Acute abdominal pain in triage: A retrospective observational study of the Manchester triage system's validity.

OBJECTIVE: Roughly 5% to 10% of patients admitted to the emergency department suffer from acute abdominal pain. Triage plays a key role in patient stratification, identifying patients who need prompt treatment versus those who can safely wait. In this regard, the aim of this study was to estimate the performance of the Manchester Triage System in classifying patients with acute abdominal pain. METHODS: A total of 9,851 patients admitted at the Emergency Department of the Merano Hospital with acute abdominal pain were retrospectively enrolled between 1 January 2017 and 30 June 2019. The study was conducted and reported according to the STROBE statement. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by the patients and their survival at seven days or the need for acute surgery within 72 h after emergency department access. RESULTS: Among the patients with acute abdominal pain (median age 50 years), 0.4% died within seven days and 8.9% required surgery within 72 hours. The sensitivity was 44.7% (29.9-61.5), specificity was 95.4% (94.9-95.8), and negative predictive value was 99.7% (99.2-100) in relation to death at seven days. CONCLUSIONS: The Manchester Triage System shows good specificity and negative predictive value. However, its sensitivity was low due to the amount of incorrect triage prediction in patients with high-priority codes (red/orange), suggesting overtriage in relation to seven-day mortality. This may be a protective measure for the patient. In contrast, the need for acute surgery within 72 h was affected by under-triage. RELEVANCE TO CLINICAL PRACTICE: The triage nurse using Manchester Triage System can correctly prioritise the majority of patients with acute abdominal pain, especially in low acuity patients. The Manchester Triage System is safe and does not underestimate the severity of the patients.

Factors associated with the undertriage of patients with abdominal pain in an emergency room.

INTRODUCTION: The triage process lasts for a very short time, which can result in over-triage and under-triage. Studies have explored factors related to under-triage among trauma patients. In Korea, the clinical characteristics and severity of cases of under-triaged patients have been investigated. However, there is limited research on the under-triage of patients experiencing abdominal pain. Therefore, this study aimed to determine the under-triage rate of emergency department (ED) patients with abdominal pain, as well as the factors associated with their under-triage. METHODS: The participants of this retrospective cohort study were 3,030 adult patients at a single tertiary hospital in Korea, who were brought to the ED for abdominal pain as the chief complaint. Participants' general characteristics, pain-related information, and environmental information were obtained from their electronic medical records. RESULTS: The under-triage rate of ED patients with abdominal pain was 31.0%. Factors related to the under-triage of these patients were sex, age, visit route, time from the onset of the pain to the visit, location of pain, and intensity of pain. CONCLUSION: These findings provide a foundation for the understanding and mitigation of under-triage in EDs through the identification of factors associated with under-triage in patients with abdominal pain.

Consideration of Testicular Torsion in Young Males With Abdominal Pain Is Essential: A Case Review.

Testicular torsion is a surgical emergency and requires prompt recognition and treatment. Health care personnel often forget this differential diagnosis in males who present with abdominal pain as their only complaint. There is a 4- to 6-hour window from the onset of symptoms to the surgical intervention to salvage the testes. It is imperative for health care personnel to consider testicular torsion in any male presenting with abdominal pain and to complete a genitourinary examination. The purpose of this case review is to highlight the importance of a genitourinary examination in recognizing testicular torsion.

The management of patients with acute abdominal pain in the emergency department: A qualitative study of nurse perceptions.

BACKGROUND: Acute abdominal pain is a common reason for presentation to the emergency department. Understanding the role of nurses involved in management of acute abdominal pain is important for improving patient care and outcomes. The aim of this study was to understand the perceptions of emergency nurses in the management of acute abdominal pain. METHODS: Using a qualitative design, a purposeful sample (n=9) of experienced registered nurses was recruited from the emergency department of a large tertiary public hospital in South Australia. Semi-structured interviews, informed by literature describing the management of acute abdominal pain, were used to identify the perceptions of emergency nurses when caring for patients with acute abdominal pain. RESULTS: Thematic analysis of interviews identified four themes: Centrality of Diagnosis; Busyness and Patient Management; Systems Issues; and Communication Challenges. Of the four themes, the Centrality of Diagnosis was especially important to the nurses' sense of contribution to patient care. Care was also affected by the busyness of the environment, the systems and processes in place to manage patients and communication in the emergency department. CONCLUSIONS: The management of patients with acute abdominal pain is influenced by how nurses participate in the diagnostic process. Nurses identified their role in this process and described how this role impacted their delivery of fundamental care. Further studies of the nursing contribution to diagnosis, communication, and the systems that affect care delivery in the emergency department are required.

