Author: Urgent Matters

In the latest volume of the Annals of Emergency Medicine, two articles discuss one of the most prominent complaints in any emergency department; pain. Pain is both difficult to evaluate and treat; numeric scoring of pain is frequently inaccurate, and the amount of medication required varies between individuals, leading to ineffective treatment and decreased patient satisfaction.

Dr. Chang et al.’s article Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query takes the discussion of pain management back to the basics.(1)  Although useful for research and utilized to meet standards set by The Joint Commission, numeric pain scoring has been found to be inaccurate and does not identify if a patient requires further analgesia. In this study, the practice of numeric scoring for pain reassessment was replaced with a simple question; “Do you want more pain medication?” Over four hours, a maximum of 4 doses of 1mg hydromorphone were given depending on patient response. 55% of study participants received only one dose of medication, and 97% of study participants were either very satisfied or satisfied with their pain treatment. While concerns for drug-seeking behavior are valid, only 3% of patients requested all four doses, and only 1% of the patients requested more than four doses of medication.

Drs. Green and Baruch dive deeper with a discussion of the history of pain scales as a way to meet Joint Commission mandates for pain screening. As most practitioners are aware, pain scales vary wildly between patients and are not predictive of a patient's analgesia requirements. In many cases, Green writes, it is more helpful to have a description of pain and inquire about analgesia needs, more so than to improve a surrogate number.

While Dr. Chang's study did not specifically identify causes of pain within the study population, it broaches important questions about how we are treating pain. With the current national epidemic of opioid abuse, physicians are in the unenviable position of both treating pain while preventing overuse. As discussed by Dr. Green, numeric pain scoring can lead to increased administration of analgesics, while many patients are willing to forgo opioid pain medications.  These articles show asking a simple question can help adequately control pain and increase satisfaction.

Sources:

-Chang A.K., Bijur P.E., Holden L., et al: Efficacy of an acute pain titration protocol driven by patient response to a simple query: Do you want more pain medication? Ann Emerg Med 2016; 67: pp. 565-572

-Green SM, Krauss BS, The Numeric Scoring of Pain: This Practice Rates a Zero Out of Ten. Ann Emerg Med 2016; 67(5):573-5. doi:10.1016/j.annemergmed.2015.06.002.

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Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital

During my undergraduate education, I worked nights and weekends as an ED tech and frequently I would walk into work with a full waiting room and grease board, eventually leading the ED to go on ‘Diversion’. At the time, my understanding of diversion was something that made the patients stop coming and the nurses start celebrating. To me, it seemed like a good idea; have EMS take patients to other hospitals to give us a chance to decrease our own patient load. Moving into medical school, it seemed to become a point of pride that the ED would rarely—if ever—go on diversion. Now, the culture is starting to shift with many states and regions moving to diversion bans to prevent hospitals from not accepting EMS patients. Massachusetts became the first state to enact a ban in 2009, and a new brief in Health Affairs discusses the most recent research and debate about hospital diversion.

Ambulance diversion was first cited in 1990, when it was viewed as an option to be used rarely, such as during a crisis or disaster when a large number of patients could potentially overwhelm an ER’s ability to function. As the new HA brief states, by the early 2000’s, 45% of EDs had gone on diversion within a year, with 70% of urban hospitals having diverted in the same time frame. EDs have utilized diversion because it works; in the short term, individual EDs are able to process the overflow of patients and return to normal function. The secondary effects, however, are bringing about regional and state bans on the practice. Once diversion is initiated, surrounding hospitals must bear the brunt of these displaced patients, potentially triggering additional diversion statuses, prolonging EMS transport times, and leading to delays in patient care. What was once considered a crisis response tool has become a frequently used means with dubious outcomes.

As a result of diversion bans, systems have seen no increase in length of stay for discharged patients, decreased length of stay for admitted patients, and faster ambulance turn-around times. As a prior ED tech, most surprising to me was that ED clinicians and administrators strongly support the diversion ban.  With diversion seemingly on the way out, other approaches to ED crowding are taking the spotlight. Recently, the Urgent Matters Podcast discussed the Advance Resource Medic (ARM) with Rick Lewis, EMT-P EMS chief for South Metro Fire Rescue. The ARM utilizes an advanced practice paramedic and nurse practitioner to provide on-scene care for non-life threatening calls, and was first piloted in 2013.

Looking toward the future, ED crowding will continue to be an issue as utilization of emergency departments increases, and new policies to increase patient flow and department decompression will be required to treat the higher number of patients.

Read the complete Health Policy Brief on ambulance diversion.

Sources:

 "Health Policy Brief: Ambulance Diversion," Health Affairs, June 2, 2016. http://www.healthaffairs.org.proxygw.wrlc.org/healthpolicybriefs/brief.php?brief_id=158

Kincaid, Cynthia. "Use the ARM." JEMS. N.p., 21 Feb. 2014. Web. 7 June 2016. http://www.jems.com/articles/2014/02/use-arm-2013.html

Urgent Matters Podcast. An Urgent Care Clinic on Wheels. Rec. 26 May 2016. N.d. MP3. https://itunes.apple.com/us/podcast/urgent-care-clinic-on-wheels/id92638...

Catherine W. Burt, Linda F. McCaig, and Roberto H. Valverde, "Analysis of Ambulance Transports and Diversions among US Emergency Departments,"Annals of Emergency Medicine 47, no. 4 (2006): 317-26.

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Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital