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252 Predictors of Responders to Analgesia in the Treatment of Acute Gout
Research Forum Abstracts
251
The Anesthetic Effect of Modified Subcutaneous Single-Injection Digital Block
Jeon W, Lee Y, Lee J, Lee SH/Inje University Ilsan Paik Hospital, Goyang, Korea, Republic of; Inje University Ilsan Paik Hospital, Goyang-si, Korea, Republic of
Study Objective: The aim of this study is to investigate anesthetic effect on modified subcutaneous single-injection digital block according to the location of finger. Methods: We recruited the volunteer in the workshop training course of interns. We injected less than 5mL of 2% lidocaine at volar side between 3rd metacarpal and proximal phalangeal joint until dorsal side of finger swelling goes up. At 10 minutes after modified subcutaneous single-injection digital block, we recorded pain score (0-10) using 11-point numeric rating pain scale (NRPS) according to the location of finger (volar proximal phalanx; VPP, volar middle phalanx; VMP, volar distal phalanx; VDP, dorsal distal phalanx; DDP, dorsal middle phalanx; DMP, dorsal proximal phalanx; DPP) by pinprick test. We analyzed and compared NRPS on the location of finger by Friedman test with Pairwise comparison. Results: Fifty eight healthy adult volunteers were enrolled into this study. The pain scale on DPP and DMP were 7.00 (4.00-8.00) and 2.00 (1.00-4.00). The pain scale on DDP, VDP, VMP and VDP were 0.00 (0.00-2.00), 0.00 (0.00-0.00), 0.00 (0.001.00) and 0.00 (0.00-1.00), respectively. The pain scale on DPP and DMP were significant differences among DDP, VPP, VMP and VPP (p<0.05). There were no significant differences of pain scale on DDP, VDP, VMP and VPP (DDP vs VDP; p¼0.592, DDP vs VMP; p¼0.749, DDP vs VPP; p >0.999, VDP vs VMP; p>0.999, VMP vs VPP; >0.999). Conclusion: Modified subcutaneous single-injection digital block may considered useful regional anesthesia at volar side of finger and dorsal side of distal phalanx.
252
Predictors of Responders to Analgesia in the Treatment of Acute Gout
Graham CA, Cheng CH, Yuen KY, Janssens HJEM, Man CY, Tam LS, Choi YF, Yau WH, Lee KH, Rainer TH/The Chinese University of Hong Kong, Hong Kong, SAR, Hong Kong; Radbound University Medical Cnetre, Nijmegen, Netherlands; Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong; Queen Elizabeth Hospital, Hong Kong, Hong Kong; United Christian Hospital, Hong Kong, Hong Kong
Study Objective: In a secondary analysis of a previous randomized controlled study comparing oral prednisolone with oral indomethacin in patients presenting to emergency departments (ED) with acute gout, we aimed to identify predictors of response to analgesia. Methods: From 1st January to 31st November 2012, a multi-center, double-blind, randomized equivalence trial of gout patients was conducted in four EDs in Hong Kong. Analgesic effectiveness was defined as changes in pain with activity> 13mm on a visual analogue scale of 100mm. Responders were defined as patients with a >13 mm change during the 2-hour ED phase of the study. 41 potential predictors were evaluated. Equivalent and clinically significant within-group reductions in mean pain score with activity (approximately 60 mm) were observed equally with indomethacin and prednisolone. Results: Of 372 patients who completed the study per protocol, 236 (63%) were classed as responders. Factors predicting response compared with no response to analgesia respectively were: older age [67.0SD14.4 v 61.616.1 years, p¼0.001], pretreatment pain score [83.40 19.28 v 78.54 22.42, 0.028], and no family history of gout [20/236 v 25/136, p¼0.005]. Conclusion: Older age, increased pain and absence of family history predict response to analgesia in the ED.
