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407
Research Forum Abstracts
406
End-of-Life Symptom and Pain Management in the Emergency Department
Bradshaw JM, Wilber ST, Stiffler KA/Summa Health System, Akron, OH; Summa Health System/NEOUCOM, Akron, OH
Background: Physicians, it has been reported, are not effective in treating pain and other symptoms at the end-of-life. Little research exists on end of life care although several authors have discussed the importance of adequate and appropriate palliative care in emergency medicine. Study Objectives: Our objectives were to determine the proportion of dying patients who received medical and palliative care interventions in the emergency department (ED), and to examine potential predictors of receiving palliative interventions. Methods: We performed a retrospective cohort study of patients seen in our adult ED during 2004 who died within 48 hours of arrival. We excluded those who did not survive for 1 hour following ED arrival, and those who were managed with all available medical resources and had no discussion of limitations on the aggressiveness of medical care documented in the medical record. Data abstracted from charts of eligible patients included: demographics, advanced directives (those present on arrival and discussed in the ED), and ED treatment. Medical interventions were defined as the administration of medications and/or other medical treatments or procedures intended to cure disease. Palliative interventions were defined as the administration of medication and/ or other medical treatments intended to relieve pain, suffering, dyspnea, or other severe symptoms. Data were analyzed using Stata software. Descriptive data is reported as proportions with 95% confidence intervals (CI), comparisons were analyzed using 95% CIs for the difference between 2 proportions, exclusion of zero is significant. Results: 57 patients met the inclusion criteria, the mean age was 78.9 ⫹/⫺ 12.7 SD years, 56% were female, 81% Caucasian and 19% African-American. 53% (30/ 57, 95% CI 39-66%) arrived in the ED with an AD and 60% (34/57, 95% CI 4672%) had AD’s created or modified in the ED. All patients either arrived with an AD or had one created in the ED; overall, 61% of patients were comfort care only (CCO) (35/57, 95% CI 48-74%). Medical interventions were performed on 77% of patients and palliative interventions on 47%, a 30% difference (95% CI 13-47%). CCO patients were more likely to receive palliative interventions (60% vs. 27%, 33% difference, 95% CI 8 to 57%). Caucasians were more likely than African-Americans to receive palliative interventions (52% vs. 27%, 25% difference, 95% CI ⫺5.1 to 55%), though this did not reach statistical significance. Causes of death included respiratory failure (n⫽18), cardiac (n⫽11), cancer (n⫽8), sepsis (n⫽6), intracranial bleed (n⫽5), and other (n⫽9). Conclusion: ED discussion and documentation of ADs was excellent. However, medical interventions still greatly exceeded palliative interventions. Those with CCO orders were more likely to receive palliative interventions, suggesting lack of comfort with palliative interventions in non-CCO patients. Racial differences in palliative interventions is concerning and needs further exploration.
407
Results: Of the 92 patients enrolled in the study 47 (51.1%) were randomized to the study group and received the anesthetic spray and 45 (48.9%) were randomized to the control group and had their IV placed in a standard method. Sixty-six patients were female (71.8%) and 26 (28.2%) were males. The mean pain score in the study group was 27mm (CI95 19.9 to 34.1) and 28mm (CI95 20.4 to 35.6) in the control group (p ⫽ 0.934). Subgroup analysis of female and male patients did not show significance. Conclusions: Our study failed to detect a difference in pain perception resulting from the pre-procedural application of a skin coolant associated with IV placement in the emergency department setting.
