue of pain among chronically ill older adults merits serious attention in light of mounting evidence that pain in this population is often undertreated or not treated at all (Institute of Medicine, 2011 ). The relationship between pain and chronic illness among adults age 50 and over was examined in this study through the use of longitudinal data from the University of Michigan Health and Retirement Study, sponsored by the National Institute on Aging and the Social Security Administration. Findings suggested positive associations between pain and chronic disease, pain and multimorbidity, as well as an inverse association between pain and education. Policy implications for workforce development and public health are many, and amplification of palliative social work roles to relieve pain and suffering among seriously ill older adults at all stages of the chronic illness trajectory is needed.
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Affiliation(s)
- Mary Beth Morrissey
- a Global Healthcare Innovation Management Center , Fordham University Graduate School of Business Administration , West Harrison , New York , USA
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