An evaluation of emergency pain management practices in fragility fractures of the pelvis.

BACKGROUND: Inadequately treated pain is associated with significant morbidity in older adults. We aimed to describe current pain management practices for patients with fragility pelvic fractures, a common emergency department (ED) presentation in older adults. METHODS: We performed a health records' review of adults ≥ 65 years old who presented to two academic EDs with nonoperative fragility pelvic fractures between 01/2014 and 09/2018. The primary outcome measures were type and timing of analgesic medications. Secondary outcome measures included ancillary service consultation, ED length of stay, admission rate and rate of return to ED at 30 days. Data were reported using descriptive statistics. RESULTS: We included 411 patients. The majority were female (339, 82.5%) with mean age 83.9 (SD 8.1) years. Nearly, one-third (130, 31.6%) did not receive any analgesia for their fracture. Analgesia was initiated in 123 (29.9%) patients through paramedic and nursing medical directives; 244 (59.4%) patients received physician-initiated opioids (hydromorphone 228 (55.5%); morphine 28 (6.8%)). Only 23.1% of patients received one or more ancillary services: physiotherapy (10.5%), social work (7.3%), geriatric nurse assessment (14.1%), and homecare (3.9%). Mean ED length of stay was 11.6 (SD 7.1) h; 210 (51.1%) patients were admitted; of those discharged, 45 (22.4%) returned to the ED within 30 days. CONCLUSION: One in three older adults presenting to the ED with nonoperative fragility pelvic fractures receive no analgesia during the course of their prehospital and ED care. Barriers to quality care must be identified and processes implemented to ensure adequate pain management for this population.

RéSUMé: CONTEXTE: La douleur insuffisamment traitée est associée à une morbidité importante chez les personnes âgées. Nous voulions décrire les pratiques actuelles de gestion de la douleur chez les patients souffrant de fractures pelviennes de fragilité, une présentation courante des services d'urgence (SU) chez les personnes âgées. MéTHODES: Nous avons effectué une revue des dossiers médicaux des adultes ≥ 65 ans qui se sont présentés à deux urgences universitaires avec des fractures pelviennes de fragilité non opérées entre 01/2014 et 09/2018. Les principaux critères d'évaluation étaient le type et le moment de la prise de médicaments analgésiques. Les critères d'évaluation secondaires comprennent la consultation des services auxiliaires, la durée moyenne de séjour aux urgences, le taux d'admission et le taux de retour aux urgences à 30 jours. Les données ont été rapportées en utilisant des statistiques descriptives. RéSULTATS: Nous avons inclus 411 patients. La majorité était des femmes (339, 82,5%) avec un âge moyen de 83,9 (écart-type 8,1) ans. Près d'un tiers (130, 31,6 %) n'ont reçu aucune analgésie pour leur fracture. L'analgésie a été initiée chez 123 (29,9%) patients par des directives médicales paramédicales et infirmières ; 244 (59,4%) patients ont reçu des opioïdes à l'initiative du médecin (hydromorphone 228 (55,5%) ; morphine 28 (6,8%)). Seuls 23,1% des patients ont bénéficié d'un ou plusieurs services auxiliaires : physiothérapie (10,5%), travail social (7,3%), évaluation infirmière gériatrique (14,1%) et soins à domicile (3,9%). La durée moyenne de séjour aux urgences était de 11,6 heures (écart-type : 7,1); 210 (51,1 %) patients ont été admis ; parmi ceux qui sont sortis, 45 (22,4 %) sont retournés aux urgences dans les 30 jours. CONCLUSION : Une personne âgée sur trois se présentant aux urgences avec des fractures du bassin non opératoires ne reçoit aucune analgésie au cours de ses soins préhospitaliers et aux urgences. Les obstacles à la qualité des soins doivent être identifiés et des processus doivent être mis en œuvre pour assurer une gestion adéquate de la douleur pour cette population.

Medical students' perspectives of their clinical comfort and curriculum for acute pain management.

OBJECTIVES: Acute pain is a common presenting complaint in health care. Yet, undertreatment of pain remains a prevailing issue that often results in poor short- and long-term patient outcomes. To address this problem, initiatives to improve teaching on pain management need to begin in medical school. In this study, we aimed to describe medical students' perspectives of their curriculum, comfort levels, and most effective pain teaching modalities. MATERIALS AND METHODS: A cross-sectional, online survey was distributed to medical students at the University of Alberta (Edmonton, Canada) from late May to early July 2015. Data were collected from pre-clerkship (year 1 and 2) and clerkship (year 3 and 4) medical students for demographic characteristics, knowledge, comfort, and attitudes regarding acute pain management. RESULTS: A total of 124/670 (19.6%) surveys were returned. Students recalled a median of 2 (interquartile range [IQR]=4), 5 (IQR=3.75), 4 (IQR=8), and 3 (IQR=3.75) hours of formal pain education from first to forth year, respectively. Clerkship students were more comfortable than pre-clerks with treating adult pain (52.1% of pre-clerks "uncomfortable" versus 22.9% of clerks, p<0.001), and overall, the majority of students were uncomfortable with managing pediatric pain (87.6% [64/73] pre-clerks and 75.0% [36/48] clerks were "uncomfortable"). For delivery of pain-related education, the majority of pre-clerks reported lectures as most effective (51.7%), whereas clerks chose bedside instruction (43.7%) and small group sessions (23.9%). Notably, 54.2%, 39.6%, and 56.2% of clerks reported incorrect doses of acetaminophen, ibuprofen, and morphine, respectively, for adults. For children, 54.2%, 54.2%, and 78.7% of clerks reported incorrect doses for these same medications. CONCLUSION: Medical students recall few hours of training in pain management and report discomfort in treating and assessing both adult and (more so) pediatric pain. Strategies are needed to improve education for future physicians regarding pain management.