Pain Triage Research Articles

The Association Between Use of Brain CT for Atraumatic Headache and 30-Day Emergency Department Revisitation.

The purpose of this article is to describe the association between initial CT for atraumatic headache and repeat emergency department (ED) visitation within 30 days of ED discharge. A retrospective observational study was performed at an academic urban ED with more than 85,000 annual visits. All adult patients with a chief complaint of headache from January through December 2010 who were discharged after ED evaluation were included in the analysis. Patients were excluded if they were transferred, died in the ED, or had a diagnosis indicating a traumatic mechanism. A propensity score-matched logistic regression model was used to determine whether the use of brain CT was associated with the primary outcome of ED revisitation within 30 days, controlling for potential confounding variables. Of 80,619 total patient visits to the ED during the study period, 922 ED discharges with a chief complaint of headache were included. A total of 139 (15.1%) patients revisited within 30 days. The return rate was 11.2% among patients who underwent CT at their initial visit and 21.1% among those who did not. In the adjusted analysis, controlling for age, race, sex, insurance status, triage vital signs, laboratory values, and triage pain level, the odds ratio for revisitation given CT performance was 0.49 (95% CI, 0.27-0.86). After adjustment for clinical factors, we found that patients who underwent a brain CT examination for atraumatic headache at an initial ED visit were less likely to return to the ED within 30 days. Future appropriate use quality metrics regarding ED imaging use may need to incorporate downstream health care use.

ED triage pain protocol reduces time to receiving analgesics in patients with painful conditions

BackgroundStudies suggest that collaborative nursing protocols initiated in triage improve emergency department (ED) throughput and decrease time to treatment. ObjectiveThe objective of the study is to determine if an ED triage pain protocol improves time to provision of analgesics. MethodsRetrospective data abstracted via electronic medical record of patients at a safety net facility with 67 000 annual adult visits. Patients older than 18 years who presented to the ED between March 1, 2011, and May 31, 2013, with 1 of 6 conditions were included: back pain, dental pain, extremity trauma, sore throat, ear pain, or pain from an abscess. A 3-month orientation to an ED nurse-initiated pain protocol began on March 1, 2012. Nurses administered oral analgesics per protocol, beginning with acetaminophen or ibuprofen and progressing to oxycodone. Preimplementation and postimplementation analyses examined differences in time to analgesics. Multivariable analysis modeled time to analgesics as a function of patient factors. ResultsOver a 27-month period, 23 409 patients were included: 13 112 received pain medications and 10 297 did not. A total of 12 240 (52%) were male, 12 578 (54%) were African American, and 7953 (34%) were white, with a mean (SD) age of 39 years (13 years). The pain protocol was used in 1002 patients. There was a significant change in mean time (minutes) to provision of analgesics between preimplementation (238) and postimplementation (168) (P < .0001). Linear regression showed the protocol-delivered medications to younger patients and of lower acuity in a reduced time. Variables not related to time to provision of medication included sex, payer, and race. ConclusionEmergency department triage pain protocol decreased time to provision of pain medications and did so without respect to payer category, sex, or race.

A Quantitative Study Investigating the Effects of Computerised Clinical Decision Support in the Emergency Department.

This paper describes the evaluation of a computerized clinical decision support system (CCDSS) for Emergency Department (ED) triage. The CCDSS for triage was developed as a means to improve ED quality and safety. Whilst there is significant research on the role of CCDSS in health care, their role in EDs remains under-investigated. In this study, a CCDSS for ED triage was developed and evaluated using a quasi-experimental interrupted time-series design. Data was collected at four time points before and after the introduction of the CCDSS to assess key aspects of quality and safety within the ED. The results demonstrated a statistically significant improvement in triage prioritization (p &lt; 0.001), pain scoring (p &lt; 0.001) and pain management (p &lt; 0.001). This study clearly identifies the positive clinical impact that a CCDSS can have on quality and safety for ED patients and provides a unique contribution to the current knowledge base.

