Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic Management
Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic Management
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DOI：
10.1111/j.1553-2712.2010.00693.x
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发表时间：
2010-04-01
影响因子：
4.4
通讯作者：
Hafner, John W.
中科院分区：
文献类型：
--
作者：
Tanabe, Paula;Artz, Nicole;Hafner, John W.
目的：的目的是报告的基线（前质量改进干预措施）患者和访问的特点和镇痛药管理的做法，每个网站参加急诊科（艾德）镰状细胞learning collaborative.Methods：一个前瞻性的，多站点的纵向队列研究的背景下，学习合作模式进行了在中西部三个ED。每个研究中心组成一个多学科团队，负责改善镰状细胞病（SCD）患者的镇痛管理。每个小组都为SCD患者制定了护士启动的镇痛方案（在一个研究中心进行了3.5个月的基线数据收集期后实施，在其他两个研究中心进行了10个月的基线数据收集期后实施）。所有临床试验机构前瞻性入组患有急性疼痛危象和SCD的成人。审查了符合研究标准的患者的所有病历。提取人口统计学、卫生服务和镇痛剂管理数据，包括艾德访视频率数据、艾德分布、到达和出院疼痛评分以及初始镇痛剂给药的名称和途径。每个研究中心每季度对艾德出院后14天内的患者进行10次访谈，询问受试者出院时可接受的最高疼痛水平。主要结局变量为至首次镇痛给药的时间。变量数据被描述为平均值和标准差（SD）或中位数和四分位数范围（IQR）为nonnormal data.Results：共155例患者符合研究标准（中位年龄= 32岁，IQR = 24-40岁），共701艾德访问。进行了86次访谈。大多数患者（71.6%）在研究期间到艾德就诊一次到三次。然而，由于数据入组期较短（3.5个月），将研究中心3从分析中删除后，影响了整个队列的平均访视次数，52%的患者在10个月内接受了1至3次艾德访视，21%的患者接受了4至9次访视，27%的患者接受了10至67次访视。59%的患者出院回家。队列中至初始镇痛的中位时间为74分钟（IQR = 48-135分钟）。不同研究中心的镇痛剂选择和给药途径存在明显差异。对于该队列，使用以下途径给予680个初始镇痛剂（硫酸吗啡，42%;氢吗啡酮，46%;哌替啶，4%;硫酸吗啡和布洛芬或酮咯酸，7%）：口服（2%）、静脉内（67%）、皮下（3%）和肌内（28%）。患者报告的目标出院疼痛评分显著降低（平均值+/- SD = 4.19 +/- 1.18）与出院45分钟内实际记录的出院疼痛评分相比（平均值+/- SD = 5.77 +/- 2.45;平均差异= 1.58，95%置信区间= 0.723至2.44，n = 43）.结论：虽然一半的患者在研究期间有1至3次艾德就诊，但许多患者的就诊频率更高。延迟接受初始镇痛剂是常见的，并且艾德后的访谈显示，镰状细胞疼痛患者从艾德出院时的疼痛评分高于他们认为理想的疼痛评分。学术急诊医学2010; 17：399-407（C）2010由学术急诊医学学会提供。
Objectives:The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative.Methods:A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data.Results:A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43).Conclusions:While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.ACADEMIC EMERGENCY MEDICINE 2010; 17:399-407 (C) 2010 by the Society for Academic Emergency Medicine.