Racial disparity in analgesic treatment for ED patients with abdominal or back pain

Objective

Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain.

Methods

This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders.

Results

Of 20?125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13?907 (69%) abdominal pain. Overall, 12?109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004).

Conclusions

After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.     

Practices and predictors of analgesic interventions for adults undergoing painful procedures.

BACKGROUND: Research is limited on analgesic practices associated with the commonly performed procedures of turning, inserting central venous catheters, removing wound drains, changing dressings on nonburn wounds, suctioning the trachea, and removing femoral sheaths. OBJECTIVES: To determine types of analgesics administered for procedures, the prevalence and amounts of drugs given, and factors predictive of analgesic administration. METHODS: Pain was assessed before and immediately after procedures. Analgesic, sedative, and anesthetic agents administered within 1 hour before and/or during each procedure were noted RESULTS: A total of 5957 adult patients at 164 national and 5 international sites participated. Pain intensity increased at the time of procedure for all procedures. More than 63% of patients received no analgesics. Less than 20% received opiates; mean total dose of opiate was 6.44 mg (SD, 8.96 mg). Only 10% of patients received combination therapy. Factors associated with the likelihood of receiving opiates were pain intensity before a procedure, femoral sheath removal, being white, and the duration of a procedure. Patients less likely to receive opiates had a medical diagnosis or were having tracheal suctioning. Only 14.5% of the variance in the amount of opiate administered was explained by factors entered into multiple regression models. Type of procedure was the only significant predictor of amount of opiate administered. CONCLUSIONS: Most patients were not intentionally medicated even though pain intensity increased during their procedure. When used, analgesic amounts were low, and combination therapy was infrequent. Clinical trials are needed to evaluate optimal pain management for patients undergoing procedures.     

More educated emergency department patients are less likely to receive opioids for acute pain

Inadequate treatment of pain in United States emergency departments (EDs) is common, in part because of the limited and idiosyncratic use of opioids by emergency providers. This study sought to determine the relationship between patient socioeconomic characteristics and the likelihood that they would receive opioids during a pain-related ED visit. We conducted a cross-sectional analysis of ED data obtained as part of a multicenter study of outcomes after minor motor vehicle collision (MVC). Study patients were non-Hispanic white patients between the ages of 18 and 65 years who were evaluated and discharged home from 1 of 8 EDs in 4 states. Socioeconomic characteristics include educational attainment and income. Of 690 enrolled patients, the majority had moderate or severe pain (80%). Patients with higher education attainment had lower levels of pain, pain catastrophizing, perceived life threat, and distress. More educated patients were also less likely to receive opioids during their ED visit. Opioids were given to 54% of patients who did not complete high school vs 10% of patients with post-college education (χ(2) test P<.001). Differences in the frequency of opioid administration between patients with the lowest educational attainment (39%, 95% confidence interval 22% to 60%) and highest educational attainment (13%, 95% confidence interval 7% to 23%) remained after adjustment for age, sex, income, and pain severity (P=.01). In this sample of post-MVC ED patients, more educated patients were less likely to receive opioids. Further study is needed to assess the generalizability of these findings and to determine the reason for the difference.     

Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic Management

Objectives: The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. Methods: A prospective, multisite longitudinal cohort study in the context of a learning‐collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse‐initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. Results: A total of 155 patients met study criteria (median age = 32 years, IQR = 24–40 years) with a total of 701 ED visits. Eighty‐six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty‐nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48–135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean ± SD = 4.19 ± 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean ± SD = 5.77 ± 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). Conclusions: While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post‐ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable. ACADEMIC EMERGENCY MEDICINE 2010; 17:399–407 © 2010 by the Society for Academic Emergency Medicine     

Epidural versus intrathecal morphine-bupivacaine: assessment of consecutive treatments in advanced cancer pain

Twenty-five patients with multifocal and multitype (somatic, visceral, and neurogenic) advanced cancer pain who experienced severe pain despite extradural (ED) morphine and bupivacaine were converted to intrathecal (IT) morphine and bupivacaine. The consecutive ED and IT periods (2-174 days, median = 50 days, and 1-305 days, median = 37 days, respectively) were assessed in clinical terms (daily analgesic dosages giving acceptable pain relief and quality of life expressed as sleeping hours and walking/daily activities). With the IT treatment, the total (all routes) opiate consumption and the daily doses of spinal morphine and spinal bupivacaine decreased significantly at the beginning of the treatment compared to the ED period, and continued to be significantly reduced for up to 1 wk for spinal opiate and bupivacaine and 6 mo for total opiate. The spinal opiate and bupivacaine doses were still lower in 50% of the patients at the end of the IT treatment compared to the end of the ED period. When final ED versus initial (2nd day) IT doses were assessed, the daily median dose ratios were 7.5 for total opiate and 4 for both spinal opiate and bupivacaine. Subsequently, lower daily volumes and higher concentrations were needed for IT administration of the drugs. During the first month of the IT treatment, sleeping and walking scores improved compared to ED treatment. Thus, the IT treatment gave more satisfactory pain relief, and--because of lower daily doses and volume--proved to be more suitable for treatment at home (continuous infusion from external pumps) than the ED treatment.     

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

Background
Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving.
Objectives
To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001.
Methods
The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998–2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment.
Results
There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998–2000 and 1,230 from 2001–2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates.
Conclusions
Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.     

Influence of Implementation of a Chest Pain Unit on Acute Coronary Syndrome Outcomes

Background: Different strategies have been described to increase promptness and efficiency in the assessment and management of patients with acute chest pain and acute coronary syndrome (ACS) in the emergency department (ED). Objective: The objective of this study is to evaluate the results of implementing a Chest Pain Unit (CPU) to assist patients with ACS, and to determine its impact on quality of health care indexes and clinical outcomes. Methods: A study was conducted with a prospective cohort of patients admitted to the ED with a chief complaint of acute chest pain or suspected ACS at two different time periods: before (n = 663) and after (n = 450) introducing a CPU as part of the ED. Quality-of-care indexes analyzed in this study were adherence to a critical pathway, length of hospital stay, and hospital mortality. Results: There was increased adherence to a critical pathway during the CPU period compared to the period with no designated CPU area, including compliance with prescribing aspirin, beta-blockers, and angiotensin-converting enzyme inhibitor, and performing coronary angiography in high-risk patients. After adjustment to baseline characteristics, admissions to a CPU resulted in a 65% reduction in mortality (odds ratio 0.35; 95% confidence interval 0.14–0.88; p = 0.03). There was no difference in median length of hospital stay, 7 days (interquartile range [IQR] 4–12) before CPU and 6 days (IQR 4–11) after introducing the CPU (p = 0.10). Conclusion: In the scenario of a crowded ED, implementation of a CPU was associated with greater adherence to a critical pathway for patients with ACS, with a concomitant reduction in mortality rates.