Improving Quality of Care for Sickle Cell Patients in the Pediatric Emergency Department.

The aim of this study was to identify the factors associated with delays in treatment of sickle pain crisis in the pediatric emergency department with the goal of discerning whether earlier pain management is correlated with better clinical outcome. This retrospective study examined data collected from clinical records of patients, aged 21 years or younger, who was treated for sickle cell pain crisis between January and June 2012. Demographic and clinical characteristics were extracted from electronic records, as well as time of registration, triage, initial pain assessment, analgesic administration, and pain reassessment. A total of 160 sickle cell pain crises visits by 67 unique patients were identified. Opiates were the most common initial pain medication prescribed and administered. The mean time to initial analgesic administration and pain reassessment was 89 and 60 minutes, respectively. Patients with orders for imaging studies experienced significant delays in time to initial analgesic medication and pain reassessment. In addition, higher triage pain score correlated with shorter time to first dose of pain medication. However, age, sex, and final disposition did not affect time to administration of analgesic medications.Earlier pain management resulted in shorter ED length of stay for all patients regardless of disposition. However, earlier pain management did not affect the total length of hospitalization for patients admitted to the inpatient services. Pediatric patients with sickle cell pain crises experienced significant delays to initial analgesic medication. A standardized approach to pain management may improve ED management of SCD crises.

Variables associated with parent satisfaction with their child's pain management.

The provision of 'adequate analgesia' (which reduces the pain score by ≥2 and to <4 [0-10 scale]) is significantly associated with high levels of satisfaction with pain management among adult patients. We aimed to determine the variables (including 'adequate analgesia') associated with parent satisfaction with their child's pain management. We undertook an observational, pilot study in a mixed, metropolitan ED. Patients aged 4-16 years with a triage pain score of ≥4 were enrolled. Data included demographics, presenting complaint, pain scores every 30 min, analgesia administered, time to first analgesia, provision of nurse-initiated analgesia (NIA), and 'adequate analgesia', and parent satisfaction 48-h post-discharge (6 point scale: very unsatisfied - very satisfied). Complete data were collected on 185 patients: mean (SD) age 10.4 (3.6) years, weight 41.9 (17.8) kg; 93 (50.3%) were male. One hundred and ten (59.4%) parents were very satisfied with their child's pain management. Children of very satisfied parents had shorter times to analgesia than those who did not (median [interquartile range] 14 (33) vs 33 (46) min, respectively, P = 0.003). Parents whose children received NIA or 'adequate analgesia' were more often very satisfied than those whose children did not. However, the differences were not significant (difference in proportions: 13.2% [95% CI -1.9, 28.3], P = 0.07 and 10.2% [95% CI -5.02, 25.34], P = 0.16, respectively). Short times to analgesia are associated with parent satisfaction. There were non-significant trends towards high levels of satisfaction following the provision of NIA and 'adequate analgesia'. These findings will inform a well-powered study to confirm this association.

Derivation and preliminary validation of a risk score to predict 30-day ED revisits for sickle cell pain

BackgroundEmergency department (ED) revisits and 30-day readmissions have been proposed as markers for quality of ED care for sickle cell disease (SCD). ObjectiveTo create a scoring system that quantifies the risk of 30-day revisit after ED discharge for SCD vaso-occlusive pain MethodsThis was a dual-center retrospective derivation and validation cohort study. The derivation was performed at an academic, tertiary care center and the validation at an urban community hospital. The primary outcome was revisit to the ED within 30 days after an ED discharge for SCD pain. Recursive partitioning was used to derive a scoring system to predict 30-day revisits. ResultsOf a total of 1456 ED visits for SCD pain, there were 680 ED discharges (admission rate of 53%) in 193 unique individuals included in the derivation cohort. There were 240 (35.3%) 30-day revisits. Of a total of 126 ED visits for SCD, there were 79 ED discharges in 41 unique individuals in the validation cohort. The final risk score included 4 variables: (1) age, (2) insurance status, (3) triage pain score, and (4) amount of opioids administered during the ED visit. Possible scores range from 0 to 6. The areas under the receiver operating characteristic curves were 0.746 (95% confidence interval, 0.71-0.78—derivation cohort) and 0.753 (95% confidence interval, 0.65-0.86—validation cohort). A cutoff of 4 or greater identified 60% of 30-day ED revisits in the derivation cohort and 80% of revisits in the validation cohort. ConclusionsA risk score can identify ED visits for SCD pain with high risk of 30-day revisit.

