Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription.

Background: Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon. Objective: This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED. Methods: A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression. Results: A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not. Conclusion: This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices.

Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on "real" reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to "Pain reassessment" (61.0%) and/or "alternative treatment prioritization" (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of "simulated" prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.

Intravenous morphine titration vs. oral hydrocodone/acetaminophen for adults with lower extremity displaced fracture in an emergency department setting: A randomized controlled trial.

The objective of the present study was to test the hypothesis that intravenous morphine titration provides superior analgesia to oral hydrocodone/acetaminophen for patients with lower extremity displaced fracture in an emergency department (ED) setting. A prospective, randomized clinical trial of ED patients suffering acute lower extremity displaced fracture pain was performed with a total of 206 participants included. After application of exclusion criteria, the cohort comprised 166 patients, 85 of which were randomly allocated to the oral hydrocodone/acetaminophen (5 mg/500 mg) group and 81 to the intravenous morphine titration (every 5 min by 3-mg increments) group. The main outcome was the visual analogue scale (VAS) at different time-points after the first dose of analgesic was administered. Secondary outcomes included the VAS change during the skeletal traction operation and short-term adverse events. The results demonstrated that the initial VSA of the participants was similar at the baseline on arrival at the ED (P=0.2582). At the time-points of 5, 15, 30 min after the first dose of analgesic administered, the intravenous morphine titration group exhibited a greater VAS reduction compared with that in the oral hydrocodone/acetaminophen group (P<0.01). The differences between the 2 groups were not statistically significant at 1 h or thereafter. The incidence of short-term adverse events was similar between the 2 groups but sedation, whose incidence in the morphine group was markedly increased, may not be arbitrarily attributed to adverse events. It was concluded that, compared with oral hydrocodone/acetaminophen, intravenous morphine titration provided a rapid and sufficient pain relief and equivalent short-term adverse events for patients with lower extremity displaced fracture in an ED setting.