Practice Patterns and Variability in Intraoperative Opioid Utilization: A Report From the Multicenter Perioperative Outcomes Group.

BACKGROUND: Opioids remain the primary mode of analgesia intraoperatively. There are limited data on how patient, procedural, and institutional characteristics influence intraoperative opioid administration. The aim of this retrospective, longitudinal study from 2012 to 2016 was to assess how intraoperative opioid dosing varies by patient and clinical care factors and across multiple institutions over time. METHODS: Demographic, surgical procedural, anesthetic technique, and intraoperative analgesia data as putative variables of intraoperative opioid utilization were collected from 10 institutions. Log parenteral morphine equivalents (PME) was modeled in a multivariable linear regression model as a function of 15 covariates: 3 continuous covariates (age, anesthesia duration, year) and 12 factor covariates (peripheral block, neuraxial block, general anesthesia, emergency status, race, sex, remifentanil infusion, major surgery, American Society of Anesthesiologists [ASA] physical status, non-opioid analgesic count, Multicenter Perioperative Outcomes Group [MPOG] institution, surgery category). One interaction (year by MPOG institution) was included in the model. The regression model adjusted simultaneously for all included variables. Comparison of levels within a factor were reported as a ratio of medians with 95% credible intervals (CrI). RESULTS: A total of 1,104,324 cases between January 2012 and December 2016 were analyzed. The median (interquartile range) PME and standardized by weight PME per case for the study period were 15 (10-28) mg and 200 (111-347) µg/kg, respectively. As estimated in the multivariable model, there was a sustained decrease in opioid use (mean, 95% CrI) dropping from 152 (151-153) µg/kg in 2012 to 129 (129-130) µg/kg in 2016. The percent of variability in PME due to institution was 25.6% (24.8%-26.5%). Less opioids were prescribed in men (130 [129-130] µg/kg) than women (144 [143-145] µg/kg). The men to women PME ratio was 0.90 (0.89-0.90). There was substantial variability in PME administration among institutions, with the lowest being 80 (79-81) µg/kg and the highest being 186 (184-187) µg/kg; this is a PME ratio of 0.43 (0.42-0.43). CONCLUSIONS: We observed a reduction in intraoperative opioid administration over time, with variability in dose ranging between sexes and by procedure type. Furthermore, there was substantial variability in opioid use between institutions even when adjusting for multiple variables.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up.

OBJECTIVE: The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. METHODS: The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. RESULTS: The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. CONCLUSION: Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Language Barriers and Timely Analgesia for Long Bone Fractures in a Pediatric Emergency Department.

INTRODUCTION: Long bone fractures are common painful conditions often managed in the pediatric emergency department (PED). Delay to providing effective pediatric pain management is multifactorial. There is limited information regarding how the issue of language spoken impacts the provision of adequate and timely institution of analgesia. We sought to determine whether there is a difference between English-speaking and non-English speaking patients with respect to time to pain management for long bone fractures in a multi-ethnic urban PED. METHODS: We conducted a retrospective cohort study of consecutive cases over 29 months of children <18 years old who presented to the PED with a first-time long bone fracture. A correlation of multiple clinical variables with timeliness to providing analgesia as a primary outcome was determined. We performed regression analysis to eliminate confounding and to determine the magnitude of each variable's effect on the outcome. RESULTS: We analyzed a total of 753 patient cases (power 0.95). Regression analysis showed that the variable of English vs non-English language spoken was the most significant predictor of timeliness to pain management (p < 0.001). There was a significant difference in median time to triage measurement of pain score (1 minute vs 4 minutes for English vs non-English speakers [p < 0.001]); median time to initial analgesia (4 minutes vs 13 minutes for English vs non-English speakers (p < 0.001]); and median time to opioid analgesia (32 minutes vs 115 minutes for English vs non-English speakers (p < 0.001]), respectively. All measurements of time were from the creation of a patient's electronic health record. Just 30% of all patients received an opioid analgesic for treatment of long bone fractures, including only 37% with moderate triage pain scores. CONCLUSION: Delay to receiving analgesic medications in pediatric patients with long bone fractures can be augmented by language barriers. Time to providing analgesia for long bone fractures is significantly delayed in non-English speaking families, contributing to disproportionate care in the PED. Furthermore, use of opioid analgesia for fractures in children remains poor.

Development of a Structured Regional Analgesia Program for Postoperative Pain Management.

