Pain score documentation and analgesia: A comparison of children and adults with appendicitis

Objective: There is a growing body of evidence suggesting that administration of analgesia in paediatric ED is inadequate. The present study was designed to assess pain score documentation and provision of opioid analgesia to children and adults with confirmed appendicitis in a mixed Australian ED. Method: A retrospective chart review of all adults and children with histologically confirmed appendicitis diagnosed in the Townsville ED during 2006 was performed. Data collected included pain score documentation, weight, opioid dose, oral analgesia, time of presentation, level of doctor and prehospital analgesia. Results: Data were collected for 106 adults and 39 children. Among them, 13 (33%) children compared with 79 (75%) adults had a pain score documented (OR 0.16, 95% CI 0.07–0.37, P < 0.001). And 11 (28%) children compared with 79 (75%) adults received i.v. morphine (OR 0.13, 95% CI 0.06–0.31, P < 0.001). Administration of oral analgesia lowered the likelihood and pain score documentation increased the likelihood of receiving morphine in both children and adults. Conclusion: Documentation of pain scores and provision of i.v. morphine is generally poor. Children are less likely than adults to have a pain score documented, or receive i.v. morphine when presenting with appendicitis.     

Awareness and Utilization of Emergency Medical Services by Limited English Proficient Caregivers of Pediatric Patients

Abstract

Background. Pain management is an important aspect of emergency care for children suffering traumatic injuries. Objectives. The objectives of this study were to characterize analgesic administration to injured children during air medical transport, to describe factors associated with analgesic use, and to examine the effects of patient race on analgesia. Methods. We used electronic records for patients transported by a regional air medical transport agency. We retrospectively examined data from 2003–2012 for patients ≤15 years old suffering traumatic injuries. We used bivariable analyses to identify associations for multivariable logistic regression models to determine factors associated with our outcomes –documentation of pain score and analgesic administration. Results. Of 5,057 patients, the median age was 8 (IQR 3–12) years. The majority of patients were male (66%, 95% CI 64–66%), were white non-Hispanic (83%, 95% CI 82–84%), and had no pain score documented (61%, 95% CI 60–62%). While only 15% of patients received analgesics overall, 70% with an initial pain score ≥5 received analgesics. In unadjusted models, non-white race was associated with lower odds of having a pain score documented (OR 0.52, 95% CI 0.44–0.62) and receiving analgesics (OR 0.64, 95% CI 0.50–0.82). After adjusting for confounders, there was no evidence of racial differences in pain management. Multivariable analysis revealed that younger age, lack of intravenous access, higher Glasgow Coma Scale, systolic blood pressure <100, transportation from the scene, initial pain score <5, and not having a pain score documented were associated with lower odds of receiving analgesics. Conclusions. Few pediatric patients had pain scores documented and fewer received analgesics during air medical transport for injuries. Racial differences in analgesia seen in unadjusted analyses did not persist after controlling for confounders. Resources, training, and appropriate pain management protocols should be made available to facilitate pain assessment in children as a strategy for increasing appropriate analgesic use during transport.     

Effect of System-Wide Interventions on the Assessment and Treatment of Pain by Emergency Medical Services Providers

Background: An estimated 20% of patients arriving by ambulance to the emergency department are in moderate to severe pain. However, the management of pain in the prehospital setting has been shown to be inadequate. Untreated pain may have negative physiologic and psychological consequences. The prehospital community has acknowledged this inadequacy and made treatment of pain a priority. Objectives: To determine if system-wide pain management improvement efforts (i.e. education and protocol implementation) improve the assessment of pain and treatment with opioid medications in the prehospital setting and to determine if improvements are maintained over time. Methods: This was a retrospective before and after study of a countywide prehospital patient care database. The study population included all adult patients transported by EMS between February 2004 and February 2012 with a working assessment of trauma or burn. EMS patient care records were searched for documentation of pain scores and opioid administration. Four time periods were examined: 1) before interventions, 2) after pediatric specific pain management education, 3) after pain management protocol implementation, and 4) maintenance phase. Frequencies and 95% confidence intervals were calculated for all patients meeting the inclusion criteria in each time period and Chi-square was used to compare frequencies between time periods. Results: 15,228 adult patients transported by EMS during the study period met the inclusion criteria. Subject demographics were similar between the four time periods. Pain score documentation improved between the time periods but was not maintained over time (13% [95%CI 12–15%] to 32% [95%CI 31–34%] to 29% [95 CI 27–30%] to 19% [95%CI 18–21%]). Opioid administration also improved between the time periods and was maintained over time (7% [95%CI 6–8%] to 18% [95%CI 16–19%] to 24% [95%CI 22–25%] to 23% [95% CI 22–24%]). Conclusions: In adult patients both pediatric-focused education and pain protocol implementation improved the administration of opioid pain medications. Documentation and assessment of pain scores was less affected by specific pain management improvement efforts.     

Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children

Background: The National Association of Emergency Medical Services Physicians’ (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed. Objective: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations. Methods: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record. Results: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02). Conclusion: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.     

Analysis of Prehospital Documentation of Injury-Related Pain Assessment and Analgesic Administration on the Contemporary Battlefield

In addition to life-saving interventions, the assessment of pain and subsequent administration of analgesia are primary benchmarks for quality emergency medical services care which should be documented and analyzed. Analyze US combat casualty data from the Department of Defense Trauma Registry (DoDTR) with a primary focus on prehospital pain assessment, analgesic administration and documentation. Retrospective cohort study of battlefield prehospital and hospital casualty data were abstracted by DoDTR from available records from 1 September 2007 through 30 June 2011. Data included demographics; injury mechanism; prehospital and initial combat hospital pain assessment documented by standard 0-to-10 numeric rating scale; analgesics administered; and survival outcome. Records were available for 8,913 casualties (median ISS of 5 [IQR 2 to 10]; 98.7% survived). Prehospital analgesic administration was documented for 1,313 cases (15%). Prehospital pain assessment was recorded for 581 cases (7%; median pain score 6 [IQR 3 to 8]), hospital pain assessment was recorded for 5,007 cases (56%; median pain score5 [CI95% 3 to 8]), and 409 cases (5%) had both prehospital and hospital pain assessments that could be paired. In this paired group, 49.1% (201/409) had alleviation of pain evidenced by a decrease in pain score (median 4,, IQR 2 to 5); 23.5% (96/409) had worsening of pain evidenced by an increase in pain score (median 3, CI95 2.8 to 3.7, IQR 1 to 5); 27.4% (112/409) had no change; and the overall difference was an average decrease in pain score of 1.1 (median 0, IQR 0 to 3, p < 0.01). Time-series analysis showed modest increases in prehospital and hospital pain assessment documentation and prehospital analgesic documentation. Our study demonstrates that prehospital pain assessment, management, and documentation remain primary targets for performance improvement on the battlefield. Results of paired prehospital to hospital pain scores and time-series analysis demonstrate both feasibility and benefit of prehospital analgesics. Future efforts must also include an expansion of the prehospital battlefield analgesic formulary.     

Implementation of paediatric pain care-bundle across South-West England clinical network of Emergency Departments and Minor Injury Units: A before and after study

IntroductionPain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs).MethodsA total of 29 centres – 5 EDs and 24 MIUs – participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records).ResultsThe likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72–8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51–2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86–3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01).ConclusionsRates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle.     

Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010–2013

Introduction: Pain is the most common symptom in patients presenting for prehospital (PH) care. Research in civilian emergency medical systems has shown wide variability in PH pain assessment and analgesic practices, yet a minimal amount is known about pain assessment and analgesic intervention practices in the military, particularly when PH care is delivered in a combat zone. Objective: To describe prehospital (PH) pain care practices for U.S. military personnel injured in Iraq and Afghanistan 2010–2013 and explore potential relationships to explain variation. Methods: An exploratory retrospective, cross-sectional study of Department of Defense Trauma Registry data from 2010 to 2013 was performed. Demographic, clinical, or health system variables for associations with three outcomes: 1) pain assessment documentation; 2) pain severity (0–10 scale); and 3) analgesic administration (yes/no). Including only variables with significant associations, backward stepwise regression was used to develop explanatory models for each outcome. Results: Patient records (n = 3,317) were evaluated for documentation of PH pain assessment and analgesic administration. The prevalence of PH pain score documentation was 37.8% (n = 1,253). Overall, the proportion of records with PH pain scores increased over time: 19.8% (2010), 35.1% (2011), 58.2% (2012), and 62.2% (2013). Severity of pain scores ranged 0–10; mean = 5.5 (SD = 3.1); median = 6 (IQR = 3–8). Analgesics were reported for 50.8% (n = 1,684), of whom 38.3% had a pain severity score documented. The pain assessment documentation model included any documented vital signs, injury year, and mechanism of injury and explained 19.3% of the variance in documentation. The pain severity model included vital signs and injury severity score (ISS) and explained 5.0% of the variance in severity. The analgesic model included any vital signs, pain severity, trauma type, mechanism of injury, ISS, and year. Conclusions: Pain assessment and treatment documentation improved each year, but remain suboptimal. Available data yielded poor prediction of the outcomes of interest, emphasizing the importance of individual assessment. Analgesic effectiveness could not be evaluated.     

