RESUMO
PURPOSES: This study was designed to evaluate the ability of a triage pain protocol to improve frequency and time to delivery of analgesia for musculoskeletal injuries in the emergency department (ED). BASIC PROCEDURES: Frequency and time to analgesic administration were measured before and after use of a triage pain protocol. The protocol allowed analgesic medications to be given at the time of triage. MAIN FINDINGS: Time to medication administration was 76 minutes (95% confidence interval [CI], 68-84 minutes) before and 40 minutes (95% CI, 32-47 minutes) after the protocol. Five hundred fifty-nine (70%) of 800 patients received analgesics using the protocol compared with 212 of 471 (45%) patients prior. PRINCIPAL CONCLUSIONS: Use of a triage pain protocol increased the number of patients with musculoskeletal injury who received pain medication in the ED. Use of the protocol also resulted in a decrease in the time to analgesic medication administration.
Assuntos
Analgésicos/administração & dosagem , Medição da Dor , Dor/tratamento farmacológico , Triagem/métodos , Adulto , Esquema de Medicação , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Sistema Musculoesquelético/lesões , Dor/etiologia , Resultado do TratamentoRESUMO
UNLABELLED: Pain is the most common reason for emergency department (ED) use, and oligoanalgesia in this setting is known to be common. The Joint Commission on Accreditation of Healthcare Organizations has revised standards for pain management; however, the impact of these regulatory changes on ED pain management practice is unknown. This prospective, multicenter study assessed the current state of ED pain management practice. After informed consent, patients aged 8 years and older with presenting pain intensity scores of 4 or greater on an 11-point numerical rating scale completed structured interviews, and their medical records were abstracted. Eight hundred forty-two patients at 20 US and Canadian hospitals participated. On arrival, pain intensity was severe (median, 8/10). Pain assessments were noted in 83% of cases; however, reassessments were uncommon. Only 60% of patients received analgesics that were administered after lengthy delays (median, 90 minutes; range, 0 to 962 minutes), and 74% of patients were discharged in moderate to severe pain. Of patients not receiving analgesics, 42% desired them; however, only 31% of these patients voiced such requests. We conclude that ED pain intensity is high, analgesics are underutilized, and delays to treatment are common. Despite efforts to improve pain management practice, oligoanalgesia remains a problem for emergency medicine. PERSPECTIVE: Despite the frequency of pain in the emergency department, few studies have examined this phenomenon. This study documents high pain intensity and suboptimal pain management practices in a large multicenter ED network in the United States and Canada. These findings suggest that there is much room for improvement in this area.
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Analgésicos/uso terapêutico , Serviços Médicos de Emergência/estatística & dados numéricos , Serviços Médicos de Emergência/tendências , Dor/tratamento farmacológico , Dor/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Criança , Estudos de Coortes , Feminino , Pessoal de Saúde/estatística & dados numéricos , Pessoal de Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Satisfação do Paciente , Estudos Prospectivos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/tendências , Inquéritos e Questionários , Fatores de Tempo , Estados UnidosRESUMO
Oligoanalgesia continues to be a large problem in the ED. An attitude of suspicion, a culture of ignoring the problem, and an environment that is not conducive to change in practice combine to present formidable obstacles for effective pain management in the emergency setting. Overcoming these obstacles for effective analgesia in the ED is not beyond the capabilities of the individual ED, the emergency physician, or the specialty of emergency medicine. Changing the attitudes of emergency medical providers about pain assessment and management will require attention in several areas of research, education and training. Oligoanalgesia remains a global problem within emergency medicine; however, this awareness is often not felt to be present "in my ED." Individual ownership of the problem may contribute to improvements in pain control. The last 15 years have seen a substantial increase in ED research focused on pain and pain management. Continued research efforts and focused clinical application of these efforts are still required. A better understanding of patient needs and expectations for pain relief, as well as continued efforts at patient education regarding pain, will also improve our treatment of pain in the ED. Recognition by providers of the ethnic, cultural, and gender differences in the expression, reporting, and expectations for treatment of pain should also continue to be a priority in changing attitudes toward pain and pain control. These goals must be realistic within the chaotic and unpredictable environment that defines emergency medicine. Practical and time-sensitive approaches to pain and pain management will continue to bea challenge to enact and enforce in our EDs. The stigma of opioids, in combination with the transient nature of the emergency physician/patient relationship, may be the largest hurdles to overcome for effective pain management not only in the ED, but also following ED discharge. Improvement in provider education of the realities, myths, and misunderstandings of opioid management may provide insight into this problem. The consequences of oligoanalgesia in the ED are not insignificant. To improve our treatment of pain in the ED, a fundamental change in attitude toward pain and the control of pain is required. This is unlikely to occur until pain is adequately addressed and treated appropriately as a true emergency.