OBJECTIVES: We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019. METHODS: A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time. RESULTS: There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups. CONCLUSIONS: We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program.

Prescription of analgesia in emergency medicine (POEM) secondary analysis: an observational multicentre comparison of pain relief provided to adults and children with an isolated limb fracture and/or dislocation.

BACKGROUND: Acute pain is a common reason for emergency department (ED) attendance. Royal College of Emergency Medicine (RCEM) pain management audits have shown national variation and room for improvement. Previous evidence suggests that children receive less satisfactory pain management than adults. METHODS: Prescription of analgesia in emergency medicine is a cross-sectional observational study of consecutive patients presenting to 12 National Health Service EDs with an isolated long bone fracture and/or dislocation, and was carried out between 2015 and 2017. Using the recommendations in the RCEM Best Practice Guidelines, pain management in ED was assessed for differences of age (adults vs children) and hospital type (children's vs all patients). RESULTS: From the total 8346 patients, 38% were children (median age 8 years). There was better adherence to the RCEM guidance for children than adults (24% (766/3196) vs 11% (579/5123)) for the combined outcome of timely assessment, pain score and appropriate analgesia. In addition, children were significantly more likely than adults to receive analgesia appropriate to the pain score (of those with a recorded pain score 67% (1168/1744) vs 52% (1238/2361)). Children's hospitals performed much better across all reported outcomes compared with general hospitals. CONCLUSIONS: In contrast to previous studies, children with a limb fracture/dislocation are more likely than adults to have a pain score documented and to receive appropriate analgesia. Unexpectedly, children's EDs performed better than general EDs in relation to timely and appropriate analgesia but the reasons for this are not apparent from the present study.

The influence of the choice of preemptive analgesia on long-term postsurgical pain after tibial plateau leveling osteotomy in dogs.

OBJECTIVE: To evaluate the prevalence of chronic postsurgical pain (CPSP) after tibial plateau leveling osteotomy (TPLO) in dogs and to determine the influence of preemptive locoregional analgesia on CPSP. STUDY DESIGN: Retrospective study. ANIMALS: One hundred twenty client-owned dogs. METHODS: Medical records of dogs that underwent TPLO between 2012 and 2016 were reviewed for demographic information and type of preemptive analgesia. Owners were contacted to retrospectively assess the quality of life of their dogs by using the Helsinki Chronic Pain Index (HCPI) before and 6 months after surgery and at the time of questioning. An HCPI score > 12 was considered indicative of CPSP. Medical records were reviewed for demographic information and type of preemptive analgesia. A cumulative logit model was used to assess correlation of type of perioperative analgesia, HCPI, and demographic data. RESULTS: The HCPI score was consistent with CPSP in 41 of 101 dogs with long-term follow-up (2.9 ± 1.5 years after surgery). Chronic postsurgical pain was documented in 11 of 32 and 13 of 28 dogs that received a spinal or epidural injection, respectively, or in 28 of 80 and 25 of 67 dogs with sciatic-femoral block at 6 months or with long-term follow-up after TPLO, respectively (P > .05). A negative correlation was found between HCPI and both weight and age 6 months after surgery. Only weight remained negatively correlated 2.9 years after surgery. CONCLUSION: Forty-one percent of dogs that were evaluated exhibited HCPI values compatible with CPSP long-term after TPLO, regardless of the type of preemptive analgesia. Increased body weight was a negative prognostic factor for CPSP development. CLINICAL SIGNIFICANCE: Additional studies are required to evaluate CPSP development after TPLO.

Racial disparities in analgesic use amongst patients presenting to the emergency department for kidney stones in the United States.

INTRODUCTION: We sought quantify racial disparities in use of analgesia amongst patients seen in Emergency Departments for renal colic. METHODS: We identified all individuals presenting to the Emergency Department with urolithiasis from 2003 to 2015 in the nationally representative Premier Hospital Database. We included patients discharged in ≤1 day and excluded those with chronic pain or renal insufficiency. We assessed the relationship between race/ethnicity and opioid dosage in morphine milligram equivalents (MME), and ketorolac, through multivariable regression models adjusting for patient and hospital characteristics. RESULTS: The cohort was 266,210 patients, comprised of White (84%), Black (6%) and Hispanic (10%) individuals. Median opioid dosage was 20 MME and 55.5% received ketorolac. Our adjusted model showed Whites had highest median MME (20 mg) with Blacks (-3.3 mg [95% CI: -4.6 mg to -2.1 mg]) and Hispanics (-6.0 mg [95% CI: -6.9 mg to -5.1 mg]) receiving less. Blacks were less likely to receive ketorolac (OR: 0.72, 95% CI: 0.62-0.84) while there was no difference between Whites and Hispanics. CONCLUSIONS: Black and Hispanic patients in American Emergency Departments with acute renal colic receive less opioid medication than White patients; Black patients are also less likely to receive ketorolac.

