Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic.

STUDY OBJECTIVE: To study the efficacy of intravenous ketorolac, morphine, and both drugs in combination in reducing pain in acute renal colic. METHODS: We conducted a prospective, double-blinded, randomized controlled trial in an urban, teaching emergency department. Patients aged 18 to 55 years and with a clinical diagnosis of acute renal colic and a pain rating greater than 5 on a 10-cm visual analogue scale or at least "moderate pain" on a 4-category verbal pain scale were eligible for inclusion. Exclusion criteria were contraindication to nonsteroidal anti-inflammatory drugs or opiates, a history of drug dependence, presence of peritonitis, or analgesics within 6 hours of presentation. Patients received either morphine 5 mg at time zero and 5 mg at 20 minutes, ketorolac 15 mg at time zero and 15 mg at 20 minutes, or a combination of both. Primary outcomes were pain reduction and the need for rescue analgesia at 40 minutes. RESULTS: Of the 555 consecutive patients screened, 158 patients met inclusion criteria and 130 patients were randomized during 6 months. Mean difference in change in pain score (visual analog scale 40 minutes minus visual analog scale 0 minutes) between combination group and morphine group was 1.8 cm (95% confidence interval [CI] -3.3 to -0.1) and, compared to the ketorolac group, was 2.2 cm (95% CI -3.7 to -0.5); P<.003. Patients with combination therapy were less likely to require rescue morphine compared to the morphine group (odds ratio 0.2; 95% CI 0.1 to 0.7; P=.007). CONCLUSION: A combination of morphine and ketorolac offered pain relief superior to either drug alone and was associated with a decreased requirement for rescue analgesia.

Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?

OBJECTIVES: We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally. BACKGROUND: Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA). METHODS: We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals. RESULTS: Top performers were those with median door-to-balloon times of < or =90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG. CONCLUSIONS: Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.