Randomized clinical trial of propofol versus alfentanil for moderate procedural sedation in the emergency department

Study objective

To compare the frequency of airway and respiratory adverse events leading to an intervention between moderate sedation using alfentanil or propofol.

Chronic pain and frequent use of emergency department: A systematic review

IntroductionEmergency department (ED) overcrowding is an important issue in healthcare worldwide. A small group of patients account for a disproportionate number of ED visits and a few studies have suggested that chronic pain (CP) sufferers may be part of that group. The aim of this study was to review all studies having examined the association between CP and frequent use of ED services.MethodsA systematic review of the literature was performed. The CINAHL, PsycINFO, PubMed and Scopus databases were searched from January 1997 to August 2019, using a strategy containing the keywords frequent use, CP and ED. Two independent reviewers screened articles and assessed methodological quality using the Joanna Briggs Institute tool for prevalence studies. To be included in the review, studies had to: (1) document frequent use of ED services; (2) evaluate CP patients; and (3) use regression models. Studies were excluded if they addressed cancer pain; evaluated an intervention; or targeted an exclusively paediatric population. A narrative synthesis was conducted.ResultsOf the 1182 articles identified, 927 remained after removing duplicates and 47 remained after the evaluation of titles and abstracts, which were read completely. Finally, five articles, published between 2004 and 2016, were included in the study. Every study showed that CP was associated with higher ED visits. Two studies documented that frequent users had a higher level of disability than non-frequent users, or that disability was associated with frequent use.ConclusionsThis review suggests that CP is associated with frequent use of ED services.     

The effect of evidence-based pain assessment protocol in pediatric emergency department on nurses' knowledge,attitudes, and practices towards pain

PurposeThis study aimed to determine the effect of the “Evidence-Based Pain Assessment Protocol in Pediatric Emergency Department” on nurses' knowledge, attitudes, and practices towards pain.MethodA pretest–posttest quasi-experimental study was conducted with 11 nurses. Before the protocol was applied, 337 nurses' records were assessed for one month. Subsequently, the nurses were educated in the Evidence-Based Pain Assessment Protocol in the Pediatric Emergency Department. After the education, the researchers assessed 315 nurses' records for one month to evaluate the protocol's effect on the nurses' clinical practice.ResultsThe study found no significant difference in the mean scores of nurses' Pediatric Pain Knowledge and Attitude Scale between the pre-and post-education periods (p > 0.05). However, there was a significant difference in the types of pain assessment tools used between these two periods (p < 0.001). In the post-education period, the frequency of both pharmacological and non-pharmacological interventions implemented increased significantly compared to the pre-education period (p < 0.001). Additionally, the study found that the frequency of nurses describing pain and reassessing pain increased significantly in the post-education period compared to the pre-education period (p < 0.001).ConclusionsThe study found that there was no significant change in the nurses' Pediatric Pain Knowledge and Attitude Scale scores before and after the training. However, it was observed that the frequency of nurses reassessing pain, using non-pharmacological interventions, and describing pain increased after the protocol was applied in the emergency department. In particular, therapeutic communication and the walking method were used more frequently in the post-training period among the non-pharmacological interventions applied by the nurses for pain.     

Potential impact of early physiotherapy in the emergency department for non-traumatic neck and back pain

BACKGROUND: Musculoskeletal complaints, especially non-traumatic neck and back pain, are routinely encountered in the emergency department (ED) and lead to ED overcrowding, a burgeoning wait time for physiotherapy and outpatient orthopedic reviews. The study aimed to evaluate the impact of early physiotherapy evaluation and treatment (EPET) vs. standard care (SC) on clinical outcomes for patients presenting to the ED with non-traumatic neck and back pain.     

Validation of different pediatric triage systems in the emergency department

BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.     

急诊危重度指数在儿科急诊中的应用

目的 例证急诊危重度指数(ESI)在儿科急诊室的应用.方法 通过收集2006年7月至2010年8月,北京儿童医院国际部急诊21 904人次患儿的ESI分级资料,应用x2检验方法,回顾性对比分析医生和护士的分诊结果.结果 ESI容易掌握,护士分诊结果与医生矫正分诊结果有较好一致性.结论 ESI分诊系统适合儿科急诊分诊,能够迅速分检危重病例,有效利用临床资源.