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study.

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage.

OBJECTIVES: To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease. METHODS: We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP. RESULTS: We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant. CONCLUSION: Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.

Lidocaine Infusion for Refractory Pain from Rat Lungworm Disease - Honolulu, Hawai'i.

Human infection with Angiostrongyloides cantonensis, or rat lungworm disease, manifests most commonly with neurologic symptoms that often include severe diffuse pain. While pain is reported by the majority of patients with rat lungworm disease, there are presently no published guidelines on the approach to pain management for these patients. Here we report a case of rat lungworm disease where severe refractory pain was the most prominent symptom and an intravenous lidocaine infusion was used as a successful treatment modality. Intravenous lidocaine has been shown to be safe and effective in neuropathic pain, refractory cancer pain, and peri-operative pain management. To our knowledge, this is the first case report on the use of lidocaine infusion for the management of refractory pain from rat lungworm disease, and among the first reports of any approach, to pain management for rat lungworm disease. We suggest that a lidocaine infusion protocol be considered when pain from rat lungworm disease fails to respond to first-line analgesics.

An analysis of analgesia and opioid prescribing for veterans after thoracic surgery.

The opioid crisis is a public health issue and has been linked to physician overprescribing. Pain management after thoracic surgery is not standardized at many centers, and we hypothesized that excessive narcotics were being dispensed on discharge. As a quality improvement initiative, we sought to understand current prescribing practices to better align the amount of opioids dispensed on discharge to actual patient needs. This was a single-center, retrospective review of patients undergoing thoracic surgery from 7/2015 to 7/2018. Demographics, operative data, perioperative pain medication use, and discharge pain medication prescriptions were analyzed. Opioids were converted to Morphine Milligram Equivalents (MME). Among 124 patients, 103 (83%) received intraoperative nerve blocks and 106 (85.5%) used PCAs. Prescribed MME/day at discharge were significantly higher than MME/day received during hospitalization (Median 30 [IQR 30-45] vs. 15 [IQR 5-24], p < 0.001) and were not associated with receiving a nerve block or PCA. By procedure, prescribed MME/day were significantly higher than inpatient MME/day for wedge resections (p < 0.001), segmentectomies (p = 0.02), lobectomies (p = 0.003), and thymectomies (p = 0.02). Patients are being discharged with significantly more opioids than they are using as inpatients. Education among prescribers and a standardized approach with patient-specific dosing may reduce excessive opioid dispensing.

Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium.

Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.

The impact of introducing nurse-led analgesia and sedation guidelines in ventilated infants following cardiac surgery.

INTRODUCTION: Enhanced clinical outcomes in the Paediatric Intensive Care Unit following standardisation of analgesia and sedation practice are reported. Little is known about the impact of standardisation of analgesia and sedation practice including incorporation of a validated distress assessment instrument on infants post cardiac surgery, a subset of whom have Trisomy 21. This study investigated whether the parallel introduction of nurse-led analgesia and sedation guidelines including regular distress assessment would impact on morphine administered to infants post cardiac surgery, and whether any differences observed would be amplified within the Trisomy 21 population. METHODOLOGY: A retrospective single centre before/after study design was used. Patients aged between 44 weeks postconceptual age and one year old who had open cardiothoracic surgery were included. RESULTS: 61 patients before and 64 patients after the intervention were included. After the intervention, a reduction in the amount of morphine administered was not evident, while greater use of adjuvant sedatives and analgesics was observed. Patients with Trisomy 21 had a shorter duration of mechanical ventilation after the change in practice. CONCLUSION: The findings from this study affirm the importance of the nurses' role in managing prescribed analgesia and sedation supported by best available evidence. A continued education and awareness focus on analgesia and sedation management in the pursuit of best patient care is imperative.