Safety of a nurse-managed,titrated analgesia protocol for the management of severe pain in the emergency department

Objectives: The objectives of this study were: (i) to determine the adverse-effects profile of a nurse-managed, titrated intravenous analgesia protocol; and (ii) to characterize the use of opioid analgesics for acute pain in a setting where an intravenous analgesia protocol was in place. Method: Retrospective chart audit of 401 consecutive cases (May–July 1996) of opioid analgesic administration for the management of pain in an adult metropolitan emergency department was performed. Results: Of the 401 cases, 345 (86%) received opioid analgesia using the nurse-managed, titrated analgesia protocol. Nineteen adverse events were documented in this group (5.5% of patients; 95% CI = 3.3–8.5%). There were 17 episodes of hypotension (blood pressure below 100 mmHg), one hypersensitivity reaction and one vagal reaction. There were no documented cases of respiratory depression and no patient was administered naloxone. Of the patients suffering hypotension, seven required no intervention and the remaining 10 responded well to an infusion of fluids. Conclusion: The nurse-managed, titrated intravenous analgesia protocol is a well-used and safe method of providing analgesia.     

Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan

Background: Previous studies have evaluated prehospital analgesia during combat operations in Iraq and Afghanistan, but were limited to the adult population. However, a significant portion of the casualties of those conflicts were children. We describe the prehospital analgesia administered to wartime pediatric trauma patients. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients (<18 years of age) admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We divided pediatric patients into 2 groups: those that had documentation of receipt of analgesic drugs in the prehospital setting (n = 618) and those who had not received analgesia before reaching a fixed-facility (n = 2,821). For characterization of drug administration, we grouped patients into those receiving acetaminophen, NSAID, fentanyl, ketamine, morphine, or other analgesics (e.g., hydromorphone, tramadol, etc.). Results: During the study period, there were 3,439 pediatric encounters with documentation of 703 instances of analgesia administrations to 618 patients (17.9% of total pediatric encounters). Of the subjects receiving analgesic agents, 46.2% (n = 325) received morphine, 30.4% (n = 214) received fentanyl, 17.4% (n = 122) received ketamine, 1.8% (n = 13) received acetaminophen, and 2.8% (n = 20) received a non-steroidal anti-inflammatory drug. The remaining 9 administrations consisted of methoxyflourane (1), nalbuphine (2), hydromorphone (3), and tramadol (3). An injury severity score (ISS) >15 increased the odds of receiving an analgesic agent (OR 1.26, 95% CI 1.02–1.56). Additionally, there was an association between analgesia administration and the following prehospital interventions: wound dressing, tourniquet, intravenous (IV) line placement, intraosseous line placement, IV fluids, intubation, and external warming. Conclusions: Overall, a low proportion of pediatric trauma subjects within this population received analgesia in the prehospital environment. The most common analgesic medication administered was morphine. Those receiving analgesic agents had more severe injuries and higher rates of concomitant interventions. These results highlight the potential need for Tactical Combat Casualty Care guidelines specifically providing recommendations for analgesia administration among pediatric patients.     

Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT III

Objective: Traumatic brain injury (TBI) causes more than 2.5 million emergency department visits, hospitalizations, or deaths annually. Prehospital endotracheal intubation has been associated with poor outcomes in patients with TBI in several retrospective observational studies. We evaluated the relationship between prehospital intubation, functional outcomes, and mortality using high quality data on clinical practice collected prospectively during a randomized multicenter clinical trial. Methods: ProTECT III was a multicenter randomized, double-blind, placebo-controlled trial of early administration of progesterone in 882 patients with acute moderate to severe nonpenetrating TBI. Patients were excluded if they had an index GCS of 3 and nonreactive pupils, those with withdrawal of life support on arrival, and if they had documented prolonged hypotension and/or hypoxia. Prehospital intubation was performed as per local clinical protocol in each participating EMS system. Models for favorable outcome and mortality included prehospital intubation, method of transport, index GCS, age, race, and ethnicity as independent variables. Significance was set at α = 0.05. Favorable outcome was defined by a stratified dichotomy of the GOS-E scores in which the definition of favorable outcome depended on the severity of the initial injury. Results: Favorable outcome was more frequent in the 349 subjects with prehospital intubation (57.3%) than in the other 533 patients (46.0%, p = 0.003). Mortality was also lower in the prehospital intubation group (13.8% v. 19.5%, p = 0.03). Logistic regression analysis of prehospital intubation and mortality, adjusted for index GCS, showed that odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated (OR = 0.53, 95% CI = 0.36–0.78). 279 patients with prehospital intubation were transported by air. Modeling transport method and mortality, adjusted for index GCS, showed increased odds of dying in those transported by ground compared to those transported by air (OR = 2.10, 95% CI = 1.40–3.15). Decreased odds of dying trended among those with prehospital intubation adjusted for transport method, index GCS score at randomization, age, and race/ethnicity (OR = 0.70, 95% CI = 0.37–1.31). Conclusions: In this study that excluded moribund patients, prehospital intubation was performed primarily in patients transported by air. Prehospital intubation and air medical transport together were associated with favorable outcomes and lower mortality. Prehospital intubation was not associated with increased morbidity or mortality regardless of transport method or severity of injury.     

