- Email: [email protected]
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Research Forum Abstracts assessed. Data included, demographics, medication and doses administered length of stay from administration of first treatment to discharge. Data were analyzed using Pearson chi square, Fisher exact, and independent group t-tests. Results: 249 visits to the ED were made in the 12-month study period that met study inclusion criteria. 153 were non-repeat visits and 96 visits were made by 36 different repeater patients. 87 (90.6%) of the repeater visits and 83 (54.2%) of the non-repeaters visits were given opioid (p ⬍ .001). 40 (41.6%) of the repeaters were given multiple doses of opioids compared with 24 (15.7%) of the non-repeaters (p⫽.02). 76 (79.2%) repeaters and 61 (39.9%) of the non-repeaters received opioids as their initial anti-migraine medication in the ED (p⫽.02). The average times from administration of first medication to discharge from the ED were 156 minutes and 122 minutes for repeaters and non-repeaters respectively (p⫽.063). The mean ED time of stay for patients given opioids was 142 minutes and 111 minutes for patients treated with non-opioids (p⫽.015). The average time from initial medication until discharge for patients given opioids initially was 140 minutes compared to 178 minutes for those with opioids used as a rescue medication (p⫽.0693). Patients administered multiple doses of opioids had a significantly longer ED stay (191 minutes) than those administered a single dose (125 minutes, p⫽.0027). Conclusion: Repeaters to the ED for migraines were significantly more likely to receive opioids as a treatment, receive multiple doses of opioids, and receive opioids as the initial pharmacological treatment than non-repeaters. Patients administered opioids, regardless of repeater status, have significantly longer ED stays.
192
Are Advancing Age, Race, or Gender Factors in Delays to Treatment of Pain in Elderly Patients with Undifferentiated Abdominal Pain?
Lee DC, Chu J, Bania TC, Rudolph GS, Perez E, Bahl A/North Shore University Hospital, Manhasset, NY; St. Luke’s-Roosevelt Hospital Centers, NY, NY
Study Objective: Prior studies have reported inadequate analgesia in vulnerable populations. These studies have suggested that age, gender, and ethnicity are associated with inadequate treatment of acute painful conditions. Our hypothesis is that elderly ED patients with acute undifferentiated abdominal pain who are female, non-Caucasian, or of advanced age have delays in the administration of pain medications (PM) as compared to their respective counterparts. Methods: We performed an IRB-approved pilot study using a retrospective chart review in a prospective manner of all elderly patients (age 65 or greater) presenting to the EDs at two separate hospitals (an inner-city academic and a suburban academic) between October 1, 2003 and December 31, 2003. Charts were identified via standardized search using defined EMSTAT software protocols. All elderly patients with a chief complaint of abdominal pain at traige were included. Data was collected by trained physician-investigators using a standardized collection tool. Data collected included demographic data, time of presentation, hospital course, and outcomes. Data analyzed was considered objective in nature and scores were not obtained. Patients who were discharged had a follow-up telephone call to obtain outcome data. Data was analyzed by chi-square using SPSSS statistical software. A p ⬍ 0.05 was considered significant. Results: 359 charts were identified: 7 were missing and 352 were reviewed. Mean age was 76.1 (95 % CI, 75.3-76.9). 221 were female (63%) and 131 were male (33%). 120 (33%) patients received PM in the ED. 109 patients less than 85 and 11 patients greater than 84 received PM. These age categories were not associated with delay to PM (p⫽0.49). 77 Caucasians and 43 non-Caucasians received PM. These race categories were not associated with delays to PM (p⫽0.07). 35 men and 85 women received PM. Gender was not associated with delays to PM (p⫽0.75). Conclusion: Contrary to prior studies, we did not find an association between advancing age, gender, or ethnicity with delays in administration of analgesic agents in elderly patients presenting with undifferentiated abdominal pain in the ED.