Clinical analgesic efficacy of pectoral nerve block in patients undergoing breast cancer surgery: A systematic review and meta-analysis.

BACKGROUND: Breast cancer is the most commonly diagnosed cancer in women, and more than half of breast surgery patients experience severe acute postoperative pain. This meta-analysis is designed to examine the clinical analgesic efficacy of Pecs block in patients undergoing breast cancer surgery. METHODS: An electronic literature search of the Library of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted to collect randomized controlled trials (RCTs) from inception to November 2018. These RCTs compared the effect of Pecs block in combination with general anesthesia (GA) to GA alone in mastectomy surgery. Pain scores, intraoperative and postoperative opioid consumption, time to first request for analgesia, and incidence of postoperative nausea and vomiting were analyzed. RESULTS: Thirteen RCTs with 940 patients were included in our analysis. The use of Pecs block significantly reduced pain scores in the postanesthesia care unit (weighted mean difference [WMD] = -1.90; 95% confidence interval [CI], -2.90 to -0.91; P < .001) and at 24 hours after surgery (WMD = -1.01; 95% CI, -1.64 to -0.38; P < .001). Moreover, Pecs block decreased postoperative opioid consumption in the postanesthesia care unit (WMD = -1.93; 95% CI, -3.51 to -0.34; P = .017) and at 24 hours (WMD = -11.88; 95% CI, -15.50 to -8.26; P < .001). Pecs block also reduced intraoperative opioid consumption (WMD = -85.52; 95% CI, -121.47 to -49.56; P < .001) and prolonged the time to first analgesic request (WMD = 296.69; 95% CI, 139.91-453.48; P < .001). There were no statistically significant differences in postoperative nausea and vomiting and block-related complications. CONCLUSIONS: Adding Pecs block to GA procedure results in lower pain scores, less opioid consumption and longer time to first analgesic request in patients undergoing breast cancer surgery compared to GA procedure alone.

Emergency department after-hours primary contact physiotherapy service reduces analgesia and orthopaedic referrals while improving treatment times.

Objective The aims of this study were to identify: (1) whether an after-hours emergency department (ED) collaborative care service using primary contact physiotherapists (PCPs) improves treatment times for musculoskeletal and simple orthopaedic presentations; and (2) differences in orthopaedic referral rates and analgesia prescription for patients managed by PCPs compared with secondary contact physiotherapists. Methods A prospective observational study was conducted of diagnosed, matched patients seen in a 4-day week after-hours ED primary contact physiotherapy service in a tertiary referral ED. Patients presenting with a musculoskeletal or simple orthopaedic diagnosis reviewed by a physiotherapist as either the primary or secondary physiotherapy contact between 1630 and 2030 hours from Saturday to Tuesday were included in the analysis. Outcome measures collected included ED length of stay, orthopaedic referrals in the ED, follow-up plan on discharge from the ED and analgesia prescriptions. Results There were no adverse events, missed diagnoses or re-presentations for any patients managed by an ED PCP. Mean (±s.d.) treatment time for patients seen by an ED PCP was 130±76min, compared with 240±115min for those seen by a secondary contact physiotherapist (P<0.001). There were significant differences between patients managed by PCP versus secondary contact physiotherapists, with decreases of 20.4% for referrals to orthopaedics in the ED, 21.2% for orthopaedic clinic referrals on discharge and 8.5% in analgesia prescriptions for patients managed by an ED PCP (P<0.001). In addition to these reductions, there was a 17.5% increase in general practitioner referrals on discharge for patients managed by an ED PCP (P<0.001). Conclusion An after-hours ED physiotherapy service is a safe service that reduces ED treatment times, as well as analgesia prescriptions and orthopaedic referrals for patients managed by a PCP. What is known about the topic? PCPs are capable of providing safe and effective care to patients in the ED who present with musculoskeletal complaints. Patients managed by physiotherapists as the primary contact require fewer X-rays and have reduced treatment times. What does this paper add? Compared with previously published articles, this study demonstrates similar reductions in ED treatment times in an after-hours setting for patients managed by an ED PCP. However, this was achieved by physiotherapists who have less reported experience. Furthermore, this study found that management of patients by PCPs resulted in a reduction in the amount of analgesia prescribed and orthopaedic input required for these patients. What are the implications for practitioners? PCPs can be trained to operate in the ED with minor or no prior ED experience while facilitating reductions in the amount of analgesia prescribed, orthopaedic referrals required (in ED and on discharge) and reducing treatment times for patients.