Factors associated with unoffered trauma analgesia in critical care transport

Objective

Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams.

Methods

This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons.

Results

Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n = 145), self-reported pain on a scale from 0 to 10 decreased from 6.8 ± 2.8 to 3.3 ± 2.4 (P ≤ .001). Three factors were associated with absence of analgesic administration: initial pain level (OR for administration, 0.13; 95% CI, 0.04-0.40), pain scale documentation (OR, 0.31; 95% CI, 0.15-0.60), and transport program (OR, 0.36; 95% CI, 0.17-0.74). No clinical factor was associated with analgesia effectiveness in treated patients.

Conclusion

The identified factors may represent opportunities for CCT teams to optimize analgesic treatment.     

ROSEN'S EMERGENCY MEDICINE: CONCEPTS AND CLINICAL PRACTICE,FIFTH EDITION

Abstract

Background. Less is known about the prevalence of pain in prehospital emergency medicine than about pain in the emergency department. Objectives. To estimate the prehospital prevalence of pain and to identify the factors associated with oligoanalgesia. Methods. The mobile intensive care units of the emergency services of a Paris suburb conducted this prospective study. All consecutive patients aged 16 years or older who were able to self-assess pain were included around the clock over a period of 11 months in 2007. Results. Among the 2,279 included patients, 947 had acute pain (42% [95% confidence interval (CI) 40–44]). Pain was intense to severe in 64% of patients. Factors associated with acute pain were trauma (odds ratio [OR] = 2.9 [1.9–4.3]) and age under 75 years (OR = 2.2 [1.7–2.8]). Intense pain was significantly associated with pain of cardiac or traumatic origin. Among the 1,364 patients transported by the mobile units, 48% experienced acute pain (71% had intense to severe pain). An analgesic agent was administered to 73%. According to multivariate analysis, only gynecologic/obstetric emergencies were associated with inadequate treatment (OR = 0.2 [95% CI 0.1–0.6]). Overall, 51% of patients [46–56] experienced pain relief. The rate of pain relief was lowest in patients suffering from trauma or a gynecologic/obstetric disorder. Conclusion. In our studied population, pain in prehospital emergency medicine affects 42% of patients. However, the rate varies widely according to the origin of the pain. Pain management is inadequate, as only one in two patients experiences relief.     

Time to analgesia for care delivered by nurse practitioners in the emergency department – a retrospective chart audit

ObjectivesTo evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by:

• 1Evaluating time to analgesia from initial presentation
• 2Evaluating time from being seen to next analgesia
• 3Measuring pain score documentation

BackgroundThe delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance.MethodsA retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED patient information system (Cerner log) and data were extracted from electronic medical records.ResultsPain scores were documented in 67 (52.3%; 95% CI: 43.3–61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30–87) minutes, with 34 (26.6%; 95% CI: 19.1–35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1–24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients who received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12–50) minutes, with 65 (61.3%; 95% CI: 51.4–70.6) patients receiving analgesia within 30 minutes of assessment.ConclusionsThe majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.     

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study

Objective

We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation.

