A week of pain in the emergency department

Distraction-based interventions for children in the emergency care setting: A realist synthesis based on primary research

BACKGROUND

The literature underscores the prevalence of pain as the most common presenting symptom in the Emergency Care Setting (ECS) and is associated with anxiety and stress for children. On top of that painful procedures are often required as part of their treatment, making procedural pain a common experience. The substantial evidence supporting the effectiveness of distraction-based interventions (DBI) in relieving pain and anxiety and reducing stress underscores the urgency of addressing this issue. However, the fragmented adoption of standardised DBI highlights the need for further research and implementation.

PURPOSE

To conduct a realist synthesis based on primary research exploring "what works for whom under what circumstances, how and why?" when implementing DBI in the ECS.

REVIEW METHODS

Empirical research evidence was retrieved systematically from eight databases covering health and social sciences. The studies were synthesised based on the principles of realist science, drawing on Pawson and Tilley's (1997) and Dalkin et al.'s (2015) programme theory development, which explains the contexts and mechanisms that generate positive outcomes about DBI for children in the ECS.

RESULTS

Of the 2099 studies screened, 64 were included. Screening was conducted 2023 to December 2024. A synthesis of the findings generated five Programme Theories (PT). PT1 focuses on the personalisation of DBI for children in the ECS, PT2 explains the importance of parental participation, PT3 highlights the importance of healthcare workers (HCWs) commitment to adopting DBI in practice, PT4 draws attention to policy-level efforts necessary for implementation support, and PT5 focuses on engaging all stakeholders in the implementation process.

CONCLUSION

To the authors' knowledge, this is the first study to apply a realist lens to understand the use of DBI in children attending the ECS and present the mechanisms that enable and/or inhibit its implementation and utilisation in everyday clinical practice.

IMPLICATIONS TO PRACTICE

This realist synthesis provides methodological guidance in the form of PT that can be utilised by clinical practitioners to adopt and implement DBI within the healthcare setting.

Feelings of Patients Admitted to the Emergency Department

Background/Objectives: Very few studies describe the various feelings experienced in the emergency department (ED). Our study describes the pain, stress, and negative and positive emotions experienced by patients admitted to the ED in relation to age, gender, and reason for ED admission. Methods: Patients admitted to the ED of seven French hospitals were surveyed as part of the randomised multicentre study SOFTER IV (n = 2846). They reported the intensity of their pain on a numerical rating scale of 0 to 10, the intensity of their stress on an equivalent scale, and their emotions on a five-point rating scale using an adapted version of the Geneva Emotion Wheel proposed by Scherer, based on eight core emotions: fear, anger, regret, sadness, relief, interest, joy, and satisfaction. Results: Patients reported an average pain rating of 4.5 (SD = 3.0) and an average stress rating of 3.4 (SD = 3.1). Forty-six percent reported at least one strong negative emotion, and the two most frequently reported were fear and sadness. Forty-seven percent of patients described feeling at least one strong positive emotion, and the two most frequently reported were interest and relief. Pain was significantly higher among female patients under 60 admitted for injury. Stress was significantly higher among female patients under 60 admitted for illness. Emotions of negative valency were significantly higher among women admitted for injury. Emotions of positive valency were significantly higher among men over 60 admitted for illness. Conclusions: Experiences of pain, stress, and emotions have a strong presence in the ED. The reporting of these feelings varies depending on age, gender, and reason for ED admission.

Analyzing pain patterns in the emergency department: Leveraging clinical text deep learning models for real-world insights

OBJECTIVE

To determine the incidence of patients presenting in pain to a large Australian inner-city emergency department (ED) using a clinical text deep learning algorithm.

MATERIALS AND METHODS

A fine-tuned, domain-specific, transformer-based clinical text deep learning model was used to interpret free-text nursing assessments in the electronic medical records of 235,789 adult presentations to the ED over a three-year period. The model classified presentations according to whether the patient had pain on arrival at the ED. Interrupted time series analysis was used to determine the incidence of pain in patients on arrival over time. We described the changes in the population characteristics and incidence of patients with pain on arrival occurring with the start of the Covid-19 pandemic.

RESULTS

55.16% (95%CI 54.95%-55.36%) of all patients presenting to this ED had pain on arrival. There were differences in demographics and arrival and departure patterns between patients with and without pain. The Covid-19 pandemic initially precipitated a decrease followed by a sharp, sustained rise in pain on arrival, with concurrent changes to the population arriving in pain and their treatment.

DISCUSSION

Applying a clinical text deep learning model has successfully identified the incidence of pain on arrival. It represents an automated, reproducible mechanism to identify pain from routinely collected medical records. The description of this population and their treatment forms the basis of intervention to improve care for patients with pain. The combination of the clinical text deep learning models and interrupted time series analysis has reported on the effects of the Covid-19 pandemic on pain care in the ED, outlining a methodology to assess the impact of significant events or interventions on pain care in the ED.