Abstract：

Objective Demonstrate the implication of Emergency Severity Index (ESI) in pediatric emergency room (ER). Method ESI categories of 21 904 visitors to ER of Beijing Children's Hospital's international department were reviewed. SPSS statistic software was employed to compare the results of ESI categories by doctors and nurses separately using x2 analysis. Results There are highly consistency in ESI categories by doctors and nurses. ESI is an easy-learned and effective triage method. Conclusions ESI is capable in pediatric emergency room regarding recognizing serious cases and saving clinical resources.     

Emergency department use after pediatric pharmaceutical ingestion: comparison of two national databases

Background.?As no “gold standard” measure exists for the number of children evaluated in emergency departments (EDs) for medication-related injuries, the public health impact is based on estimates. In January 2006 the Morbidity and Mortality Weekly Report published a National Electronic Injury Surveillance System–All Injury Program (NEISS–AIP) estimate on unintentional pediatric medication exposure to children ≤4 years of age that resulted in an ED visit: 53,517 per year for the period 2001–2003. We sought to generate a parallel estimate using American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS) to see how these estimates compare.?Methods.?To match data reported from the NEISS–AIP, NPDS was searched for the electronic medical records of children ≤4 years of age whose call type was an unintentional exposure to a pharmaceutical that involved presenting to a health care facility (HCF) in 2001–2003. Results.?178,513 met all of the criteria: 57,100 in 2001; 60,098 in 2002; and 61,315 in 2003. Comparing NEISS–AIP to NPDS: 10% versus 13% were hospitalized; 72% versus 68% were either 1 or 2 years of age; and the substance distribution was acetaminophen (8.1%, 6.8%), cough/cold (7.5%, 9.6%), cardiovascular (7.8%, 11.0%), anticonvulsant (3.6%, 3.2%), and vitamins (4.5%, 3.4%).?Conclusion.?These results are close suggesting that the actual number is near these numbers. The NPDS number is greater than NEISS–AIP point estimate but within the 95% confidence interval. As NPDS is an actual count and NEISS–AIP is an extrapolation from a sample, to the extent that every child presenting to an ED following a medication exposure is not reported to a poison center, both databases may underestimate the problem. The NEISS–AIP extrapolation tool may need to be reassessed.     

Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands

Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians. METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire. RESULTS: The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insuf cient numbers of trained staff to support PSA in the ED and insuf cient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients. CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both quali ed in PSA and available in the ED.     

The influence of crowding on clinical practice in the emergency department

Background

This study aimed to clarify the association between the crowding and clinical practice in the emergency department (ED).

Outcomes of a nurse-initiated intravenous analgesic protocol for abdominal pain in an emergency department: A quasi-experimental study

Background

Abdominal pain is one of the most frequent reasons for seeking care in an emergency department. Surveys have shown that patients are not satisfied with the pain management they receive. Reasons for giving inadequate pain management may include poor knowledge about pain assessment, myths concerning pain, lack of communication between the patient and healthcare professional, and organizational limitations.

Objectives

The aim of the study was to investigate the outcome of nursing assessment, pain assessment and nurse-initiated intravenous opioid analgesic compared to standard procedure for patients seeking emergency care for abdominal pain. Outcome measures were: (a) pain intensity, (b) frequency of received analgesic, (c) time to analgesic, (d) transit time, and (e) patients’ perceptions of the quality of care in pain management.

Design

A quasi-experimental design with ABA phases was used.

Setting

The study was conducted in an emergency department at a Swedish university hospital.

Participants

Patients with abdominal pain seeking care in the emergency department were invited to participate. A total of 50, 100 and 50 patients, respectively, were included for the three phases of the study. The inclusion criteria were: ongoing abdominal pain not lasting for more than 2 days, ≥18 years of age and oriented to person, place and time. Exclusion criteria were: abdominal pain due to trauma, in need of immediate care and pain intensity scored as 9-10.

Methods

The patients’ perceptions of the quality of care in pain management in the emergency department were evaluated by means of a patient questionnaire carried out in the three study phases. The intervention phase included education, nursing assessment protocol and a range order for analgesic.

Results

The nursing assessment and the nurse-initiated intravenous opioid analgesic resulted in significant improvement in frequency of receiving analgesic and a reduction in time to analgesic. Patients perceived lower pain intensity and improved quality of care in pain management.

Conclusions

The intervention improved the pain management in the emergency department. A structured nursing assessment could also affect the patients’ perceptions of the quality of care in pain management in the emergency department.     