The Reality of Pain Scoring in the Emergency Department: Findings From a Multiple Case Study Design.

STUDY OBJECTIVE: Documentation of pain severity with pain scores is recommended within emergency departments (EDs) to improve consistency of assessment and management of pain. Pain scores are used in treatment guidelines and triage algorithms to determine pain management and in audit and research to evaluate pain management practices. Despite significant debate of their benefits, there has been limited evaluation of their use in practice. We use naturalistic, qualitative methods to understand how pain scores are used in practice and the mechanisms by which pain scoring may influence pain management. METHODS: We undertook a multiple case study design, using qualitative research in 3 EDs in England (the cases). Case studies incorporated 143 hours of nonparticipant observation, documentary analysis, and semistructured interviews with 36 staff and 19 patients. Data were analyzed with thematic analysis. RESULTS: Analysis identified that ED staff used the pain score for 2 conflicting purposes: as an auditable tool for guiding patient management and as a tool for monitoring patient experience. This led to ED staff's facing conflict between reporting their own judgment of what the pain score ought to be and what the patient said it was. Staff justified recording their own judgment according to concerns of accountability and appropriateness of management decisions. Staff thought that pain scoring had value in raising awareness and prompting action. CONCLUSION: In practice, pain scoring may not accurately reflect patient experience. Using pain scoring to determine the appropriateness of triage and treatment decisions reduces its validity as a measure of patient experience. Pain scoring should not be central to audit and systems of accountability for pain management.

Clinical protocols for adults with acute abdominal pain in Australian emergency departments.

RATIONALE, AIMS AND OBJECTIVES: Patients with acute abdominal pain are a common presentation in hospital emergency departments; however, international studies have demonstrated that hospitals often lack clinical protocols to guide care. This study aimed to investigate whether Australian hospital emergency departments have acute abdominal pain clinical protocols, identify hospital-level predictors of the presence of these clinical protocols, and assess the quality of protocols. METHODS: A survey was sent to all Australian hospitals with emergency departments, collecting data on hospital characteristics and the presence of acute abdominal pain clinical protocols. Participating hospitals (n = 73, 26% response rate) were also asked to provide a copy of these protocols. The quality of these protocols was assessed using Appraisal of Guidelines for REsearch & Evaluation (AGREE) II. RESULTS: Slightly more than half (n = 40) of the hospitals surveyed had acute abdominal pain clinical protocols, while 16 had a general pain protocol. In binomial logistic regression, two independent variables were related to the presence of a protocol, geographic region (P = 0.008) and advanced practice nurses/nurse practitioners' presence on staff (P = 0.024). The mean score for the overall quality assessment of these protocols was 4.2 on a seven-point Likert scale; in terms of the six domains of quality, "Clarity of presentation" and "Scope and purpose" were highest. The overall quality of clinical protocols increased with remoteness, χ2 (3) = 8.341, P = 0.039, and was lower in hospitals with medical staff on site (U = 2.5, P = 0.007). CONCLUSION: There is a documented standard for pain management of acute abdominal pain in about three quarters of participating Australian emergency departments. The use and quality of clinical protocols is influenced by the physical location of hospitals and staff and skill mix of clinicians.

Enhancing Self-management for Adults With Functional Abdominal Pain: A Registered Nurse-Led Cognitive-Behavioral Therapy Approach.

Chronic disease accounts for three-quarters of today's medical expenditures. Functional abdominal pain (FAP) syndrome and associated gastrointestinal symptoms affect 0.5% to 2% of North Americans. Persons with FAP routinely seek healthcare, with little resolution of symptoms, despite high costs. National reports advocate for innovative redesign of ambulatory care services. Cognitive-behavioral therapy (CBT) is a low-cost, effective self-management approach. The objective of this study was to implement a registered nurse-led CBT approach to enhance self-management and satisfaction with care for adults with functional gastrointestinal disorder (FGID). We conducted a pre- and postintervention group comparison study in an outpatient gastroenterology subspecialty clinic within a large medical center. Twelve patients (seen May to July 2015) received nurse-led education about the pain phenomenon and CBT techniques to self-manage pain and associated symptoms of FAP. Methods and effectiveness of CBT for promoting self-management of chronic pain symptoms were reviewed. Subsequently, we conducted a project that incorporated nurse-led CBT into standard practice. Pre- and post-CBT questionnaire data showed patients had improved symptoms, well-being, and satisfaction. Registered nurses practicing at the highest level of their scope of practice within ambulatory care service models can enhance care management by educating, coaching, and counseling to improve self-care for patients with FGID.

Emergency Department Use of Contrast Computed Tomography in Patients With Renal Dysfunction.