CONCLUSION

Applying a novel deep learning approach to identifying pain guides methodological approaches to evaluating pain care interventions in the ED, giving previously unavailable population-level insights.

Evaluation of the prehospital use of a Valsalva assist device in the emergency treatment of supraventricular tachycardia (EVADE SVT): study protocol for a stepped wedge cluster randomised controlled trial

INTRODUCTION

Patients with episodes of supraventricular tachycardia (SVT), a common heart arrhythmia, are often attended by ambulance services. International guidelines advocate treatment with the Valsalva manoeuvre (VM), but this simple physical treatment has a low success rate, with most patients requiring conveyance to hospital. The Valsalva Assist Device (VAD) is a simple device that might help practitioners and patients perform a more effective VM and reduce the need for patients to be taken to hospital.

METHODS AND ANALYSIS

This stepped wedge cluster randomised controlled trial, conducted within a UK ambulance service, compares the current standard VM with a VAD-delivered VM in stable adult patients presenting to the ambulance service with SVT. The primary outcome is conveyance to hospital; secondary outcomes measures include cardioversion rates, duration of ambulance care and number of subsequent episodes of SVT requiring ambulance service care. We plan to recruit approximately 800 patients, to have 90% power to detect an absolute reduction in conveyance rate of 10% (from 90% to 80%) between the standard VM (control) and VAD-delivered VM (intervention). Such a reduction in conveyance would benefit patients, the ambulance service and receiving emergency departments. It is estimated potential savings would pay for devices for the entire ambulance trust within 7 months.

ETHICS AND DISSEMINATION

The study has been approved by the Oxford Research Ethics Committee (reference 22/SC/0032). Dissemination will be through peer-reviewed journal publication, presentation at national and international conferences and by the Arrhythmia Alliance, a patient support charity.

TRIAL REGISTRATION NUMBER

ISRCTN16145266.

Does prescribing of immediate release oxycodone by emergency medicine physicians result in persistence of Schedule 8 opioids following discharge?

OBJECTIVES

To identify the prevalence of oxycodone immediate release (IR) prescribed during an ED admission and the persistence of Schedule 8 (S8) opioids following an ED admission.

METHODS

A retrospective cross-sectional audit was undertaken reviewing all admission at the ED of the Royal Hobart Hospital, Tasmania, between 1 August and 30 September 2016. The admissions lists for ED were cross matched with the narcotic registers for oxycodone IR (the most commonly supplied S8 in ED) to identify how many patients received IR oxycodone during their ED admissions. Determination of the persistence of opioid use in opioid naïve patients was then undertaken using the Tasmanian real time reporting database of all S8 opioid dispensed in Tasmania (DAPIS).

RESULTS

There were 8432 ED admissions for 7065 patients aged over 13 years. IR oxycodone was prescribed during 1049 of these admissions (12.4%). Of the patients who were not taking regularly prescribed S8 opioids prior to their ED admission (n = 853), 48 patients (5.6%) were taking S8 opioids at both 2 and 6 months following their ED admission. Thirty patients (2.8%) were approved for authorities for long-term opioids for non-cancer pain.

CONCLUSION

These findings suggest that prescribing of IR oxycodone within ED is lower than previous studies. Additionally, the progression to regular chronic opioid use following an ED admission where IR oxycodone was given was relatively low with 3.0% of opioid naïve patients being approved for indications related to chronic non-cancer pain in the following 6 months.

Barriers to nursing pain management in the emergency department: A qualitative study

BACKGROUND

Although pain is a common complaint among patients presenting to emergency departments (EDs), there is a dearth of nursing literature about barriers to pain management.

PURPOSE

The study aimed to uncover and understand barriers to pain management in the ED from the registered nurse (RN) perspective.

METHODS

Semistructured interviews were conducted with 12 ED nurses in a Jordanian hospital. Data were collected throughout August 2016.

RESULTS

Two broad categories with subcategories emerged. The first category describes the idea of types of patient, which included three particular groups. These were patients who are violent, patients with relatives who are, and patients with expectations of care that nurses view as unrealistic. The second category describes the taxing ED environment, with two subcategories of staff shortages and physician dominance of pain management. Nurses reported feeling as if they are the victims of external factors and perceived that barriers affected teamwork and led to distress which impairs pain management.

CONCLUSIONS

The role of ED nurses in pain management is multifaceted. Therefore, implementing policies to overcome barriers such as violence among ED attenders and the perceived hostility of the ED environment through mandatory security systems, and continuing nursing education including for violence prevention may be beneficial.