Analyzing pain patterns in the emergency department: Leveraging clinical text deep learning models for real-world insights.

OBJECTIVE: To determine the incidence of patients presenting in pain to a large Australian inner-city emergency department (ED) using a clinical text deep learning algorithm. MATERIALS AND METHODS: A fine-tuned, domain-specific, transformer-based clinical text deep learning model was used to interpret free-text nursing assessments in the electronic medical records of 235,789 adult presentations to the ED over a three-year period. The model classified presentations according to whether the patient had pain on arrival at the ED. Interrupted time series analysis was used to determine the incidence of pain in patients on arrival over time. We described the changes in the population characteristics and incidence of patients with pain on arrival occurring with the start of the Covid-19 pandemic. RESULTS: 55.16% (95%CI 54.95%-55.36%) of all patients presenting to this ED had pain on arrival. There were differences in demographics and arrival and departure patterns between patients with and without pain. The Covid-19 pandemic initially precipitated a decrease followed by a sharp, sustained rise in pain on arrival, with concurrent changes to the population arriving in pain and their treatment. DISCUSSION: Applying a clinical text deep learning model has successfully identified the incidence of pain on arrival. It represents an automated, reproducible mechanism to identify pain from routinely collected medical records. The description of this population and their treatment forms the basis of intervention to improve care for patients with pain. The combination of the clinical text deep learning models and interrupted time series analysis has reported on the effects of the Covid-19 pandemic on pain care in the ED, outlining a methodology to assess the impact of significant events or interventions on pain care in the ED. CONCLUSION: Applying a novel deep learning approach to identifying pain guides methodological approaches to evaluating pain care interventions in the ED, giving previously unavailable population-level insights.

Enhancing pain care with the American Pain Society Patient Outcome Questionnaire for use in the emergency department (APS-POQ-RED): validating a patient-reported outcome measure.

BACKGROUND: In general, the quality of pain care in emergency departments (ED) is poor, despite up to 80% of all ED patients presenting with pain. This may be due to the lack of well-validated patient-reported outcome measures (PROMs) of pain care in the ED setting. The American Pain Society-Patient Outcome Questionnaire-Revised Edition (APS-POQ-R), with slight modification for ED patients, is a potentially useful PROM for the adult ED, however it is yet to be completely validated. METHODS: Adult patients, who had presented with moderate to severe acute pain, were recruited at two large inner-city EDs in Australia. A modified version of the APS-POQ-R was administered at the completion of their ED care. Responses were randomly split into three groups and underwent multiple rounds of exploratory and confirmatory factor analysis with testing for construct, convergent, divergent validity and internal consistency. RESULTS: A total of 646 ED patients (55.6% female), with a median age of 48.3 years, and moderate to severe pain on arrival, completed the ED-modified APS-POQ-R. Psychometric evaluation resulted in a reduced nine-question tool, which measures three constructs (pain relief and satisfaction (α=0.891), affective distress (α=0.823) and pain interference (α=0.908)) and demonstrated construct, convergent, divergent validity, and internal consistency. CONCLUSIONS: This new tool, which we refer to as the American Pain Society-Patient Outcome Questionnaire-Revised for the ED (APS-POQ-RED), should form the basis for reporting patient-reported outcomes of ED pain care in future quality improvement and research.

Developing Robust Clinical Text Deep Learning Models - A "Painless" Approach.

The success of deep learning in natural language processing relies on ample labelled training data. However, models in the health domain often face data inadequacy due to the high cost and difficulty of acquiring training data. Developing such models thus requires robustness and performance on new data. A generalised incremental multiphase framework is proposed for developing robust and performant clinical text deep learning classifiers. It incorporates incremental multiphases for training data size assessments, cross-validation setup to avoid test data bias, and robustness testing through inter/intra-model significance analysis. The framework's effectiveness and generalisation were confirmed by the task of identifying patients presenting in 'pain' to the emergency department.

Determinants of fatigue in emergency department clinicians who wear personal protective equipment.