193
What Does a Pain Score of “X” Mean Anyway? Classification of NRS Pain Severity Scores for ED Patients Based Upon Interference with Function
Fosnocht D, Homel P, Todd K, Crandall C, Choiniere M, Ducharme J, Tanabe P/ University of Utah, Salt Lake City, UT; Beth Israel Medical Center, New York, NY; University of New Mexico, Albuquerque, NM; Universite de Montreal, Montreal, Province Of Quebec, Canada; Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada; Northwestern University, Chicago, IL
Study Objectives: Assessment of pain is mandated for all patients presenting to the emergency department (ED). The 11 point (0-10) numerical rating scale (NRS) is
S60 Annals of Emergency Medicine
the most commonly utilized pain measurement scale. The meaning of the numbers obtained with the NRS is commonly questioned. The study objective was to assign categories of mild, moderate, and severe pain to NRS values for ED patient reported average and worst pain based upon interference with function. Methods: Study design was an observational, multicenter, prospective, cohort study. The setting was 20 largely urban EDs from the United States and Canada(3). Participants were ED patients presenting with pain enrolled in the Pain and Emergency Medicine Initiative. At one week median follow-up patient worst and average pain were recorded using the NRS. Functional interference in the categories of activity, mood, walking, work, relationship, enjoyment, sleep, appetite and concentration were recorded using the Brief Pain Inventory (BPI). Common NRS cut points for mild, moderate and severe pain were assigned values of cp36 (mild pain 1-3, moderate 4-6 and severe 7-10), cp37 (mild 1-3, moderate 4-7 and severe 8-10), cp46 (mild 1-4, moderate 5-6 and severe 7-10), or cp47 (mild 1-4, moderate 5-7 and severe 8-10). Clinically important differences in pain severity are expected to have large differences in interference with function. Comparisons of the differences in interference with function between the 4 different boundaries for mild, moderate and severe pain were performed using MANOVA. Pillai, Wilks, and Hotellings f values were compared to determine which pain boundaries maximized the differences in interference with function. Results: There were 639 patients enrolled with 372 females and mean age 36 years. The highest f values for the Pillai, Wilks and Hotelling test on both average and worst pain were obtained for cp47, indicating that the optimal cut points for mild, moderate and severe pain categories in ED patients were mild pain 1-4, moderate pain 5-7 and severe pain 8-10. (Table 1.) Conclusion: ED patients can be placed in the clinically useful categories of mild (1-4), moderate (5-7) or severe (8-10) pain using commonly obtained NRS pain severity scores. ED patients with mild, moderate and severe pain show different levels of functional interference with activity, mood, walking, work, relationship, enjoyment, sleep, appetite and concentration at one week follow-up. Decreasing pain across the boundaries defined here for ED patients may provide clinically significant goals for pain relief. This provides one answer to the question What does a pain score of “X” mean anyway?
194
Pain Assessment and Management of Hip Fractures in the Emergency Department
Akhtar S, Demuth-Anderson L, Stoller M, Meyer M, Todd K/Beth Israel Medical Center, New York, NY
Study Objectives: Hip fractures are an important cause of morbidity and mortality among the elderly and patients with hip fractures experience significant pain. However, the elderly may receive inadequate pain assessment and analgesics. Researchers report that pain undertreatment may be associated with delirium. The purpose of this study was to describe pain assessment and management practices for ED patients with hip fractures. Methods: After IRB approval, a retrospective study was performed. ED records of consecutive patients aged 50 years or older with an initial evaluation in the ED and subsequent diagnoses of acute hip fracture were reviewed. Charts were abstracted using a standardized data collection form. Information regarding patient demographics, pain assessments, pain management, and final diagnoses were analyzed. Results: A total of 48 charts were reviewed. The median patient age was 83 (IQR 74 to 88.4 years) and 75% were female. Only 67% (32/48) of charts contained a pain assessment. Of these 32 patients, the median pain score was 7 (IQR 2.5-9, range 010). Twenty-five percent (8/32) had mild or no pain (0-3), 19% (6/32) had moderate pain (4-6) and 56% (18/32) had severe pain (7-10). Twenty-three percent of patients (11/48) received no analgesics. For the remaining 37 patients, opioids were
Volume , . : October
192
Are Advancing Age, Race, or Gender Factors in Delays to Treatment of Pain in Elderly Patients with Undifferentiated Abdominal Pain?
Lee DC, Chu J, Bania TC, Rudolph GS, Perez E, Bahl A/North Shore University Hospital, Manhasset, NY; St. Luke’s-Roosevelt Hospital Centers, NY, NY
Study Objective: Prior studies have reported inadequate analgesia in vulnerable populations. These studies have suggested that age, gender, and ethnicity are associated with inadequate treatment of acute painful conditions. Our hypothesis is that elderly ED patients with acute undifferentiated abdominal pain who are female, non-Caucasian, or of advanced age have delays in the administration of pain medications (PM) as compared to their respective counterparts. Methods: We performed an IRB-approved pilot study using a retrospective chart review in a prospective manner of all elderly patients (age 65 or greater) presenting to the EDs at two separate hospitals (an inner-city academic and a suburban academic) between October 1, 2003 and December 31, 2003. Charts were identified via standardized search using defined EMSTAT software protocols. All elderly patients with a chief complaint of abdominal pain at traige were included. Data was collected by trained physician-investigators using a standardized collection tool. Data collected included demographic data, time of presentation, hospital course, and outcomes. Data analyzed was considered objective in nature and scores were not obtained. Patients who were discharged had a follow-up telephone call to obtain outcome data. Data was analyzed by chi-square using SPSSS statistical software. A p ⬍ 0.05 was considered significant. Results: 359 charts were identified: 7 were missing and 352 were reviewed. Mean age was 76.1 (95 % CI, 75.3-76.9). 221 were female (63%) and 131 were male (33%). 120 (33%) patients received PM in the ED. 109 patients less than 85 and 11 patients greater than 84 received PM. These age categories were not associated with delay to PM (p⫽0.49). 77 Caucasians and 43 non-Caucasians received PM. These race categories were not associated with delays to PM (p⫽0.07). 35 men and 85 women received PM. Gender was not associated with delays to PM (p⫽0.75). Conclusion: Contrary to prior studies, we did not find an association between advancing age, gender, or ethnicity with delays in administration of analgesic agents in elderly patients presenting with undifferentiated abdominal pain in the ED.