253
pain scale ratings may not improve patient satisfaction scores. In 2014, regional emergency department (ED) leadership in a community health system in Southeastern Minnesota identified two key metrics as opportunities for improvement: 1. The lumped satisfaction score, “patient satisfaction with pain control,” as collected from third-party (Avatar, Inc.) patient surveys of patients presenting to the ED; and 2. The quality measure, “time to pain management for long bone fracture,” collected for Centers for Medicare and Medicaid Services’ OP-21 quality measure. Our aim was to improve our overall pain management by developing and implementing simultaneous strategies to improve time to analgesia for long bone fractures, and improve patient satisfaction scores for overall pain management. Methods: Context: Our workgroup included emergency physicians, nurse managers, a quality specialist, and a patient experience expert. The setting was three mid-sized community EDs in southeast (rural) Minnesota. Measures: Commercial vendor (Avatar, Inc) satisfaction data and CMS OP-21 data studied for the prior 12 months (pre-intervention) were used for baseline. Current State Analysis: We held kaizen-type events to understand why our measures and metrics were performing worse than expected. We determined that staff were poorly informed on current measures, preventing them from understanding the importance of timely pain management. In addition, we recognized that patients were poorly informed on expectations for pain management. Proposed Intervention: We created a two-phase plan to address our gaps. First, intra-departmental education to address long-bone and overall pain management was delivered during the summer of 2014. Second, a patient education pamphlet was created through a collaborative process and deployed in the fall of 2014. Data were to be followed for 12 months, but collection had to stop after 11 months when our hospital system changed satisfaction vendor. Results: Overall patient satisfaction with regard to pain management showed significant improvement (p < 0.05) after our intervention. None of the specific patient satisfaction survey questions, nor time-to-analgesia for long bone fractures, showed show statistical significance, but each measure showed a trend towards improvement (Figure 1). Conclusion: An educational effort, focused on both staff and patients, improved overall perception of pain management on patient satisfaction scores. The same may improve time to analgesia in long bone fractures as well, but larger study is needed. Limitations include small numbers of survey respondents and patients included in OP21 data.
A Multifaceted Approach to Improved Timeliness of Analgesia for Long Bone Fractures and Patient Satisfaction With Pain Management
Walker LE, Carlson K, Placzek E, Niles D, Shaft J, Wolter K, Crabtree R, Gisslen J, Nestler DM/Mayo Clinic, Rochester, MN; Mayo Clinic Health System, Owatonna, MN; Mayo Clinic Health Systems, Albert Lea, MN; Mayo Clinic Health System, Cannon Falls, MN; Mayo Clinic Health System, Albert Lea, MN; Mayo Clinic Health System, Austin, MN; Mayo Clinic Health System, Red Wing, MN
Study Objective: Prior studies have reported inadequate pain control for long bone fractures. Analgesic protocols may result in improved pain scale ratings, but improved
S98 Annals of Emergency Medicine
Volume 68, no. 4s : October 2016
251
The Anesthetic Effect of Modified Subcutaneous Single-Injection Digital Block
Jeon W, Lee Y, Lee J, Lee SH/Inje University Ilsan Paik Hospital, Goyang, Korea, Republic of; Inje University Ilsan Paik Hospital, Goyang-si, Korea, Republic of
Study Objective: The aim of this study is to investigate anesthetic effect on modified subcutaneous single-injection digital block according to the location of finger. Methods: We recruited the volunteer in the workshop training course of interns. We injected less than 5mL of 2% lidocaine at volar side between 3rd metacarpal and proximal phalangeal joint until dorsal side of finger swelling goes up. At 10 minutes after modified subcutaneous single-injection digital block, we recorded pain score (0-10) using 11-point numeric rating pain scale (NRPS) according to the location of finger (volar proximal phalanx; VPP, volar middle phalanx; VMP, volar distal phalanx; VDP, dorsal distal phalanx; DDP, dorsal middle phalanx; DMP, dorsal proximal phalanx; DPP) by pinprick test. We analyzed and compared NRPS on the location of finger by Friedman test with Pairwise comparison. Results: Fifty eight healthy adult volunteers were enrolled into this study. The pain scale on DPP and DMP were 7.00 (4.00-8.00) and 2.00 (1.00-4.00). The pain scale on DDP, VDP, VMP and VDP were 0.00 (0.00-2.00), 0.00 (0.00-0.00), 0.00 (0.001.00) and 0.00 (0.00-1.00), respectively. The pain scale on DPP and DMP were significant differences among DDP, VPP, VMP and VPP (p<0.05). There were no significant differences of pain scale on DDP, VDP, VMP and VPP (DDP vs VDP; p¼0.592, DDP vs VMP; p¼0.749, DDP vs VPP; p >0.999, VDP vs VMP; p>0.999, VMP vs VPP; >0.999). Conclusion: Modified subcutaneous single-injection digital block may considered useful regional anesthesia at volar side of finger and dorsal side of distal phalanx.