408
Family Presence During Pediatric Procedures: An Emergency Medicine Residents’ Perspective
Barata IA, LaMantia J, Riccardi D, Livote E, Litroff A, D’Abbracci P, Ward M, Sama A/North Shore University Hospital, Manhasset, NY
Study Objective: Describe emergency medicine (EM) residents’ comfort and acceptance of family presence (FP) during pediatric invasive procedures and resuscitation. Methods: A prospective cross-sectional/anonymous survey of EM residents in ACGME-accredited residency programs. The survey consisted of case scenarios with Likert-scale questions of residents’ belief FP would interfere with performance of procedures and resuscitation, and their acceptance of FP. Results: Responses received from 63 (47%) programs. 521 surveys completed: 193 EM-1, 170 EM-2, 127 EM-3, and 16 EM-4; 129 residents completed an internship year other than EM; 169 evaluated pediatric patients in the setting of children’s hospital ED. With increasing EM seniority there was a slight decreasing trend to believe FP is an interfering factor during invasive procedures and resuscitation and an increasing trend towards allowing FF during procedures (Figures 1 and 2). This decreasing trend regarding FP as less of an interfering factor was
Pain Management During Intravenous Catheter Placement Using a Topical Skin Coolant in the Emergency Department
Hartstein BH, Barry JD/Brooke Army Medical Center, San Antonio, TX
Study Objectives: Although intravenous (IV) line placement, a common procedure in the emergency department (ED), is an uncomfortable experience for many patients, topical analgesic agents are rarely used because they have long onset of action and thereby cause unacceptable treatment delays. Cryoanesthesia, the use of cooling agents to reduce pain, has been recognized for many years as a potential pain management strategy. The purpose of this study is to determine whether an instantaneous topical skin coolant spray (Pain Ease®) reduces patient’s pain during IV cannulation and represents a feasable alternative for cutaneous analgesia in the ED setting. Methods: We conducted an unblinded, randomized, controlled study, in a convenience sample of ED patients. Utilizing a random number generator to assign patients to the control or study group, patients over the age of 18 years who required IV cannulation as part of their evaluation were enrolled at two military tertiary care hospitals. In both groups, IVs were placed in accordance with accepted clinical standards of practice, with the single addition of the coolant spray delivered to the IV site before needle insertion in the study group. All study participants answered questionnaires before and after IV placement and rated pain during procedure on a 100mm visual analogue scale.
S122 Annals of Emergency Medicine
Volume , . : October
406
End-of-Life Symptom and Pain Management in the Emergency Department
Bradshaw JM, Wilber ST, Stiffler KA/Summa Health System, Akron, OH; Summa Health System/NEOUCOM, Akron, OH
Background: Physicians, it has been reported, are not effective in treating pain and other symptoms at the end-of-life. Little research exists on end of life care although several authors have discussed the importance of adequate and appropriate palliative care in emergency medicine. Study Objectives: Our objectives were to determine the proportion of dying patients who received medical and palliative care interventions in the emergency department (ED), and to examine potential predictors of receiving palliative interventions. Methods: We performed a retrospective cohort study of patients seen in our adult ED during 2004 who died within 48 hours of arrival. We excluded those who did not survive for 1 hour following ED arrival, and those who were managed with all available medical resources and had no discussion of limitations on the aggressiveness of medical care documented in the medical record. Data abstracted from charts of eligible patients included: demographics, advanced directives (those present on arrival and discussed in the ED), and ED treatment. Medical interventions were defined as the administration of medications and/or other medical treatments or procedures intended to cure disease. Palliative interventions were defined as the administration of medication and/ or other medical treatments intended to relieve pain, suffering, dyspnea, or other severe symptoms. Data were analyzed using Stata software. Descriptive data is reported as proportions with 95% confidence intervals (CI), comparisons were analyzed using 95% CIs for the difference between 2 proportions, exclusion of zero is significant. Results: 57 patients met the inclusion criteria, the mean age was 78.9 ⫹/⫺ 12.7 SD years, 56% were female, 81% Caucasian and 19% African-American. 53% (30/ 57, 95% CI 39-66%) arrived in the ED with an AD and 60% (34/57, 95% CI 4672%) had AD’s created or modified in the ED. All patients either arrived with an AD or had one created in the ED; overall, 61% of patients were comfort care only (CCO) (35/57, 95% CI 48-74%). Medical interventions were performed on 77% of patients and palliative interventions on 47%, a 30% difference (95% CI 13-47%). CCO patients were more likely to receive palliative interventions (60% vs. 27%, 33% difference, 95% CI 8 to 57%). Caucasians were more likely than African-Americans to receive palliative interventions (52% vs. 27%, 25% difference, 95% CI ⫺5.1 to 55%), though this did not reach statistical significance. Causes of death included respiratory failure (n⫽18), cardiac (n⫽11), cancer (n⫽8), sepsis (n⫽6), intracranial bleed (n⫽5), and other (n⫽9). Conclusion: ED discussion and documentation of ADs was excellent. However, medical interventions still greatly exceeded palliative interventions. Those with CCO orders were more likely to receive palliative interventions, suggesting lack of comfort with palliative interventions in non-CCO patients. Racial differences in palliative interventions is concerning and needs further exploration.