The Research to Practice Column is designed to improve translational research critique skills of advanced practice nurses. In this issue, the article "Risk of Acute Kidney Injury After Intravenous Contrast Media Administration" () is discussed in the context of a patient presenting to the emergency department with acute abdominal pain. The study was designed to assess the risk of acute kidney injury and adverse clinical outcomes in patients receiving intravenous contrast for computed tomography. Advanced practice nurses need to be aware of advances in types of intravenous contrast and current recommendations for administration of intravenous contrast for diagnostic purposes in patients at risk for acute kidney injury to facilitate making timely and accurate diagnoses.

Inadequate environment, resources and values lead to missed nursing care: A focused ethnographic study on the surgical ward using the Fundamentals of Care framework.

AIMS AND OBJECTIVES: To explore the delivery of care from the perspective of patients with acute abdominal pain focusing on the contextual factors at system level using the Fundamentals of Care framework. BACKGROUND: The Fundamentals of Care framework describes several contextual and systemic factors that can impact the delivery of care. To deliver high-quality, person-centred care, it is important to understand how these factors affect patients' experiences and care needs. DESIGN: A focused ethnographic approach. METHOD: A total of 20 observations were performed on two surgical wards at a Swedish university hospital. Data were collected using participant observation and informal interviews and analysed using deductive content analysis. RESULTS: The findings, presented in four categories, reflect the value patients place on the caring relationship and a friendly atmosphere on the ward. Patients had concerns about the environment, particularly the high-tempo culture on the ward and its impact on their integrity, rest and sleep, access to information and planning, and need for support in addressing their existential thoughts. The observers also noted that missed nursing care had serious consequences for patient safety. CONCLUSION: Patients with acute abdominal pain were cared for in the high-tempo culture of a surgical ward with limited resources, unclear leadership and challenges to patients' safety. The findings highlight the crucial importance of prioritising and valuing the patients' fundamental care needs for recovery. RELEVANCE TO CLINICAL PRACTICE: Nursing leaders and nurses need to take the lead to reconceptualise the value of fundamental care in the acute care setting. To improve clinical practice, the value of fundamentals of care must be addressed regardless of patient's clinical condition. Providing a caring relationship is paramount to ensure a positive impact on patient's well-being and recovery.

School Nurses on the Front Lines of Medicine: An Adolescent Female Student with Severe Abdominal Pain.

Abdominal pain is a common chief complaint encountered by school nurses. This article explains the etiology of abdominal pain in children and adolescents, describes the office assessment, and delineates life-threatening conditions associated with severe abdominal pain that may prompt the school nurse to transfer the student to a local emergency department.

Why Do Patients Return to the Emergency Department?

Review of recent evidence with translation to practice for the advanced practice nurse (APN) role is presented using a case study module for "Return Visits to the Emergency Department: The Patient Perspective." This qualitative inquiry performed 60 semistructured interviews of patients who returned to the emergency department within 9 days of their primary visit for the same complaint. Patients most often returned because of concerns that their initial visit did not adequately address their complaint, and they needed assurance from providers that their clinical condition was not a serious health concern. Patients also expressed a lack of contact with a provider between the 2 visits either to answer questions or to address ongoing concerns. This study highlights the important role of the APN in providing quality care, reassurance, and communication related to follow-up care.

Implementation of an Advanced Nursing Directive for Children With Right Lower Quadrant Pain: Identifying Those Requiring Further Investigation and Improving Flow Metrics.

OBJECTIVES: Advanced nursing directives (ANDs) empower nursing staff to provide advanced levels of care before physician assessment. The objectives of this study were (1) to determine whether an AND for right lower quadrant (RLQ) pain could identify children who required any further investigation to diagnose appendicitis and (2) to determine whether children meeting AND criteria had better emergency department (ED) flow metrics compared with those who did not meet the criteria. METHODS: Health records of children aged 3 to 17 years presenting to the ED with abdominal pain who were managed using the departmental AND for RLQ pain were reviewed. Primary outcomes included (1) the proportion of patients requiring further investigation to diagnose appendicitis and (2) the time interval from triage to blood draw. Secondary outcomes included additional ED flow metrics, perforation rate, and negative appendectomy rate. RESULTS: An AND was completed for 210 children. Those who met the AND criteria were more likely to undergo further investigation to rule out appendicitis than those who did not meet the criteria (92/137 [67.2%] vs 32/73 [43.8%]; odds ratio [OR], 2.62; 95% confidence interval [CI], 1.40-4.90). Time to blood draw was significantly lower for those children meeting the AND criteria (74 vs 162 minutes, P < 0.001) as was time to hospital admission (271 vs 395 minutes, P = 0.008) and appendectomy (498 vs 602 minutes, P = 0.015). The negative appendectomy rate was 8.6% (5/58) for children meeting the AND criteria and 9.1% (2/22) for those not meeting the criteria (OR, 0.94; 95% CI, 0.14-10.67); the perforation rate was 29.3% (17/58) and 4.5% (1/22), respectively (OR, 8.17; 95% CI, 1.17-380.86). CONCLUSIONS: Children presenting to the ED with RLQ pain who meet the AND criteria are more likely to require further investigation to rule out appendicitis and have better department flow metrics than those who do not meet the criteria. Our results provide further evidence of the utility of ANDs in the ED.