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Analgesia/tendências , Atitude do Pessoal de Saúde , Medicina de Emergência/tendências , Conhecimentos, Atitudes e Prática em Saúde , Manejo da Dor , Dor/diagnóstico , Analgesia/métodos , Analgésicos Opioides/uso terapêutico , Medicina de Emergência/métodos , Serviço Hospitalar de Emergência/tendências , Feminino , Ambiente de Instituições de Saúde , Humanos , Masculino , América do Norte , Cultura Organizacional , Satisfação do Paciente , Padrões de Prática Médica/tendências , PreconceitoRESUMO
OBJECTIVES: To evaluate the validity of change in visual analog Scale (VAS) as a measure of pain relief using a verbal descriptor Scale (VDS) of change in pain. METHODS: A prospective observational study of emergency department patients measured pain with VAS and recorded verbal report of change in pain. RESULTS: One thousand four hundred ninety patients yielded 1999 comparisons between change in VAS and VDS. Correlation of change in VAS and VDS of change in pain was rho = 0.667 ( P < .001). A wide range of change in VAS, large standard deviations for the mean change in VAS, and discordance in the direction of change in VAS were present within each verbal descriptor category. CONCLUSIONS: Change in VAS is moderately correlated with a VDS of change in pain. Wide variability in change in VAS and discordance with a VDS demonstrate that change in VAS is not a valid indicator of pain relief for individual patients.
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Analgesia/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Medição da Dor/estatística & dados numéricos , Dor/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Estudos Prospectivos , Valores de ReferênciaRESUMO
Airway management is an essential component of the air medical transport of critically ill or injured patients. Many controversies surround the use of rapid sequence intubation (RSI) in the prehospital setting. The challenges of establishing an airway in this environment may exceed those in the hospital. However, it is clear that the same high standards for success demanded in the hospital must be applied to RSI in the prehospital setting for the practice to be accepted and result in positive outcomes. Given their volume of high acuity patients, air medical providers are ideal candidates for performing prehospital RSI. Undertaking this responsibility requires commitment to training and quality improvement. We present the components required to establish and maintain a successful air medical RSI program.
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Resgate Aéreo , Serviços Médicos de Emergência/organização & administração , Intubação Intratraqueal/métodos , Serviços Médicos de Emergência/normas , Capacitação em Serviço , Objetivos Organizacionais , Estados UnidosRESUMO
OBJECTIVE: This study compares etomidate with midazolam for prehospital rapid-sequence intubation (RSI). METHODS: The authors conducted a retrospective review of consecutive intubations at a university-based air medical program from January 1995 to December 2000. Exclusion criteria were patients not undergoing RSI, age <15 years, and incomplete chart data. Outcome measures included intubation success, incidence of hypotension, and percentage of change in heart rate (HR) and systolic blood pressure (SBP). RESULTS: The intubation success rate was 110 out of 112 (98%) with etomidate, and 96 out of 97 (99%) with midazolam. Mean ages, patient gender distributions, and initial SBPs and HRs did not differ between the two groups. The mean dose of etomidate was 24 mg, the mean percentage of change in HR was -1% (95% confidence interval [CI], -6 to 4), and the mean percentage of change in SBP was 2% (95% CI, -3 to 7). The mean dose of midazolam was 3.5 mg, the mean percentage of change in HR was 1% (95% CI, -5 to 7), and the mean percentage change in SBP was 3% (95% CI, -3 to 9). The number of hypotensive episodes with etomidate (7 out of 74) compared with midazolam (3 out of 56) did not differ significantly (Fisher's exact test, p=0.51). CONCLUSION: Intubation success rate was very high with both etomidate (98%) and midazolam (99%). There was no statistically significant mean percentage of change in SBP or HR with either agent. The authors found a low incidence of hypotension with both agents, although the mean dose of midazolam used was considerably less than typically recommended for induction.