193
What Does a Pain Score of “X” Mean Anyway? Classification of NRS Pain Severity Scores for ED Patients Based Upon Interference with Function
Fosnocht D, Homel P, Todd K, Crandall C, Choiniere M, Ducharme J, Tanabe P/ University of Utah, Salt Lake City, UT; Beth Israel Medical Center, New York, NY; University of New Mexico, Albuquerque, NM; Universite de Montreal, Montreal, Province Of Quebec, Canada; Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada; Northwestern University, Chicago, IL
Study Objectives: Assessment of pain is mandated for all patients presenting to the emergency department (ED). The 11 point (0-10) numerical rating scale (NRS) is
S60 Annals of Emergency Medicine
the most commonly utilized pain measurement scale. The meaning of the numbers obtained with the NRS is commonly questioned. The study objective was to assign categories of mild, moderate, and severe pain to NRS values for ED patient reported average and worst pain based upon interference with function. Methods: Study design was an observational, multicenter, prospective, cohort study. The setting was 20 largely urban EDs from the United States and Canada(3). Participants were ED patients presenting with pain enrolled in the Pain and Emergency Medicine Initiative. At one week median follow-up patient worst and average pain were recorded using the NRS. Functional interference in the categories of activity, mood, walking, work, relationship, enjoyment, sleep, appetite and concentration were recorded using the Brief Pain Inventory (BPI). Common NRS cut points for mild, moderate and severe pain were assigned values of cp36 (mild pain 1-3, moderate 4-6 and severe 7-10), cp37 (mild 1-3, moderate 4-7 and severe 8-10), cp46 (mild 1-4, moderate 5-6 and severe 7-10), or cp47 (mild 1-4, moderate 5-7 and severe 8-10). Clinically important differences in pain severity are expected to have large differences in interference with function. Comparisons of the differences in interference with function between the 4 different boundaries for mild, moderate and severe pain were performed using MANOVA. Pillai, Wilks, and Hotellings f values were compared to determine which pain boundaries maximized the differences in interference with function. Results: There were 639 patients enrolled with 372 females and mean age 36 years. The highest f values for the Pillai, Wilks and Hotelling test on both average and worst pain were obtained for cp47, indicating that the optimal cut points for mild, moderate and severe pain categories in ED patients were mild pain 1-4, moderate pain 5-7 and severe pain 8-10. (Table 1.) Conclusion: ED patients can be placed in the clinically useful categories of mild (1-4), moderate (5-7) or severe (8-10) pain using commonly obtained NRS pain severity scores. ED patients with mild, moderate and severe pain show different levels of functional interference with activity, mood, walking, work, relationship, enjoyment, sleep, appetite and concentration at one week follow-up. Decreasing pain across the boundaries defined here for ED patients may provide clinically significant goals for pain relief. This provides one answer to the question What does a pain score of “X” mean anyway?
194
Pain Assessment and Management of Hip Fractures in the Emergency Department
Akhtar S, Demuth-Anderson L, Stoller M, Meyer M, Todd K/Beth Israel Medical Center, New York, NY
Study Objectives: Hip fractures are an important cause of morbidity and mortality among the elderly and patients with hip fractures experience significant pain. However, the elderly may receive inadequate pain assessment and analgesics. Researchers report that pain undertreatment may be associated with delirium. The purpose of this study was to describe pain assessment and management practices for ED patients with hip fractures. Methods: After IRB approval, a retrospective study was performed. ED records of consecutive patients aged 50 years or older with an initial evaluation in the ED and subsequent diagnoses of acute hip fracture were reviewed. Charts were abstracted using a standardized data collection form. Information regarding patient demographics, pain assessments, pain management, and final diagnoses were analyzed. Results: A total of 48 charts were reviewed. The median patient age was 83 (IQR 74 to 88.4 years) and 75% were female. Only 67% (32/48) of charts contained a pain assessment. Of these 32 patients, the median pain score was 7 (IQR 2.5-9, range 010). Twenty-five percent (8/32) had mild or no pain (0-3), 19% (6/32) had moderate pain (4-6) and 56% (18/32) had severe pain (7-10). Twenty-three percent of patients (11/48) received no analgesics. For the remaining 37 patients, opioids were
Volume , . : October