Improving door-to-analgesia timing in musculoskeletal injuries in an academic emergency department in India: a quality improvement project.

INTRODUCTION: Pain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many EDs face challenges in pain management and present opportunities for improvement. This initiative aimed to expedite the administration of the first analgesic in patients with musculoskeletal pain in the ED. LOCAL PROBLEM: Observations within our ED revealed that patients with musculoskeletal injuries triaged to yellow or green areas experienced prolonged waiting times, leading to delayed analgesic administration, thereby adversely affecting clinical care and patient satisfaction. SPECIFIC AIM: The aim of our quality improvement (QI) project was to reduce the time to administration of first analgesia by 30% from baseline, in patients with musculoskeletal injuries presenting to our academic ED, in a period of 8 weeks after the baseline phase. METHODS: A multidisciplinary QI team systematically applied Point-of-Care Quality Improvement and Plan-Do-Study-Act (PDSA) cycle methodologies. Process mapping and fishbone analyses identified the challenges in analgesia administration. Targeted interventions were iteratively refined through PDSA cycles. INTERVENTIONS: Interventions such as pain score documentation at triage, fast-tracking of patients with moderate-to-severe pain, resident awareness sessions, a pain management protocol and prescription audits were executed during the PDSA cycles. Successful elements were reinforced and adjustments were made to address the identified challenges. RESULTS: The median door-to-analgesia timing during the baseline phase was 55.5 min (IQR, 25.75-108 min). During the postintervention phase, the median was significantly reduced to 15 min (IQR, 5-37 min), exceeding the anticipated outcomes and indicating a substantial 73% reduction (p value <0.001) from baseline. CONCLUSION: Implementing simple change ideas resulted in a substantial improvement in door-to-analgesia timing within the ED. These findings significantly contribute to ongoing discussions on the optimisation of pain management in emergency care.

Diagnostic Value of Point-of-Care Ultrasound-Guided Assessment of Relative Afferent Pupillary Defect in Adult Ocular Trauma Patients Presenting to the Emergency Department: A Prospective Cohort Study.

OBJECTIVES: Early diagnosis of relative afferent pupillary defects (RAPDs) in patients with ocular trauma is crucial for timely management and improved outcomes. However, clinical examination can be challenging for patients with periorbital ecchymosis. This study aimed to compare the diagnostic accuracy of point-of-care ultrasound (POCUS) and clinical examination by emergency physicians for detecting RAPD in adult ocular trauma patients and to evaluate the proportion of RAPD in patients with ocular trauma who presented to the ED. METHODS: This prospective cohort study was conducted at an academic emergency department in South India. Adult ocular trauma patients were assessed for RAPD using clinical examinations by emergency physicians and POCUS. The diagnostic accuracies of both methods were compared, with the ophthalmologist's final diagnosis serving as the gold standard. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for both techniques. RESULTS: A total of 376 patients (median age, 35 years) were included in this study. RAPD was identified in 14.63% of the patients. The sensitivity and specificity of POCUS in detecting RAPD were 92.73% and 99.38%, respectively, which were higher than those of clinical examination, with a sensitivity of 81.82% and specificity of 99.07%. The PPV and NPV of the clinical examination were 93.75% and 96.95%, respectively, whereas the PPV and NPV of POCUS were 96.23% and 98.76%, respectively. POCUS accurately diagnosed RAPD in patients with periorbital ecchymosis. CONCLUSION: POCUS-guided RAPD assessment proves to be a better diagnostic adjunct compared to clinical examination in patients with ocular trauma presenting to the emergency department.