252
Predictors of Responders to Analgesia in the Treatment of Acute Gout
Graham CA, Cheng CH, Yuen KY, Janssens HJEM, Man CY, Tam LS, Choi YF, Yau WH, Lee KH, Rainer TH/The Chinese University of Hong Kong, Hong Kong, SAR, Hong Kong; Radbound University Medical Cnetre, Nijmegen, Netherlands; Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong; Queen Elizabeth Hospital, Hong Kong, Hong Kong; United Christian Hospital, Hong Kong, Hong Kong
Study Objective: In a secondary analysis of a previous randomized controlled study comparing oral prednisolone with oral indomethacin in patients presenting to emergency departments (ED) with acute gout, we aimed to identify predictors of response to analgesia. Methods: From 1st January to 31st November 2012, a multi-center, double-blind, randomized equivalence trial of gout patients was conducted in four EDs in Hong Kong. Analgesic effectiveness was defined as changes in pain with activity> 13mm on a visual analogue scale of 100mm. Responders were defined as patients with a >13 mm change during the 2-hour ED phase of the study. 41 potential predictors were evaluated. Equivalent and clinically significant within-group reductions in mean pain score with activity (approximately 60 mm) were observed equally with indomethacin and prednisolone. Results: Of 372 patients who completed the study per protocol, 236 (63%) were classed as responders. Factors predicting response compared with no response to analgesia respectively were: older age [67.0SD14.4 v 61.616.1 years, p¼0.001], pretreatment pain score [83.40 19.28 v 78.54 22.42, 0.028], and no family history of gout [20/236 v 25/136, p¼0.005]. Conclusion: Older age, increased pain and absence of family history predict response to analgesia in the ED.
253
pain scale ratings may not improve patient satisfaction scores. In 2014, regional emergency department (ED) leadership in a community health system in Southeastern Minnesota identified two key metrics as opportunities for improvement: 1. The lumped satisfaction score, “patient satisfaction with pain control,” as collected from third-party (Avatar, Inc.) patient surveys of patients presenting to the ED; and 2. The quality measure, “time to pain management for long bone fracture,” collected for Centers for Medicare and Medicaid Services’ OP-21 quality measure. Our aim was to improve our overall pain management by developing and implementing simultaneous strategies to improve time to analgesia for long bone fractures, and improve patient satisfaction scores for overall pain management. Methods: Context: Our workgroup included emergency physicians, nurse managers, a quality specialist, and a patient experience expert. The setting was three mid-sized community EDs in southeast (rural) Minnesota. Measures: Commercial vendor (Avatar, Inc) satisfaction data and CMS OP-21 data studied for the prior 12 months (pre-intervention) were used for baseline. Current State Analysis: We held kaizen-type events to understand why our measures and metrics were performing worse than expected. We determined that staff were poorly informed on current measures, preventing them from understanding the importance of timely pain management. In addition, we recognized that patients were poorly informed on expectations for pain management. Proposed Intervention: We created a two-phase plan to address our gaps. First, intra-departmental education to address long-bone and overall pain management was delivered during the summer of 2014. Second, a patient education pamphlet was created through a collaborative process and deployed in the fall of 2014. Data were to be followed for 12 months, but collection had to stop after 11 months when our hospital system changed satisfaction vendor. Results: Overall patient satisfaction with regard to pain management showed significant improvement (p < 0.05) after our intervention. None of the specific patient satisfaction survey questions, nor time-to-analgesia for long bone fractures, showed show statistical significance, but each measure showed a trend towards improvement (Figure 1). Conclusion: An educational effort, focused on both staff and patients, improved overall perception of pain management on patient satisfaction scores. The same may improve time to analgesia in long bone fractures as well, but larger study is needed. Limitations include small numbers of survey respondents and patients included in OP21 data.
A Multifaceted Approach to Improved Timeliness of Analgesia for Long Bone Fractures and Patient Satisfaction With Pain Management
Walker LE, Carlson K, Placzek E, Niles D, Shaft J, Wolter K, Crabtree R, Gisslen J, Nestler DM/Mayo Clinic, Rochester, MN; Mayo Clinic Health System, Owatonna, MN; Mayo Clinic Health Systems, Albert Lea, MN; Mayo Clinic Health System, Cannon Falls, MN; Mayo Clinic Health System, Albert Lea, MN; Mayo Clinic Health System, Austin, MN; Mayo Clinic Health System, Red Wing, MN
Study Objective: Prior studies have reported inadequate pain control for long bone fractures. Analgesic protocols may result in improved pain scale ratings, but improved
S98 Annals of Emergency Medicine
Volume 68, no. 4s : October 2016