OBJECTIVE: To determine the independent predictors for clinician fatigue and decline in cognitive function following a shift in the ED during early stages of the COVID-19 pandemic. METHODS: This was a prospective, quasi-experimental study conducted in a metropolitan adult tertiary-referral hospital ED over 20 weeks in 2021. The participants were ED doctors and nurses working clinical shifts in an ED isolation area or high-risk zone (HRZ) with stringent personal protective equipment (PPE). The participants' objective and subjective fatigue was measured by the Samn-Perelli fatigue score and a psychomotor vigilance 'smart game' score, respectively. Postural signs/symptoms and urine specific gravity (SG) were measured as markers of dehydration. RESULTS: Sixty-three participants provided data for 263 shifts. Median (interquartile range) age was 33 (28-38) years, 73% were female. Worsening fatigue score was associated with working afternoon shifts (afternoon vs day, adjusted odds ratio [aOR] 5.16 [95% confidence interval (CI) 1.32-20.02]) and in non-HRZ locations (HRZ vs non-HRZ, aOR 0.23 [95% CI 0.06-0.87]). Worsening cognitive function (game score) was associated with new onset postural symptoms (new vs no symptoms, aOR 4.14 [95% CI 1.34-12.51]) and afternoon shifts (afternoon vs day, aOR 3.13 [95% CI 1.16-8.44]). Working in the HRZ was not associated with declining cognitive function. Thirty-four (37%) of the 92 participants had an end of shift urine SG >1.030. CONCLUSION: Working afternoon shifts was associated with fatigue. There was no association between HRZ allocation and fatigue, but our study was limited by a low COVID workload and fluctuating PPE requirements in the non-HRZs. Workplace interventions that target the prevention of fatigue in ED clinicians working afternoon shifts should be prioritised.

The Emergency nurse Protocols Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) trial: protocol for a stepped wedge implementation trial.

INTRODUCTION: Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes. METHODS AND ANALYSIS: This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped-wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys. ETHICS AND DISSEMINATION: Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022. TRIAL REGISTRATION: Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.

Dietary intake of micronutrients are predictor of premenstrual syndrome, a machine learning method.

BACKGROUND & AIMS: Premenstrual syndrome (PMS) is a common disorder affecting 30-40% of women of reproductive age. Many modifiable risk factors associated with PMS involve nutrition and poor eating habits. This study aims to explore the correlation between micronutrients and PMS in a group of Iranian women and to build a predictor model showing the PMS using nutritional and anthropometric variables. METHODS: This is a cross-sectional study which was conducted on 223 females in Iran. Anthropometric indices were measured, including Body Mass Index (BMI) and skinfold thickness. Machine learning methods were used to assess participants' dietary intakes, Food Frequency Questionnaire (FFQ) and analyze the data. RESULTS: After applying different variable selection techniques, we have created machine learning models such as KNN. KNN achieved 80.3% accuracy rate and 76.3% F1 score indicating that our model is a curate and valid proof to show a strong relationship between input variables (sodium intake, Skin fold thickness of suprailiac, irregular menstruation, total calorie intake, total fiber intake, trans fatty acids, painful menstruation (dysmenorrhea), total sugar intake, total fat intake, and biotin) and the output variable (PMS). We sorted these effective variables based on their 'Shapley values' and figured out that Na intake, suprailiac skinfold thickness, biotin intake, total fat intake and total sugar intake have a major impact on having PMS. CONCLUSIONS: Dietary intake and anthropometric measurements are highly associated with the occurrence of PMS, and in our model, these variables can predict PMS in women with a high accuracy rate.

Missed Nursing Care in Medical and Surgical Wards in Jordan: A Cross-Sectional Study.

Missed nursing care is a multifaceted patient safety issue receiving increased attention among healthcare scholars worldwide. There is limited research on missed nursing care in the Jordanian healthcare context. The current study sought to examine the perceptions of Jordanian nurses toward the amount and types of missed nursing care in medical and surgical wards. We also examined the differences in missed care items between public, private, and university hospitals in Jordan. This was a cross-sectional study using the MISSCARE Survey tool. Data collection spanned 4 months between March and July 2021. The final study sample consisted of 672 registered nurses employed in five public, three private, and two university hospitals in Jordan. Data were analyzed using descriptive statistics, Analysis of variance, and Pearson correlation coefficent test. Of the 672 registered nurses who participated, the majority were females (n = 421; 62.6%). Most participants held a bachelor's degree in nursing (n = 577; 85.9%). The three most common missed nursing activities in the participating hospitals were: ambulation, oral care, and emotional support. Nurses working in public hospitals reported the highest missed nursing care. The age and number of patients under care significantly correlated with missed nursing care. The findings could help nursing managers develop plans to reduce missed nursing care in their healthcare institutions.

