Timely pain management in the emergency department
BACKGROUND:Delivering timely pain relief remains a challenge for most emergency departments. OBJECTIVE:To evaluate the effectiveness of a policy aimed at delivering analgesics within 30 min to patients presenting to an emergency department with severe pain. METHODS:Subjects were aged â‰¥19 years, had a principal diagnosis of renal colic, hip fracture, or sickle cell disease, reported a pain score â‰¥8 on a scale of 0 to 10 at triage, and continued to report a score in this range until receiving analgesia. The study compared proportions of patients receiving analgesics within the 30-min target, median time to analgesic administration, and median time to relief of severe pain (decline in pain level to score <8) during 6 months before vs. 6 months after implementation of the new pain management policy. RESULTS:Paradoxically, the median total waiting time to analgesic administration increased from 64 min (n = 75) to 80 min (n = 70) after policy implementation (p = 0.01), and the proportion of patients receiving analgesics within 30 min declined from 17% (13/75) to 7% (5/70) (p = 0.08). Median time to relief of severe pain did not differ significantly between periods (130.5 vs. 153 min; p = 0.31). CONCLUSIONS:After implementation of the new pain management policy, the proportion of patients with severe pain receiving analgesics within 30 min actually declined. Although a 30-min target may be unrealistic, it seems reasonable to conclude that something is wrong when patients with notoriously painful conditions must typically wait 1-2 h to obtain relief. Given the millions of individuals who receive care in emergency departments nationwide each year, the suffering caused by delays occurs on a large scale, so creative approaches are clearly needed to overcome the obstacles.
Impact of first contact on symptom onset-to-door time in patients presenting for primary percutaneous coronary intervention
OBJECTIVES/OBJECTIVE:To determine effect of first medical contact type on symptom onset-to-door time (SODT). BACKGROUND:Shorter total ischemic time is associated with improved outcomes in ST-elevation myocardial infarction. METHODS:From 2005 to 2009, we reviewed records of all consecutive patients treated with primary percutaneous coronary intervention for ST-elevation myocardial infarction at our tertiary care teaching hospital (median follow-up 3.85 years). We compared SODT in patients whose first medical contact was a private physician (in person or via telephone) vs patients who presented to the emergency department (ED) directly (in person or via Emergency Medical Services). RESULTS:Of 366 patients, 84 (23%) contacted a physician (group A) while 282 (77.6%) did not (group B). Group A had higher median SODT (239.5 vs 130 minutes, P = .0043) and significantly higher mortality (log rank P = .0392, Cox Proportional Hazard Model risk factors: physician contact first [P < .013], age [P < .0001] and peripheral vascular disease [P < .035]). Two factors associated with prolonged SODT: (1) contacting a physician first P = .002 and (2) personal mode of transportation, P = .002. Patients presenting during "on-hours" (weekdays) were more likely to first contact a physician compared with those presenting during "off-hours" (weeknights and weekends) (66.67% in group A vs 45.04% in group B, P < .001). CONCLUSIONS:Patients whose first medical contact was a physician had greater pre-hospital delays and worse survival compared to those who sought emergent medical care directly. This pattern occurred more often during "on-hours." Educational efforts aimed at both patient and physician office practices are warranted.
Anaphylaxis in the community setting: determining risk factors for admission
BACKGROUND:Although the identification and management of anaphylaxis in an emergency department setting has been well studied, our understanding of the risk factors for admission in a community-based hospital is lacking. OBJECTIVE:To determine the demographics and the predictors of hospitalization, in patients presenting with anaphylaxis to a community-based emergency department (ED). METHODS:We performed a five-year retrospective chart review of all patients seen in the ED of Winthrop University Hospital, a community-based institution, with an International Classification of Diseases, 9(th)Edition code related to anaphylaxis. RESULTS:Fifty-eight visits met inclusion criteria, of which 34% resulted in hospital admission (95% CI: 22-48%). Univariate predictors for admission included (1) the involvement of 2, 3, and 4 organ systems (26%, 55%, and 75%, respectively; P < .02); (2) gastrointestinal symptoms vs no symptoms (59% vs 24%, P < .02); (3) non-sting (ingested and other allergens) vs insect sting allergen (50% vs 12.5%, P < .005); and (4) a history of an ED visit for anaphylaxis vs none (67% vs 30%, P < .05). Multivariate analysis (logistic regression) confirmed non-sting allergens (p < 0.02) and number of organ systems involved (P < .05) as independent predictors of hospitalization. CONCLUSION/CONCLUSIONS:In our study population, the involvement of multiple organ systems, particularly gastrointestinal involvement, a history of ED visits for anaphylaxis, and involvement of ingested or other allergens (non-sting) demonstrated higher admission rates.