Pain assessment in emergency department as part of triage system has limited interobserver agreement

Background In the Danish Emergency Process Triage (DEPT) pain is used as an independent contributor for triaging patients and is validated by the Numerical Pain Rating scale, NRS11. Prior studies have assessed the congruence between nurse’s assessment of their patients’ pain intensity and the patients’ own pain perception with mixed results. The aim of this study was to examine the correlation in pain score between nurse and patient and the inter-rater agreement between nurses when the pain score is used in a triage system in an Emergency Department.

Application effect of new triage record list on acute chest pain

Objective To introduce triage standard for non-traumatic chest pain and SOAPIE triage method into triage work for acute chest pain patients, and to investigate its effect. Methods Based on triage standard for non-traumatic chest pain and SOAPIE triage method, a new triage record was established. And triage time, triage accuracy and patient satisfaction were compared with conventional methods. Results The triage time of the research group was (1.94±0.30) minutes, which was significantly lower than (2.27±0.35) minutes of the control group (t=6.99, P<0.05). The triage accuracy of the research group was 96.0%, which was significantly higher than 82.0% of the control group (χ2=10.01, P<0.05). The score of patients′ satisfaction was (98.94±1.06), which was significantly higher than (89.30±5.95) of the control group (t=15.96, P<0.01). Conclusions The new triage method can shorten the triage time, improve the triage accuracy and patients′ satisfaction, which is worthy of promotion. Key words: Chest pain; Satisfaction; Triage; Nurse

Pediatric Pain Management in the Emergency Department: The Triage Nurses’ Perspective

Understanding triage nurses' perspectives of pain management is essential for timely pain care for children in the emergency department. Objectives of this study were to describe the triage pain treatment protocols used, knowledge of pain management modalities, and barriers and attitudes towards implementation of pain treatment protocols. A paper-based survey was administered to all triage nurses at three Canadian pediatric emergency departments, between December 2011 and January 2012. The response rate was 86% (n=126/147). The mean respondent age was 40 years (standard deviation [SD] 9.3) with 8.6 years (SD 7.7) of triage experience. General triage emergency department (GTED) nurses rated adequacy of triage pain treatment lower than pediatric-only triage emergency department (PTED) nurses (P < .001). GTED nurses reported a longer acceptable delay between triage time and administration of analgesia than PTED nurses (P < .002). Most nurses rated more comfort with a protocol involving administration of acetaminophen (97 mm, interquartile range [IQR] 92, 99) or ibuprofen (97 mm, IQR 93, 100) than for oral morphine (67 mm, IQR 35, 94) or oxycodone (57 mm, IQR 15, 81). The top three reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. Willingness to implement a triage-initiated pain protocol was rated as 81 mm (IQR 71, 96). Triage nurses are willing to implement pain protocols for children in the emergency department, but differences in comfort and experience exist between PTED and GTED nurses. Provision of triage initiated pain protocols and associated education may empower nurses to improve care for children in pain in the emergency department.

Multiple interventions improve analgesic treatment of supracondylar humerus fractures in a pediatric emergency department.