A Cross-sectional Study Evaluating the Association Between the Nursing Practice Environment and Missed Nursing Care in Medical and Surgical Wards in Jordan.

BACKGROUND: Missed nursing care can jeopardize the safety of patients. The practice environment contains various elements that may impact nursing staff's capability to provide appropriate care. PURPOSE: To examine the association between the practice environment and missed nursing care in Jordanian hospitals. METHODS: A cross-sectional design, including the MISSCARE survey and the Practice Environment Scale of the Nursing Work Index, was used for this study. RESULTS: Data were gathered from 672 nurses working in 10 hospitals between March and July 2021. Findings revealed significant negative correlations between nurses' participation in hospital affairs ( r = -0.077, P = .046), nursing foundations for quality of care ( r = -0.139, P < .001), and missed nursing care. CONCLUSION: Information from this study can help nursing leaders modify practice environment elements that impact missed nursing care occurrences, which will help improve the quality of care provided to patients.

Adult pain and anticipatory anxiety assessment in the emergency department: An integrative literature review.

INTRODUCTION: Patients presenting to the emergency departments in pain often experience co-occurring symptoms. Anticipatory anxiety in the emergency department may be currently under-recognised. Clinical tools to facilitate the assessment of co-occurring symptoms aligns with providing more patient centred care and improved outcomes and experience. AIMS: This integrative review aimed to identify and examine the psychometric properties of tools currently used for pain and anticipatory anxiety assessment in adult patients presenting to the emergency department. This study also aimed to identify the current clinical practice used to assess adult pain and anticipatory anxiety. METHODS: Whittemore and Knafl's methodology guided the review process, and it is reported according to relevant items from PRISMA checklist. Studies were included if they focused on tools for pain or anxiety assessment of adults in emergency departments in English language publications since 2010. Quality of studies was evaluated using the Mixed Methods Appraisal Tool (MMAT). The results were summarised through narrative synthesis. RESULTS: A total of 15 studies were identified for narrative synthesis. Six tools for pain, and four tools for anticipative anxiety were found. All currently used clinical tools assess symptoms in isolation. There was limited discussion of the clinical context of identified tools within the included studies. CONCLUSION: Pain and anxiety assessment are currently performed in symptom isolation with a variety of tools with varying degrees of reliability. There exists a lack of clinical tools able to assess co-occurring symptoms of pain and anticipatory anxiety in the clinical setting of the emergency department. No studies discussed clinical tool use in current practice. RELEVANCE TO CLINICAL PRACTICE: The reconstruction of available pain and anxiety assessment tools into one validated and holistic tool for assessment in the ED clinical setting, would provide a contextually appropriate guide to clinical assessment and treatment. Acknowledging and measuring these symptoms may facilitate future rigorous testing of experimental studies of novel methods to reduce pain and anxiety in the ED. NO PATIENT OR PUBLIC CONTRIBUTION: Patient or public contribution does not apply to this Integrative Review. CLINICAL TRIAL REGISTRATION NUMBER: Not applicable.

Factors associated with the experience of patients presenting in pain to the emergency department.