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Resgate Aéreo , Serviços Médicos de Emergência/métodos , Etomidato/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Intubação Intratraqueal/métodos , Midazolam/uso terapêutico , Centros Médicos Acadêmicos , Adolescente , Adulto , Etomidato/administração & dosagem , Etomidato/efeitos adversos , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/classificação , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Incidência , Masculino , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
The objective of the study was to assess patient expectations for pain relief in the ED. A convenience sample of 522 patients with pain and 144 patients without pain were enrolled in a prospective observational study at a university ED. Patients reported a mean expectation for pain relief of 72 % (95% CI 70-74). Eighteen percent expected complete (100%) pain relief in the ED. Patient expectations for pain relief were poorly correlated (r = 0.150) with initial pain intensity. Patients without pain reported a mean expectation for pain relief of 74% (95% CI 71-77) if they had presented with pain. There were no differences in patient expectations for pain relief based on age or gender. Patients expect a large percentage of their pain to be relieved in the ED, and many expect complete analgesia. Patient expectations for pain relief do not vary based on age, gender or pain intensity.
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Analgesia/psicologia , Atitude , Serviço Hospitalar de Emergência , Manejo da Dor , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/psicologia , Medição da Dor , Satisfação do Paciente , Estudos ProspectivosRESUMO
INTRODUCTION: The purpose of this study is to compare intubation success rate and time to intubation for the intubating laryngeal mask airway (I-LMA) versus direct laryngoscopy (DL) using a manikin model during a simulated in-flight scenario. SETTING: The setting for the study was a University hospital-based air medical program. METHODS: This was a prospective, randomized, crossover trial. Eight nurses and 7 paramedics were randomly assigned to perform 3 intubations with either the I-LMA or DL first and then 3 intubations using the alternate technique. Descriptive statistics, 95% confidence intervals (CIs) of means, and Fisher's Exact test were conducted for comparisons. RESULTS: Fifteen set-ups and 45 intubations were performed with each technique. Previous experience was 74 mm (95% CI 64-84) with DL and 18 mm (95% CI 9-27) with the I-LMA. Set-up time was 33 seconds (95% CI 26-40) for DL and 40 seconds (95% CI 29-50) for I-LMA. Time to intubation was 12 seconds (95% CI 10-14) for DL and 39 seconds (95% CI 31-48) for I-LMA. Success rate was 100% for DL and I-LMA placement and 98% for intubation through the I-LMA. Crew rated difficulty of DL 13 mm (95% CI 6-20), placing the I-LMA 23 mm (95% CI 13-32), and intubating through the I-LMA 17 mm (95% CI 10-24). CONCLUSION: Intubation success was very high for both DL and the I-LMA, despite less flight crew experience with the I-LMA. Total time to intubation was longer with the I-LMA but still less than 1 minute. The flight crews considered both techniques easy to perform. The I-LMA appears to be a useful adjunct for airway management in the Bell 206-L3 helicopter.
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Resgate Aéreo , Intubação Intratraqueal/instrumentação , Máscaras Laríngeas , Humanos , Laringoscopia , Trabalho de Resgate , Fatores de TempoRESUMO
We sought to determine Emergency Department (ED) patient preference for oral (p.o.), intramuscular (i.m.), or intravenous (i.v.) pain medication and patient expectations of time to medication effect by route. A prospective, observational study of 1276 patients presenting with painful illness or injury was performed in a university ED. Patient preferences were 66% p.o., 15% i.m., and 19% i.v. pain medication. Patients aged greater than 55 years were more likely to prefer parenteral medication than younger patients. Patients in severe pain were also more likely to prefer parenteral medication than those with less severe pain. Despite these differences, a majority of patients in all groups preferred oral medications. There were no differences in preference based on ethnicity or gender. Patient expectations for time to pain medication effect were 27 min p.o. (95% CI 26-28), 12 min i.m. (95% CI 11-13), and 7.5 min i.v. (95% CI 6.9-8.0).