Provision of appropriate and timely treatment for pain in the pediatric population has been challenging. Children with painful conditions commonly present to emergency departments (EDs), a setting in which it may be particularly difficult to consistently provide timely analgesic interventions. To measure the effectiveness of a set of interventions in improving the rate and timeliness of analgesic medication administration, as well as appropriate backslab immobilization (application of a moldable plaster or fiberglass splint), in a pediatric ED. Data regarding pain management were collected on a consecutive sample of cases of supracondylar fracture over a 13-month period. This followed the implementation of a formal triage pain assessment and treatment medical directive, supplemented with relevant education of nursing and house staff, and posters in the ED. These data were compared with data previously collected from a similar cohort of cases, which presented before the interventions. Postintervention, the proportion of patients treated with an analgesic within 60 min of triage increased from 15% to 54% (P<0.001), and the median time to administration of an analgesic decreased from 72.5&nbsp;min to 11 min (P<0.001). Rates for backslab application before radiography were similar before and after the intervention (29% and 33%, respectively; P=0.646). A multifaceted approach to improving early analgesic interventions was associated with considerably improved rates of early analgesic treatments for supracondylar fracture; however, no improvement in early immobilization was observed.

Role of cardiac multidetector computed tomography beyond coronary angiography.

Cardiac multidetector computed tomography (MDCT) has become a useful noninvasive modality for anatomical imaging of coronary artery disease (CAD). Currently, the main clinical advantage of coronary computed tomography angiography (CCTA) appears to be related to its high negative predictive value at low or intermediate pretest probability for CAD. With the development of technical aspects of MDCT, clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology, myocardial perfusion, and patient outcomes. The presence of positive vessel remodeling, low-attenuation plaques, napkin-ring sign, or spotty calcification on CCTA could be useful information on high-risk vulnerable plaques. The napkin-ring sign, especially, showed higher accuracy for the detection of thin-cap fibroatheroma. Recently, it was reported that cardiac 3D single-photon emission tomography/CT fusion imaging, noninvasive fractional flow reserve computed from CT, and integrated CCTA and CT myocardial perfusion were associated with improved diagnostic accuracy for the detection of hemodynamically significant CAD. Furthermore, several randomized, large clinical trials have evaluated the clinical value of CCTA for chest pain triage in the emergency department or long-term reduction in death, myocardial infarction, or hospitalization for unstable angina. In this review we discuss the role of cardiac MDCT beyond coronary angiography, including a comparison with other currently available imaging modalities used to examine atherosclerotic plaque and myocardial perfusion.

Application of "PQRST" method on non-traumatic pain triage in Department of Emergency

Application of "PQRST" method on non-traumatic pain triage in Department of Emergency

370 Acute Management of Pain from the Emergency Department: Initial Report of a Patient-Reported Outcomes Registry

370 Acute Management of Pain from the Emergency Department: Initial Report of a Patient-Reported Outcomes Registry

Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey.

Published data from 1998 revealed that most patients treated for migraine in an emergency department received opioids. Over the intervening years, a large body of evidence has emerged demonstrating the efficacy and safety of non-opioid alternatives. Expert opinion during these years has cautioned against use of opioids for migraine. Our objectives were to compare current frequency of use of various medications for acute migraine in US emergency departments with use of these same medications in 1998 and to identify factors independently associated with opioid use. We analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the most current dataset available. The National Hospital Ambulatory Medical Care Survey is a public dataset collected and distributed by the Centers for Disease Control and Prevention. It is a multi-stage probability sample from randomly selected emergency departments across the country, designed to be representative of all US emergency department visits. We included in our analysis all patients with the ICD9 emergency department discharge diagnosis of migraine. We tabulated frequency of use of specific medications in 2010 and compared these results with the 1998 data. Using a logistic regression model, into which all of the following variables were entered, we explored the independent association between any opioid use in 2010 and sex, age, race/ethnicity, geographic region, type of hospital, triage pain score and history of emergency department use within the previous 12 months. In 2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits to US emergency departments. Including opioid-containing oral analgesic combinations, opioids were administered in 59% of visits (95% confidence interval 51, 67). The most commonly used parenteral agent, hydromorphone, was used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than 1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had decreased markedly over the same timeframe. In 2010, it was used in just 7% (95% confidence interval 4, 12) of visits compared to 37% (95% confidence interval 29, 45) in 1998. Metoclopramide, the most commonly used anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11) of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the predictor variables listed above, only emergency department use within the previous 12 months was associated with opioid administration (adjusted odds ratio: 2.87 (95% confidence interval 1.03, 7.97)). In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.