Predictors for opioid analgesia administration in children with abdominal pain presenting to the emergency department

OBJECTIVES: Abdominal pain is one of the most common symptoms in children. The aim of this study was to determine the rate of opioid analgesia in children with abdominal pain presenting to the pediatric Emergency Department (ED) and to identify factors associated with administration of opioids. METHODS: We retrospectively reviewed all charts of patients with abdominal pain < 7 days presenting to the ED of a tertiary pediatric hospital over a 3-month period. Demographic and illness-related variables were recorded, and the primary outcome variable was whether opioid analgesia was used to relieve abdominal pain. We analyzed the data with a univariate analysis and a multivariate stepwise regression analysis to determine independent influences on the rate of opioid prescribing. RESULTS: Of 582 children included in the analysis, 53 (9%) received opioid analgesia. Pain in the right lower quadrant on examination, documentation of a pain score in triage, and the level of acuity as determined by the triage nurse were predictors of administration of opioids by the physician. Thirty-four (77%) of the opioids given were below the recommended dose for the child. CONCLUSIONS: Few pediatric patients with abdominal pain are treated with pain medications. The decision to use opioid analgesia for acute abdominal pain in the pediatric ED is influenced by acuity level, pain score documentation in triage, and location of abdominal pain. Efforts should be made to educate physicians on the appropriate administration and dose of opioids in children with abdominal pain in the ED.     

Prehospital administration of tranexamic acid in trauma patients: A 1:1 matched comparative study from a level 1 trauma center

PurposeThe purpose of this study was to test the efficacy of prehospital administration of tranexamic acid (TXA) to injured patients on mortality, thromboembolic events and need for blood transfusion in a level 1 trauma center.MethodsWe conducted a retrospective study comparing adult trauma patients receiving or not receiving prehospital TXA between January 2017 and September 2018. Patients not receiving TXA but transfused within 4 h of admission were 1:1 matched to TXA-treated patients for age, sex, injury severity score, head abbreviated injury score, prehospital heart rate and systolic blood pressure.ResultsIn total 204 patients were included (102 TXA and 102 control), with a mean age of 31 years. On admission, shock index (p = 0.03) and serum lactate (p = 0.001) were greater in the control group, whereas the initial base deficit, hemoglobin levels and EMS time were comparable in both groups. The odd ratio (OR) for shock index ≥0.9 after TXA administration was 0.44 (95% CI 0.23–0.84). The median amount of blood transfusion was greater in the control group [eight units (range 1–40) vs three (range 0–40), p = 0.01] as well as the use of massive blood transfusion [OR 0.35 (95% CI 0.19–0.67)]. In the TXA group, VTE was higher [OR 2.0 (95% CI 0.37–11.40)]; whereas the overall mortality was lower [OR 0.78 (95% CI 0.42–1.45)] without reaching statistical significance.ConclusionsPrehospital TXA administration is associated with less in-hospital blood transfusion and massive transfusion protocol (MTP). There is no significant increase in the thromboembolic events and mortality, however, further evaluation in larger clinical trials is needed.     

Racial/Ethnic Differences in Staff-Assessed Pain Behaviors Among Newly Admitted Nursing Home Residents

ContextNonverbal pain behaviors are effective indicators of pain among persons who have difficulty communicating. In nursing homes, racial/ethnic differences in self-reported pain and pain management have been documented.ObjectivesWe sought to examine racial/ethnic differences in nonverbal pain behaviors and pain management among residents with staff-assessed pain.MethodsWe used the U.S. national Minimum Data Set 3.0 and identified 994,510 newly admitted nursing home residents for whom staff evaluated pain behaviors and pain treatments between 2010 and 2016. Adjusted prevalence ratios (aPRs) and 95% CIs estimated using robust Poisson models compared pain behaviors and treatments across racial/ethnic groups.ResultsVocal complaints were most commonly recorded (18.3% non-Hispanic black residents, 19.3% of Hispanic residents, and 30.3% of non-Hispanic white residents). Documentation of pain behaviors was less frequent among non-Hispanic black and Hispanic residents than non-Hispanic white residents (e.g., vocal complaints: aPR_Black: 0.76; 95% CI: 0.73–0.78; with similar estimates for other pain behaviors). Non-Hispanic blacks (47.3%) and Hispanics (48.6%) were less likely to receive any type of pharmacologic pain intervention compared with non-Hispanic white residents (59.3%) (aPR_Black: 0.87; 95% CI: 0.86–0.88; aPR_Hispanics: 0.87; 95% CI: 0.84–0.89).ConclusionAmong residents requiring staff assessment of pain because they are unable to self-report, nursing home staff documented pain and its treatment less often in Non-Hispanic blacks and Hispanics than in non-Hispanic white residents. Studies to understand the role of differences in expression of pain, explicit bias, and implicit bias are needed to inform interventions to reduce disparities in pain documentation and treatment.