Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices.

Virginie Eve Lvovschi,Karl Hermann,Marie-Pierre Tavolacci,Frédéric Lapostolle,Luc-Marie Joly

doi:10.3390/jcm10215089

Abstract

Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.

Highlights

The management of severe acute pain in emergency departments (EDs) is problematic worldwide, as emphasized by reports regarding oligoanalgesia [1,2,3,4]
Severe pain management in EDs remains critical: low rates of morphine prescription and delays before IV administration [39,40,41] are indicative of the challenges concerning physician compliance with health policies [42,43,44,45]
IV morphine titration is a daily practice recommended as an automatic analgesic modality, isolated or combined with other methods and/or drugs for each patient with severe pain identified at triage and admitted in the care areas, regardless of the time of day

Summary

Introduction

The management of severe acute pain in emergency departments (EDs) is problematic worldwide, as emphasized by reports regarding oligoanalgesia [1,2,3,4]. The underprescription of opioids is a major concern even if health policies have been adopted because of the opioid crisis [5,6,7], and risk factors for opioid misuse have been identified [8,9,10] To explain this underprescription phenomenon, most authors have focused on pain evaluation failure [11,12,13,14,15,16], including two issues that influence opioid management: heterogeneous caregiver education [17,18,19,20,21,22,23] and ED crowding [24,25,26]. Severe pain management in EDs remains critical: low rates of morphine prescription and delays before IV administration [39,40,41] are indicative of the challenges concerning physician compliance with health policies [42,43,44,45]

Methods

Discussion

Conclusion