Perfil de los pacientes sometidos a colonoscopia en un hospital universitario / Perfil dos pacientes submetidos à colonoscopia em um hospital universitário / Perfil dos pacientes submetidos à colonoscopia em um hospital universitário / Profile of the patients submitted to colonoscopy in a university hospital

Esta investigación tuvo como objetivo analizar las características sociodemográficas y clínicas, tabaquismo, alcoholismo, práctica de ejercicios físicos de pacientes sometidos a colonoscopia, en el período de febrero a junio de 2012. Se ha observado que en los 84 pacientes entrevistados los síntomas de mayor prevalencia que llevaron a la indicación de la Colonoscopia fueron el dolor abdominal con 39 (46,4%). De los entrevistados cinco (6%) presentaron cáncer colorrectal (CCR), y la historia familiar de esta neoplasia fue relatada por 18 (21,4%) personas y la neoplasia en cuestión apareció en cinco (6%) de los encuestados, el tabaquismo estuvo presente en 17 (20,2%) de los pacientes y el consumo de bebida alcohólica fue negada por 26 (31%) de los entrevistados. En relación a la práctica de actividad física 71 (84,5%) de los pacientes eran insuficientemente activos (AU)

Esta pesquisa objetivou-se em analisar as características sociodemográficas e clínicas, tabagismo, alcoolismo e prática de exercícios físicos de pacientes submetidos à Colonoscopia, no período de fevereiro a junho de 2012. Verificou-se entre os 84 pacientes entrevistados o sintoma de maior prevalência que levou a indicação da Colonoscopia foi à dor abdominal 39 (46,4%). Ressalta-se a história familiar de neoplasia colorretal que apareceu em 18 (21,4%) dos pacientes e a neoplasia em questão apareceu em cinco (6%) dos entrevistados, a neoplasia o tabagismo esteve presente em 17 (20,2%) e o consumo de bebida alcoólica foi negada por 26 (31%) pacientes. Relacionado à prática de atividade física, 71 (84,5%) dos entrevistados são insuficientemente ativos

This research had the goal of analyzing the sociodemographic and clinical characteristics, food habits, smoking, alcoholism, practice of physical exercises and abdominal symptoms of patients submitted to colonoscopy during the period from february to June, 2012. It was observed that in the 84 patients interviewed the symptoms of higher prevalence that led to indication of colonoscopy were abdominal pain in 39 (46.4%). From the interviewed ones five (6%) presented CRC and familial history of this carcinoma was reported by 18 (21.4%) and neoplasm in question appeared in five (6%) of respondents, smoking was present in 17 (20.2%) of the patients and alcoholic beverage consumption was denied by 26 (31%) of the interviewed ones. Related to practice of physical exercises 71 (84.5%) of the patients were insufficiently active (AU)

To Receive or Not to Receive Analgesics in the Emergency Department: The Importance of the Pain Intensity Assessment and Initial Nursing Assessment.

Patients seeking emergency care for abdominal pain still experience poor pain management. Pain intensity is not always seen as a mandatory parameter in the initial nurse assessment. Despite the development of nurse-initiated analgesic protocols, many patients do not receive analgesics in the emergency department. The aim of this study was to describe initial nursing assessment related to pain management and to identify predictors for receiving or not receiving analgesics in the emergency department. The sample consists of 100 patients from an intervention group in a previously undertaken Swedish intervention study. The main findings were that the registered nurses assessed 62 patients as being in need of analgesics, and that 52 of these obtained analgesics. The majority of the patients assessed as not being in need of analgesics did not receive analgesics because they did not want medication. Median value for pain intensity at initial assessment was 6 on the numerical rating scale. The results for the logistic regression (n = 80) showed significant differences between receiving analgesics/not receiving analgesics and the predictor pain intensity (measured at initial nurse assessment). Nurses in emergency departments play a crucial role, in that their initial assessment is of specific importance for the patient's further care and whether the patient may or may not receive analgesics. However, more attention has to be paid to patients' experiences and their expectations regarding the pain management in the emergency department. These complex questions have to be studied further in a more systematic way.