High-sensitivity versus conventional troponin for management and prognosis assessment of patients with acute chest pain

ObjectivesHigh-sensitivity troponin (hs-cTn) is substituting conventional cTn for evaluation of chest pain. Our aim was to assess the impact on patient management and outcome.MethodsA total of 1372 consecutive patients presenting...

Chest Pain Triage

Der akute Thoraxschmerz ist eine sehr häufige Diagnose in den Notfallambulanzen. In den USA werden jährlich mehr als 6,4 Millionen PatientInnen mit dieser Diagnose in einer Notfallambulanz abgeklärt bei insgesamt 119 Millionen Patienten jährlich. Diese PatientInnen verursachen jährlich Kosten von etwa 119 Milliarden USD. 15 – 25% dieser PatientInnen haben ein akutes Koronarsyndrom – auf der anderen Seite werden 2 – 8% der akuten Koronarsyndrome nicht erkannt, diese wiederum haben eine Mortalität von 25%.

Pain scores among ED patients: correlation with desire for pain medication

Introduction: Pain has been identified as the most common reason for Emergency Department (ED) visits. The verbal numeric rating pain scale (VNRS) is commonly used to assess pain in the ED. This study was undertaken to determine whether VNRS pain scores correlate with desire for pain medication among ED patients. Methods: In this prospective survey study, eligible patients included Emergency Department patients over 18 with painful conditions. The primary outcome measures included self-reported VNRS, ED diagnosis, number of ED visits and number of ED admissions within the past year, and the self-reported desire for pain medication. Results: Among 482 participants in 2012, the median triage pain score was 8 (IQR 6-10); the most frequently occurring score was 10. Overall, there were significant differences in pain scores with patient desire for analgesics. 67% reported desire for pain medications. Patients who did not want pain medications had significantly lower pain scores (median 6; IQR 4-8) compared to those who wanted medication (median 8; IQR 7-10) (p&lt;0.001) and compared to those who were ambivalent about medication (median 7; IQR 6-10) (p=0.01). There was no association between desire for pain medication and demographics including age, gender, race, or insurance status. Conclusions: ED patients who did not desire pain medication had significantly lower pain scores than patients who desired pain medication. Pain scores usually effectively predicted which patients desired pain medications. Desire for pain medication was not associated with age, gender, race, or insurance status.

Effectiveness of Using the Front Door Score to Enhance the Chest Pain Triage Accuracy of Emergency Nurse Triage Decisions

Nurses lack a standard tool to stratify the risk of chest pain in triage patients. The type of risk stratification may correspond to the type of acuity rating of the 5-level triage scale adopted by nurses for chest pain triage, based on the Front Door Score, simplified from the Thrombolysis in Myocardial Infarction Risk Score for unstable angina or non-ST-segment elevation myocardial infarction. This study aimed to evaluate the ability of using the Front Door Score to enhance the accuracy of emergency nurse triage decisions for patients who present with chest pain. A cross-sectional descriptive design was used. A convenience sample of 200 subjects was obtained from an emergency department in Hong Kong. Data were collected via a questionnaire. The final physician diagnoses were used as the gold standard in justifying the appropriateness of the risk stratification of chest pain. The agreement rates among the final physician diagnoses, Thrombolysis in Myocardial Infarction Risk Score for unstable angina or non-ST-segment elevation myocardial infarction, nurses using the triage scale, and nurses using the Front Door Score were computed using κ statistics. A significant substantial agreement was observed between the final physician diagnoses and nurses using the Front Door Score. In comparison, the agreement between the final physician diagnoses and nurses using the triage scale was poor. The chest pain triage reliability of nurses using the Front Door Score was found to be much more credible than that of nurses using the triage scale. A suggested conversion of the scales of Front Door Score was established. The Front Door Score should be considered as a standard tool to enhance the chest pain triage accuracy of emergency nurse triage decisions.