AIMS AND OBJECTIVES: This study aims to examine the association between person, environment, health and illness factors, pain care and the patient experience in the emergency department, guided by symptom management theory. BACKGROUND: Current outcome measures of pain care in the emergency department focus on process measures such as the time taken to deliver analgesic medication. Patient-reported outcomes of pain care are rare in emergency department literature and predominantly focus on patient satisfaction. Measuring overall patient experience is common, with extensive surveys undertaken in the United Kingdom, United States of America and Australia; however, these are not used as an outcome of pain care. DESIGN: Prospective cohort study. METHODS: One hundred and ninety patients arriving at a large, inner-city adults-only emergency department in moderate to severe pain were recruited to answer a modified version of the emergency department patient experience of care survey. RESULTS: Fifteen factors were identified as influencing the patient experience of care when presenting in pain. These influences of patient experience included the emergency department environment, time to first analgesic medication and the provision of analgesic medication. CONCLUSIONS: In addition to pain care factors, there is a significant association between the emergency department environment-especially workload, throughput and patient placement-and the experience of patients who present in pain to the emergency department. RELEVANCE TO CLINICAL PRACTICE: This study demonstrated an association between time to first analgesic medication and the patient experience of care. Providing timely care, including pain care, in emergency departments is difficult, but necessary to improve the patient experience of care.

Hematoma After Continuous Erector Spinae Plane Block With Catheter Placement: A Case Report.

The erector spinae plane block (ESPB) is described as a safe and effective alternative when epidural or paravertebral blocks are contraindicated by anticoagulation therapy. We present a case of subcutaneous hematoma after ESPB catheter placement. The patient received bilateral ESPB catheters for perioperative pain control. Postoperatively, the patient developed tenderness to palpation at the left catheter site. Physical examination revealed a well circumscribed, fluctuant mass that produced bloody material during incision and drainage. This case report describes hematoma as a potential complication of the ESPB. After the procedure, patients should be closely monitored for complications, including hematoma.

The documentation of pain intensity and its influences on care in the emergency department.

BACKGROUND: Assessment and reassessment of self reported pain intensity scores form the basis of acute pain care in the emergency deprtment (ED), however are frequently undocumented. The effects of not documenting pain assessments on time to first analgesic medication (TTA) and ED length of stay (EDLOS) are unknown. METHODS: This is a retrospective cross-sectional study to investigate the association between documented evidence of pain intensity scores, TTA and EDLOS in the ED. It also examined the factors associated with the documentation of pain intensity scores. Univariate and multivariable modelling was used on a random sample of presentations. RESULTS: There were no statistically significant associations between the documented evidence of pain intensity scores and TTA or EDLOS. Modelling suggests that patients were less likely to have documented evidence of pain intensity scores if they were male, were streamed to the fast-track treatment area, had a lower burden of co-morbidities, or when the general departmental workload was increased. CONCLUSIONS: The documentation of pain intensity scores was not associated with TTA or EDLOS. Some demographic, illness and workload factors are associated with the lack of pain intensity score documentation, however, the effect on patients outcomes needs further investigation.

Factors associated with time to first analgesic medication in the emergency department.

AIM AND OBJECTIVE: To examine the factors associated with time to first analgesic medication in the emergency department. BACKGROUND: Pain is the most common symptom presenting to the emergency department, and the time taken to deliver analgesic medication is a common outcome measure. Factors associated with time to first analgesic medication are likely to be multifaceted, but currently poorly described. DESIGN: Retrospective cohort study. METHODS: Cox proportional hazards regression modelling was undertaken to evaluate the associations between person, environment, health and illness variables within Symptom Management Theory and time to first analgesic medication in a sample of adult patients presenting with moderate-to-severe pain to an emergency department over twelve months. This study was completed in line with the STROBE statement. RESULTS: 383 patients were included in the study, 290 (75.92%) of these patients received an analgesic medication in a median time of 45 minutes (interquartile range, 70 minutes). A model containing nine explanatory variables associated with time to first analgesic medication was identified. These nine variables (employment status, discharge location, triage score, Charlson score, arrival pain score, socio-economic status, first location, daily total treatment time and patient time to be seen) represent all of the domains of the Symptom Management Theory. CONCLUSIONS: Person, environment, health and illness factors are associated with the time taken to deliver analgesic medication to those in pain in the emergency department. This study demonstrates the complexity of factors associated with pain care and the applicability of Symptom Management Theory to pain care in the emergency department. RELEVANCE TO CLINICAL PRACTICE: Identifying a model of factors that are associated with the time in which the most common symptom presenting to the emergency department is treated allows for targeted interventions to groups likely to receive poor care and a framework for its evaluation.