Treating abdominal pain in young people.

A common complaint in children, abdominal pain can be clinically challenging for healthcare professionals to diagnose and treat. Accurate assessment and thorough investigations, combined with the measurement and monitoring of vital signs, are essential to eliminate any underlying conditions. Self-reporting tools can be used to aid communication with children, who may have difficulties articulating their thoughts and feelings. This article refers to a case study to discuss the care of children who present to emergency departments (EDs) with abdominal pain. It suggests that children's nursing students can be valuable assets in busy EDs because they have the knowledge and skills required to care for young people.

Assessment of inflammatory bowel disease patient's needs and problems from a nursing perspective.

BACKGROUND: In this study, we aimed at assessing Inflammatory Bowel Disease patients' needs and current nursing practice to investigate to what extent consensus statements (European Crohn's and Colitis Organization) on the nursing roles in caring for patients with IBD concur with local practice. METHODS: We used a mixed-method convergent design to combine quantitative data prospectively collected in the Swiss IBD cohort study and qualitative data from structured interviews with IBD healthcare experts. Symptoms, quality of life, and anxiety and depression scores were retrieved from physician charts and patient self-reported questionnaires. Descriptive analyses were performed based on quantitative and qualitative data. RESULTS: 230 patients of a single center were included, 60% of patients were males, and median age was 40 (range 18-85). The prevalence of abdominal pain was 42%. Self-reported data were obtained from 75 out of 230 patients. General health was perceived significantly lower compared with the general population (p < 0.001). Prevalence of tiredness was 73%; sleep problems, 78%; issues related to work, 20%; sexual constraints, 35%; diarrhea, 67%; being afraid of not finding a bathroom, 42%; depression, 11%; and anxiety symptoms, 23%. According to experts' interviews, the consensus statements are found mostly relevant with many recommendations that are not yet realized in clinical practice. CONCLUSION: Identified prevalence may help clinicians in detecting patients at risk and improve patient management.

Experiences of Indonesian mother managing preschool children's acute abdominal pain in Taiwan.

The aim of this study was to understand the Indonesian mothers' experiences of managing preschool children's acute abdominal pain. The descriptive qualitative research design comprises semi-structured interviews with 11 Indonesian mothers. The qualitative content analysis revealed three themes, including (1) insight of abdominal pain, (2) "inheritance of the strategies for assessment of management for abdominal pain from the family of origin", (3) "obstacles and insights related to cultural differences". The results presented that pain management was affected by family, environment, cultural background and religious beliefs. Healthcare providers should provide culturally competent pain management care for the patients of difference nationalities.

Perspectives of patients with acute abdominal pain in an emergency department observation unit and a surgical assessment unit: a prospective comparative study.

AIMS AND OBJECTIVES: To investigate the patient perspective when admitted with acute abdominal pain to an emergency department observation unit compared with the perspective when admitted to a surgical assessment unit. BACKGROUND: An increase in emergency department observation units has led to more short-term admissions and has changed the patient journey from admission to specialised wards staffed by specialist nurses to stays in units staffed by emergency nurses. DESIGN: A comparative field study. METHODS: The study included 21 patients. Participant observation and qualitative interviews were performed, and the analyses were phenomenological-hermeneutic. RESULTS: Emergency department observation unit patients had extensive interaction with health professionals, which could create distrust. Surgical assessment unit patients experienced lack of interaction with nurses, also creating distrust. Emergency department observation unit patients had more encounters with fellow patients than the surgical assessment unit patients did, which was beneficial when needing assistance, but disturbing when needing rest. The limited contact with other patients in the surgical assessment unit revealed the opposite effect. In both units, there was nonpersonalised care, making it difficult for patients to make informed decisions. CONCLUSION: The multibedded rooms in the emergency department observation unit had a positive influence on patient­nurse interaction, but a negative influence on privacy; the opposite was found in the surgical assessment unit with its rooms with fewer beds. The extensive professional­patient interactions in the emergency department observation unit created distrust. The limited professional­patient interaction in the surgical assessment unit did the same. That the emergency department observation unit was staffed by emergency nurses seemed to have a positive influence on the length of patient­nurse interactions, while the surgical assessment unit staffed by specialist nurses seemed to have the opposite effect. There was lack of information and personalised care in both units. RELEVANCE TO CLINICAL PRACTICE: Units receiving acute patients need to provide personalised care and information about how the unit functions and about care and treatment to improve the patients' ability to make decisions during admission.