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Analgésicos/administração & dosagem , Serviço Hospitalar de Emergência , Dor/tratamento farmacológico , Satisfação do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitais Urbanos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos ProspectivosRESUMO
The objective of this study was to determine the frequency and types of pain medications taken before ED arrival based on pain intensity, duration of pain, chief complaint, gender, age, and race. A convenience sample of patients in pain was enrolled in this university hospital-based prospective, observational study. A total of 1233 patients were enrolled. Five hundred thirty-nine of 1233 (44%) patients took pain medication before arrival. Two hundred three (38%) took ibuprofen, 147 of 539 (27%) took oral opioids, and 135 of 539 (25%) took acetaminophen, which were the most frequently used medications. Severity of pain, age, duration of pain, and chief complaint were associated (chi-squared P <.05) with variations in prior medication use. Race and gender were not associated (chi-squared P >.05) with differences in medication use before arrival. Many patients (44%) take medication before arrival in the ED. Age, severity and duration of pain, as well as chief complaint are associated with differences in frequency of self-administered medication.
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Analgésicos/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Dor/tratamento farmacológico , Automedicação/estatística & dados numéricos , Fatores Etários , Humanos , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
INTRODUCTION: The local emergency medical services (EMS) provider level within a nearby EMS system changed from EMT-I to paramedic. This increase in level of care was expected to decrease utilization of air medical transport and increase acuity of patients flown. SETTING: Semirural, mountainous area with an annual volume of 2800 transports. METHODS: Retrospective review of the EMS database performed for the 24-month period before and after the change in local provider level. The number and acuity of patients flown was recorded. Data analysis was performed using chi-square with significance at P <.05. RESULTS: A total of 53 flights with an EMS call volume of 2544 were flown in the 24-month period before the change in EMS provider level, and 54 flights with a call volume of 2842 in the following 24-month period (P >.05). The number of patients with abnormal vital signs or injury severity markers was not different between the 2 periods (P >.05). CONCLUSION: The change in EMS provider level from EMT-I to paramedic in this semirural area had no impact on the number of air medical transports. The acuity of patients flown after the change in EMS provider level remained similar based on common hemodynamic and injury severity markers.
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Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/organização & administração , Transporte de Pacientes , Auxiliares de Emergência/classificação , Humanos , Escala de Gravidade do Ferimento , Avaliação de Resultados em Cuidados de Saúde , Utah , Recursos HumanosRESUMO
INTRODUCTION: The purpose of this study was to determine the impact of an airway education program (AEP) on prehospital intubation. SETTING: University-based air medical program METHODS: Retrospective review of 372 consecutive intubations for 3 years before and 3 years after the institution of an AEP. Descriptive statistics were used and comparisons were made using chi-square analysis. RESULTS: Intubation success rate was 170/180 (94%) for the preAEP group and 186/192 (97%) for the postAEP group (P > 0.05). Neuromuscular blockade (NMB) was used in 113/180 (63%) of preAEP intubations and 145/192 (76%) of postAEP intubations (P < 0.01). NMB without sedation decreased from 62/113 (55%) in the preAEP group to 12/145 (8%) in the postAEP group (P < 0.001). Cricothyrotomy rate decreased from 10/180 (6%) in the preAEP group to 3/192 (2%) in the postAEP group (P < 0.05). Failed intubation rate in nonarrested patients during the 6-year period was 10/154 (6%) in patients receiving no medications or partial rapid sequence intubation (RSI) compared with 3/184 (2%) in patients who had full RSI (P < 0.025). CONCLUSION: Establishment of an AEP resulted in an increase in NMB for intubation, a dramatic decrease in the use of NMB without sedation, and a decrease in cricothyrotomy rate. The rate of intubation failure in nonarrested patients was higher in those who received no medications or partial RSI compared with full RSI.