Feasibility of pre-hospital chest pain triage at home or in the ambulance by paramedics using the HEART score based upon a single high-sensitive troponin T analysis

Purpose: Triage of patients with chest pain after an Emergency Medical System (EMS) call normally occurs in the hospital emergency room (ER). It has been shown that the HEART-score offers a simple and quick risk-stratifying tool in these patients. Additionally the high-sensitive Troponin T (hs-cTnT) provides a greater diagnostic accuracy and detection of Acute Myocardial Infarction (AMI) compared to the fourth generation TnT. This study investigates whether pre-hospital chest pain triage is feasible, in terms of ruling out AMI already in the ambulance by paramedics using a single hs-TnT measurement in combination with the HEART score. Methods: Patients with acute onset chest pain (with the exclusion of STEMI) who called the EMS, from June -to November 2012 were prospectively evaluated at First Medical Contact (FMC), often at home, by ambulance paramedics including hs-TnT assessment. All patients were then transported immediately to the ER and managed by emergency physicians without knowledge of the HEART score as assessed by the ambulance crew at FMC. Follow-up was performed at 30 days in terms of MACE. Discharge diagnoses were evaluated in case AMI was ruled out. Results: A total of 207 patients were included. The hs-cTnT values was negative (< 0.014 ng/mL) in 123 patients (59%) and the HEART score was 3 or less in 42 patients (34%), as shown in the table. None of the patients with a HEART score of 3 or less had an AMI. The discharge diagnoses of patients with a HEART score of 3 or less were benign, non-cardiac chest pain in 39 patients (93%), a suspicion of supraventicular arrythmia in 2 patients (3.1%) and a suspected biliary colic in 1 patient. View this table: Conclusion: A large number of patients (34%) with symptoms suspicious of AMI who were presented to the EMS system could be identified as being low risk already in the ambulance. This pre-hospital triage provides an excellent tool in identifying both low- and high-risk patients and might help in optimizing logistics and cost-effectiveness for patients with chest pain before hospital admission.

Nurse‐initiated analgesia pathway for paediatric patients in the emergency department: A clinical intervention trial

The study aims to evaluate the impact of a nurse-initiated analgesia pathway (NIAP) intervention for paediatric patients in the ED. We undertook a pre- and post-intervention trial in a large, tertiary referral, mixed ED. The intervention comprised development and implementation of a comprehensive NIA Standing Order. In addition to paracetamol, which nurses could initiate pre-intervention, they were authorised to administer ibuprofen, paracetamol/codeine combinations and topical local anaesthetics prior to a doctor assessing the patient. All nurses were trained and credentialed prior to administering the NIAP. Patients aged 5-17 years with a triage pain score of ≥4 (Wong-Baker or numerical rating scale) were eligible for enrolment. The primary outcome was time to analgesia. Secondary outcomes were the proportion of patients who received 'adequate analgesia' and parental satisfaction with ED pain management (measured 48 h post-discharge). Fifty-one children were enrolled in both the pre- and post-intervention periods. Patient sex and mean age, weight and triage pain score did not differ between the groups (P > 0.05). At post-intervention, significantly more patients received nurse-initiated analgesia (3.0% vs 43.9%; P < 0.001) and the median time to analgesia was significantly reduced (58 min vs 23 min; P < 0.01). Also, significantly more patients received 'adequate analgesia' post-intervention (41.2% vs 72.5%; P < 0.001). At follow up, the proportion of parents who were very satisfied with their child's overall pain management trended upwards in the post-intervention period (47.1% vs 66.7%; P = 0.07). No adverse events were observed during either period. The NIAP significantly reduced time to analgesia. It was associated with high levels of parental satisfaction.