An initial psychometric evaluation of the APS-POQ-R in acute pain presenting to the emergency department.

AIM: The purpose of this study was to examine the psychometric properties of a modified version of the American Pain Societies - Patient Outcome Questionnaire - Revised edition in adult patients presenting with acute pain to the emergency department. BACKGROUND: There is a lack of validation and use of patient-reported outcome measures of pain care in the adult emergency setting. DESIGN: Prospective psychometric evaluation. METHODS: Adult patients who had presented with acute pain were invited to participate in the study after their emergency department care. The Questionnaire was administered by one of the investigators. Exploratory factor analysis (principal axis factoring) was used to explore items mapping to constructs. The number of constructs with an Eigenvalue closest to 1 was considered the correct fit for the data. Assessment of the analysis was conducted using the Kaiser-Meier-Olkin test of sampling adequacy, and the fit was assessed using Bartlett's test of sphericity. RESULTS: The Questionnaire demonstrated construct validity in these patients. Exploratory factor analysis demonstrated five constructs. The tool demonstrated discriminatory ability based on patient urgency, and subscale measurement was associated with patient satisfaction with care CONCLUSIONS: The Questionnaire has demonstrable construct validity in adult patients presenting with acute pain to the ED.

Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review.

Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.

Missed nursing care and complexity theory: a conceptual paper.

BACKGROUND: Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care. AIM: This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory. METHODS: The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare. RESULTS: We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care. CONCLUSIONS: This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Nurse-Led Randomized Controlled Trials in the Perioperative Setting: A Scoping Review.

PURPOSE: Nurses provide care at each phase of the complex, perioperative pathway and are well placed to identify areas of care requiring investigation in randomized controlled trials. Yet, currently, the scope of nurse-led randomized controlled trials conducted within the perioperative setting are unknown. This scoping review aims to identify areas of perioperative care in which nurse-led randomized controlled trials have been conducted, to identify issues impacting upon the quality of these trials and identify gaps for future investigation. METHODS: This scoping review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Searches were conducted in PubMed, Embase, Cumulative Index for Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials, with a date range of 2014-19. Sources of unpublished literature included Open Grey, and ProQuest Dissertation and Theses, Clinical Trials.gov and the Australian and New Zealand Clinical Trials Registry. After title and abstract checking, full-text retrieval and data extraction, studies were appraised using the Joanna Briggs Institute Critical Appraisal Checklists for randomized controlled trials. Data were synthesized according to the main objectives. Key information was tabulated. RESULTS: From the 86 included studies, key areas where nurses have led randomized controlled trials include patient or caregiver anxiety; postoperative pain relief; surgical site infection prevention: patient and caregiver knowledge; perioperative hypothermia prevention; postoperative nausea and vomiting; in addition to other diverse outcomes. Issues impacting upon quality (including poorly reported randomization), and gaps for future investigation (including a focus on vulnerable populations), are evident. CONCLUSION: Nurse-led randomized controlled trials in the perioperative setting have focused on key areas of perioperative care. Yet, opportunities exist for nurses to lead experimental research in other perioperative priority areas and within different populations that have been neglected, such as in the population of older adults undergoing surgery.

Increasing the Rate of Documentation of Security Interventions in the Emergency Department: Big Orange Security Sticker (BOSS) Project.

BACKGROUND: Security interventions in aggressive and violent patients in the emergency department (ED) are not always documented in the clinical record, which can compromise the effectiveness of communication, and increase clinical risks. LOCAL PROBLEM: Fewer than half of all security interventions are documented in the clinical record. METHODS: The study had a pre- and posttest design including a retrospective audit of patient medical records and a staff survey. INTERVENTION: A dedicated sticker, to be completed by nursing and security staff, was placed into the clinical notes as a record of the security intervention. RESULTS: From 1 month before to 1 month after implementation, the rate of documentation of security interventions in clinical notes increased from 43.3% to 68.8% (P = .01), and was maintained for 3 months after implementation. CONCLUSIONS: The rate of documentation of ED security interventions in clinical notes can be increased by encouraging clinicians and security staff to collaborate and share documentation responsibilities.