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil.

OBJECTIVE: To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. METHODS: A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. RESULTS: Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. CONCLUSION: This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

Neonatal Admission and Its Relationship to Maternal Pain: Pain Scores and Analgesia.

The aim of this study was to determine whether postnatal women whose babies required neonatal intensive care unit (NICU) admission self-reported lower pain scores and required less analgesia than women whose babies remained with them. A prospective matched audit comparing pain scores and analgesia requirements where every woman with a baby admitted to the NICU was matched to 2 women whose babies remained on the ward was undertaken. Matches were based on age, number of previous births, type of birth, episiotomy, and epidural or spinal analgesia use. Data were collected on pain scores and analgesia administered in the first 72 hours postbirth. A total of 150 women were recruited and matched from November 2015 to May 2017. No statistically significant differences were found between the 2 groups for opiate analgesia use (P = .91) or pain scores (P = .89). Regardless of NICU admission, significantly higher pain scores were reported in participants who had episiotomies (P = .03). Birth via cesarean birth resulted in significantly higher pain scores (P < .01) and greater opiate administration (P < .01). This study found no statistically significant difference between pain scores or analgesia use of mothers whose babies required NICU admission and mothers whose babies remained with them.

Improving timely analgesia administration for musculoskeletal pain in the emergency department.

Delays to adequate analgesia result in worse patient care, decreased patient and provider satisfaction and increased patient complaints. The leading presenting symptom to emergency departments (EDs) is pain, with approximately 34 000 such patients per year in our academic hospital ED and 3300 visits specific for musculoskeletal (MSK) injuries. Our aim was to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 min) in 9 months' time (May 2018). Our outcome measures included mean TTA and ED length of stay (LOS). Process measures included rates of analgesia administration and of use of medical directives. We obtained weekly data capture for Statistical Process Control (SPC) charts, as well as Mann-Whitney U tests for before-and-after evaluation. We performed wide stakeholder engagement, root cause analyses and created a Pareto Diagram to inform Plan-Do-Study-Act (PDSA) cycles, which included: (1) nurse-initiated analgesia at triage; (2) a new triage documentation aid for medication administration; (3) a quick reference medical directive badge for nurses; and (4) weekly targeted feedback of the project's progress at clinical team huddle. TTA decreased from 129 min (n=153) to 100 min (22.5%; n=87, p<0.05). Special cause variation was identified on the ED LOS SPC chart with nine values below the midline after the first PDSA. The number of patients that received any analgesia increased from 42% (n=372) to 47% (n=192; p=0.13) and those that received them via medical directives increased from 22% (n=154) to 44% (n=87; p<0.001). We achieved a significant reduction of TTA and an increased use of medical directives through front-line focused improvements.

Survey of analgesia and sedation in pediatric intensive care units in Japan.

BACKGROUND: High-quality evidence of analgesia and sedation management in pediatric intensive care units (PICUs) is lacking. METHODS: An online survey concerning the institutional management of pain, sedation, delirium, and withdrawal syndrome, as well as non-pharmacological interventions to reduce pain and / or to provide comfort, was conducted with the medical directors of 31 PICUs in Japan. The survey was conducted from September to November 2016. RESULTS: The response rate was 77% (24/31). Pain was routinely assessed in nine (38%) PICUs. Self-report pain scales were used in 14 (58%) PICUs. Observational pain scales for children who were unable to self-report were used in only one PICU. Physician-driven analgesia protocols were used in two (8%) PICUs. Although sedation scales for intubated patients were used in 15 (63%) PICUs, they were used for the goal-directed sedation management in nine (38%). Nurse-driven sedation protocols were used in two (8%) PICUs. Five (21%) PICUs used delirium assessment tools, and delirium screening was not routinely done in any PICU. Five (21%) PICUs regularly used withdrawal assessment tools for a high-risk group of patients with withdrawal syndrome. Non-pharmacological interventions for analgesia and comfort were frequently practiced for mechanically ventilated patients. CONCLUSIONS: This study is the first survey conducted by physicians regarding pain and agitation management in PICUs in Japan, and the results revealed great diversity in practice. The implementation strategies to assess pain, delirium, and withdrawal syndrome, as well as to set goals regarding sedation level, are lacking. Protocols for analgesia and sedation management are uncommon.