A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures

Siddiqui, Ammar Ahmed; Belland, Laura; Rivera-Reyes, Laura; Handel, Daniel A.; Yadav, Kabir; Heard, Kennon; Eisenberg, Amanda; Khelemsky, Yury; Hwang, Ula

doi:10.1093/pm/pnw072

Cited by 3 publications

(3 citation statements)

References 23 publications

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“…Although emergency physicians are generally less likely to prescribe opioids than most other physicians, 5 this potentially represents an opportunity to further reduce EM opioid prescribing. The reported rate of opioid prescribing among our respondents was higher than that reported in previous studies evaluating emergency physicians' use of opioids in patients with long bone fractures (51%-65%), [10][11][12][13] although those studies included undifferentiated long bone fractures (eg, radius, humerus, tibia, femur, clavicle) in both admitted and discharged patients, and-with one exception 13 -did not distinguish between analgesia in the ED and prescriptions for analgesics at the time of discharge.…”

Section: Discussioncontrasting

confidence: 80%

Uncomplicated Distal Radius Fractures: An Opportunity to Reduce Emergency Medicine Opioid Prescribing?

Altman¹,

Wyatt²,

Brown³

2021

Southern Medical Journal

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Objectives: To assess emergency physician prescribing for simple extremity fractures-specifically, distal radius fractures-and describe the opportunity for reducing opioid prescribing.Methods: An electronic survey was distributed to 1238 emergency physicians employed by a nationwide practice serving 220 sites in 20 states. The survey presented two plain film views of a simple Colles fracture and asked: "For the last patient you discharged . . . with the above injury, which pain medications did you prescribe or recommend?" Responses were collected using a clickable checklist of common opioid and nonopioid pain medications. Respondents also specified the number of days covered by any prescription. We assessed associations between physician characteristics and opioid prescribing using the χ 2 test, the Wilcoxon ranksum test, and multivariable regression models.Results: Responses were received from 447 (36%) physicians working in 18 states; 93% were trained in emergency medicine, 33% worked at academic sites, 68% had site volumes between 25,000 and 75,000, and the median experience was 10 (interquartile range 5-19) years. Overall, 92% (95% confidence interval 89%-95%) had prescribed an opioid for a median of 3 (interquartile range 3-4) days. The most commonly prescribed opioids were hydrocodone/acetaminophen (55%) and oxycodone/ acetaminophen (20%). Physicians at academic sites prescribed opioids less frequently than those at nonacademic sites (88% vs 94%), but in multivariable regression there were no significant associations between physician characteristics and opioid prescribing.Conclusions: Emergency physicians commonly prescribe opioids for simple distal radius fractures. This represents a potential opportunity to reduce opioid prescribing.

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Section: Discussioncontrasting

confidence: 80%

Uncomplicated Distal Radius Fractures: An Opportunity to Reduce Emergency Medicine Opioid Prescribing?

Altman¹,

Wyatt²,

Brown³

2021

Southern Medical Journal

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“…In addition, patients in the intervention group were twice as likely to be prescribed pain medication compared to patients in the non-intervention group. These results are readily understandable in comparison with the results of a recent multicenter study on pain management according to the type of fracture, which suggested that analgesics are prescribed at a higher rate because long-bone fractures are more common in elderly patients [ 9 ].…”

Section: Discussionmentioning

confidence: 67%

Quality improvement activity for improving pain management in acute extremity injuries in the emergency department

et al. 2018

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ObjectiveThe aim of this study was to investigate the effectiveness of a quality improvement activity for pain management in patients with extremity injury in the emergency department (ED).MethodsThis was a retrospective interventional study. The patient group consisted of those at least 19 years of age who visited the ED and were diagnosed with International Classification of Diseases codes S40–S99 (extremity injuries). The quality improvement activity consisted of three measures: a survey regarding activities, education, and the triage nurse’s pain assessment, including change of pain documentation on electronic medical records. The intervention was conducted from January to April in 2014 and outcome was compared between May and August in 2013 and 2014. The primary outcome was the rate of analgesic prescription, and the secondary outcome was the time to analgesic prescription.ResultsA total of 1,739 patients were included, and 20.3% of 867 patients in the pre-intervention period, and 28.8% of 872 patients in the post-intervention period received analgesics (P< 0.001). The prescription rate of analgesics for moderate-to-severe injuries was 36.4% in 2013 and 44.5% in 2014 (P=0.026). The time to analgesics prescription was 116.6 minutes (standard deviation 225.6) in 2013 and 64 minutes (standard deviation 75.5) in 2014 for all extremity injuries. The pain scoring increased from 1.4% to 51.6%.ConclusionED-based quality improvement activities including education and change of pain score documentation can improve the rate of analgesic prescription and time to prescription for patients with extremity injury in the ED.

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“…18 The most frequently reported indication for ketamine was pain relief, especially to decrease the pain of fracture manipulation, which is not surprising because long-bone fractures induce severe pain. 19 The most frequent reason for use of ketamine instead of or with fentanyl is that ketamine provides deeper analgesia. This response is consistent with a retrospective study conducted in the same HEMS that found a positive correlation between the severity of pain and ketamine administration.…”

Section: Methods Of Usementioning

confidence: 99%

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service

Vanolli

Eidenbenz

Suter

et al. 2020

Wilderness & Environmental Medicine

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IntroductiondAlthough ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. MethodsdThe survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. ResultsdKetamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg$kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1e2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. ConclusionsdKetamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.

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A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures

Cited by 3 publications

References 23 publications

Uncomplicated Distal Radius Fractures: An Opportunity to Reduce Emergency Medicine Opioid Prescribing?

Uncomplicated Distal Radius Fractures: An Opportunity to Reduce Emergency Medicine Opioid Prescribing?

Quality improvement activity for improving pain management in acute extremity injuries in the emergency department

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service

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