Acute non-specific back pain management in the emergency setting: A review of the literature

Back pain affects a large number of Australians each year. Patients frequently attend emergency departments with acute episodes of back pain. There is a growing body of evidence regarding management of non-specific back pain. A comprehensive review of the literature was undertaken to identify the current evidence base for management of non specific lower back pain. Clinicians managing patients presenting with lower back pain should exclude high risk illnesses with a diagnostic triage including a thorough history and physical examination. If signs and symptoms of serious pathology are excluded imaging and pathology tests are unwarranted. The literature suggests conservative management with simple analgesia and advice to maintain activity and avoid bed rest results in improved outcomes although a proportion of patients will progress to chronic back pain. Psychosocial and work factors are important in the progression to chronicity and clinicians should be aware of these risk factors. Further research is required to determine the clinical relevance of many aspects of the current management of lower back pain. This review provides an update for clinicians and suggests a conservative approach is appropriate in the management of most acute episodes of back pain presenting to the emergency department.     

CK-MB isoforms for early risk stratification of emergency department patients

The potential clinical utility of single sample CK-MB isoforms measurement for early risk stratification of Emergency Department (ED) patients with possible myocardial ischemia was evaluated among 405 patients presenting to two urban EDs. Clinical and serologic data were prospectively collected and the occurrence of adverse events (AEs) and myocardial infarction (MI) during the 14-day outcome period was recorded and utilized to calculate and compare relative risks (RR) and predictive values of isoforms and CK-MB alone. Among the 405 patients, 67 accrued 105 AEs. Both isoforms and CK-MB alone were predictive of AEs with RR of 3.32 (2.09, 5.27) and 6.28 (4.64, 8.52), respectively. Isoforms had higher sensitivity for AEs compared to CK-MB (65.7% [54.3, 77.0] vs. 14.9% [6.4, 23.5]; p<0.01) but lower specificity (69.2% [64.3, 74.2] vs. 99.7% [99.1,100.0]; p<0.01). Isoforms’ superior sensitivity allowed identification of many high risk patients missed by CK-MB alone. Further, for the prediction of MI, isoforms had superior diagnostic sensitivity and equivalent specificity. This investigation supports the emergency department use of early, single sample CK-MB isoform testing.     

Mechanical ventilation in the emergency department for 24 hours or longer is associated with delayed weaning

Purpose

We examined various aspects of critical care to identify factors in the emergency department (ED) that affected the overall duration of mechanical ventilation (MV). We specifically focused on whether 24 hours of ED MV affected the weaning success and the duration of MV.

Materials and Methods

Mechanical ventilation cases that started in the ED because of purely respiratory problems were enrolled in the retrospective cohort. We recorded demographic data, duration of MV in ED, various severity scores, previously known factors of prolonged MV, and achievement of ventilator weaning. All the significant factors in univariate survival analyses were included in a multivariate analysis.

Results

The estimated median of the entire duration of MV was longer in patients who received 24 hours or more of MV in ED compared with that of patients who received MV for less than 24 hours (33.0 vs 15.4 days, P = .003). Mechanical ventilation for longer than 24 hours in the ED remained a significant factor that prolonged the entire MV duration in the multivariate analysis (hazard ratio, 0.577; P = .019). Hypoalbuminemia and abbreviated mortality in ED sepsis (MEDS) score were also independently correlated (P ≤ .001 for both).

Conclusions

Mechanical ventilation in the ED for 24 hours or longer is associated with delayed ventilator weaning.     

Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department

A prospective study was conducted to see whether emergent esophagogastroduodenoscopy (EGD) in patients with active upper gastrointestinal (GI) bleeding is associated with more oxygen desaturation than nonemergent EGD. Emergent EGD was performed in the study patients with active upper GI bleeding. Nonemergent EGD was performed in the control patients. Determination of oxygen saturation (Sao₂) was measured by pulse oximeter. A decrease in Sao₂ of>4% was more frequent in the study patients (26%, 13 of 50) than in controls (6%, 3 of 50) (P < .01). During EGD, mean oxygen saturation decreased significantly in both groups of patients. After EGD, mean oxygen saturation did not recover toward the pre-endoscopy insertion level in the study group (P < .01). A linear association was found that oxygen DESATURATION = 5.46 + 0.15 (status) − 0.06 (baseline oxygen saturation). Emergent EGD for active upper GI bleeding in the emergency department tends to be associated with more frequent significant oxygen desaturation than nonemergent EGD. Continuous oxygen supplementation and oxygen saturation monitoring may be used during emergent nonsedated EGO in the emergency department.