407
Results: Of the 92 patients enrolled in the study 47 (51.1%) were randomized to the study group and received the anesthetic spray and 45 (48.9%) were randomized to the control group and had their IV placed in a standard method. Sixty-six patients were female (71.8%) and 26 (28.2%) were males. The mean pain score in the study group was 27mm (CI95 19.9 to 34.1) and 28mm (CI95 20.4 to 35.6) in the control group (p ⫽ 0.934). Subgroup analysis of female and male patients did not show significance. Conclusions: Our study failed to detect a difference in pain perception resulting from the pre-procedural application of a skin coolant associated with IV placement in the emergency department setting.
408
Family Presence During Pediatric Procedures: An Emergency Medicine Residents’ Perspective
Barata IA, LaMantia J, Riccardi D, Livote E, Litroff A, D’Abbracci P, Ward M, Sama A/North Shore University Hospital, Manhasset, NY
Study Objective: Describe emergency medicine (EM) residents’ comfort and acceptance of family presence (FP) during pediatric invasive procedures and resuscitation. Methods: A prospective cross-sectional/anonymous survey of EM residents in ACGME-accredited residency programs. The survey consisted of case scenarios with Likert-scale questions of residents’ belief FP would interfere with performance of procedures and resuscitation, and their acceptance of FP. Results: Responses received from 63 (47%) programs. 521 surveys completed: 193 EM-1, 170 EM-2, 127 EM-3, and 16 EM-4; 129 residents completed an internship year other than EM; 169 evaluated pediatric patients in the setting of children’s hospital ED. With increasing EM seniority there was a slight decreasing trend to believe FP is an interfering factor during invasive procedures and resuscitation and an increasing trend towards allowing FF during procedures (Figures 1 and 2). This decreasing trend regarding FP as less of an interfering factor was
Pain Management During Intravenous Catheter Placement Using a Topical Skin Coolant in the Emergency Department
Hartstein BH, Barry JD/Brooke Army Medical Center, San Antonio, TX
Study Objectives: Although intravenous (IV) line placement, a common procedure in the emergency department (ED), is an uncomfortable experience for many patients, topical analgesic agents are rarely used because they have long onset of action and thereby cause unacceptable treatment delays. Cryoanesthesia, the use of cooling agents to reduce pain, has been recognized for many years as a potential pain management strategy. The purpose of this study is to determine whether an instantaneous topical skin coolant spray (Pain Ease®) reduces patient’s pain during IV cannulation and represents a feasable alternative for cutaneous analgesia in the ED setting. Methods: We conducted an unblinded, randomized, controlled study, in a convenience sample of ED patients. Utilizing a random number generator to assign patients to the control or study group, patients over the age of 18 years who required IV cannulation as part of their evaluation were enrolled at two military tertiary care hospitals. In both groups, IVs were placed in accordance with accepted clinical standards of practice, with the single addition of the coolant spray delivered to the IV site before needle insertion in the study group. All study participants answered questionnaires before and after IV placement and rated pain during procedure on a 100mm visual analogue scale.
S122 Annals of Emergency Medicine
Volume , . : October