Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial.

STUDY OBJECTIVE: We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma. METHODS: The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia. RESULTS: One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin. CONCLUSION: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

['Advanced triage' improves patient flow in the emergency department without affecting the quality of care]. / 'Advanced triage' geeft snellere patiëntdoorstroming SEH, zonder verlies aan kwaliteit van zorg.

OBJECTIVE: To investigate whether 'advanced triage' improved patient flow among self-referred patients in the emergency department of a level 1 trauma centre and, most importantly, whether the quality of medical care was maintained. In advanced triage, the triage nurse initiates additional diagnostic investigations independently. DESIGN: Interventional study. METHODS: After a baseline measurement had been carried out for eleven days (n = 506), the advanced triage protocol was tested during ten day or evening shifts (n = 198). The length of stay in the emergency department was measured. The attending emergency physician assessed the correctness and completeness of the additional diagnostics initiated by the triage nurse. Two traumatologists and two radiologists assessed the quality of x-ray imaging requests independently of each other. RESULTS: Average patient length of stay (LOS) was reduced by fourteen minutes (14%). The improvement was achieved primarily in patients who required additional diagnostic investigations. Their average LOS decreased by 27 minutes (18%). There was an 8% increase in the total number of diagnostic investigations requested. The triage nurse initiated the investigations correctly and fully in 93% of cases. The quality of x-ray imaging requests remained the same as before the introduction of advanced triage. CONCLUSION: The implementation of advanced triage improved patient flow for self-referred patients in the emergency department without affecting the quality of medical care. Advanced triage was successful in the Dutch system, too.