Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.
Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.
复制标题
患有镰状细胞疼痛危机的成人急诊科患者：改善镇痛管理的质量改进学习协作模型的结果。
DOI：
10.1111/j.1553-2712.2012.01330.x
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发表时间：
2012
期刊：
影响因子：
--
通讯作者：
Artz,Nicole
中科院分区：
文献类型：
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作者：
Tanabe,Paula;Hafner,JohnW;Martinovich,Zoran;Artz,Nicole
Academic Emergency Medicine 2012; 19：430-438 © 2012 by the Society for Academic Emergency MedicineAbstractObjectives：The aims of this study were to 1）estimate differences in pain management process and patient‐reported outcomes，pre-and postimplementation of analgesic protocols for adults with sickle cell disease（SCD），and 2）examine the effects of site and visit frequencies on changes in pain scores and time to analges.Methods：A multicenter，prospective，longitudinal study ented patients from three academic medical centers between October 2007 and September 2009.所有以镰状细胞疼痛发作为主诉的18岁或以上的艾德患者均入选。 临床试验机构组成了SCD质量改进（QI）团队，并实施了标准的护士发起的急诊科（艾德）镇痛方案;比较了定义为方案实施前后的研究阶段之间的结局。进行病历审查，以测量至初始镇痛剂给药的时间、使用的阿片类药物、阿片类药物给药途径、从到达至出院的疼痛评分变化（负数反映疼痛评分降低）以及研究期间每个研究中心每例患者的艾德访视次数。在艾德访视后第7天，进行了随访电话访谈。使用1 - 10分量表（1 =显著，10 =最差）询问患者的艾德疼痛管理情况。 描述性统计用于报告结果。构建普通最小二乘回归模型以测量时间段、部位和每位患者的就诊次数对疼痛评分变化的影响。结果：在研究期间，入组了342例独特患者（57%为女性，平均± SD年龄=32 ± 11岁），共进行了2，934次就诊。 两个研究阶段之间的初始镇痛剂给药时间无差异。总体而言，干预前后研究期间从到达到出院的疼痛评分显著降低：实施后期间到达到出院疼痛评分（cm）的平均差异大于干预前期间（-4.1 vs.-3.6，t = 2.6，p <0.01）。 在研究期间，部位1有显著改善（平均差异=-0.87，t = 2.63，p <0.01; F = 14.3，p <0.01）。 与非常频繁的艾德访视（>19次访视）患者相比，很少有艾德访视的患者（每年1 - 6次，平均差异=-1.55，t = 2.1，p =0.04）和经常有艾德访视的患者（每年7 - 19次，平均差异=-1.65，t = 3.52，p <0.01）疼痛评分显著降低。 在研究期间，硫酸吗啡（MS）的使用总体减少，氢吗啡酮的使用增加（χ2= 105.67，p <0.001），口服（PO）和皮下（SC）途径的使用显著增加，静脉（IV）途径相应减少（χ2=13.67，p <0.001）。 在研究期间，患者报告的对艾德疼痛管理尝试的满意度无统计学显著差异（p = 0.54）。结论：虽然使用学习协作和实施护士发起的镇痛方案与初始镇痛剂给药时间的改善无关，但在ED的SCD成人中，注意到到达出院疼痛评分降低的改善以及氢吗啡酮和SC途径的使用增加。
ACADEMIC EMERGENCY MEDICINE 2012; 19: 430–438 © 2012 by the Society for Academic Emergency MedicineAbstractObjectives:The aims of this study were to 1) estimate differences in pain management process and patient‐reported outcomes, pre‐ and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic.Methods:A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse‐initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre‐ and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow‐up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least‐squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score.Results:During the study period, 342 unique patients (57% female, mean ± SD age =32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre‐ and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (−4.1 vs. −3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = −0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = −1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = −1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ2= 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ2= 13.67, p < 0.001). There were no statistically significant differences in patient‐reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54).Conclusions:While the use of a learning collaborative and implementation of nurse‐initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED.