Article, Traumatology

Factors associated with unoffered trauma analgesia in critical care transport

Original Contribution

Factors associated with unoffered trauma analgesia in critical care transport

Michael A. Frakes APRN, MS, EMTPa,b,?, Wendy R. Lord RN, BSN, EMTPa,d,

Christine Kociszewski EMTP, MPHb, Suzanne K. Wedel MDb,c

aLIFE STAR/Hartford Hospital, PO Box 5037, Hartford, CT 06102-5037, USA

bBoston MedFlight, Bedford, MA 01730, USA

cBoston Medical Center, Boston, MA 02118, USA

dConnecticut Children’s Medical Center, Hartford, CT 06106, USA

Received 16 July 2007; revised 15 January 2008; accepted 16 January 2008

Abstract

Objective: Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-Administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams.

Methods: This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons.

Results: Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 receivED analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n = 145), self-reported pain on a scale from 0 to 10 decreased from 6.8 +- 2.8 to 3.3 +- 2.4 (P <= .001). Three factors were associated with absence of analgesic administration: initial pain level (OR for administration, 0.13; 95% CI, 0.04-0.40), pain scale documentation (OR, 0.31; 95% CI, 0.15-0.60), and transport program (OR, 0.36; 95% CI, 0.17-0.74). No clinical factor was associated with analgesia effectiveness in treated patients.

Conclusion: The identified factors may represent opportunities for CCT teams to optimize analgesic treatment.

(C) 2009

Introduction

* Corresponding author. LIFE STAR/Hartford Hospital, PO Box 5037, Hartford, CT 06102-5037, USA. Tel.: +1 860 545 4369 (Work), +1 860 563 5082 (Home).

Pain relief is a practice focus throughout the health care system and was identified by the Emergency Medical Services Outcomes Project as one of the most relevant out- of-hospital patient care outcome measures [1-4]. The need,

0735-6757/$ – see front matter (C) 2009 doi:10.1016/j.ajem.2008.01.005

safety, and effectiveness of analgesic administration to trauma patients by specialty critical care transport CCT) teams are well reported. Nevertheless, as few as 1.8% of trauma patients receive analgesia from out-of-hospital providers [5]. Speci- alty CCT teams have reported higher administration rates than other out-of-hospital providers but still do not offer analgesia to many trauma patients with pain [5-13]. Even in the emergency department, the overall rate of analgesic delivery hovers near 50%, and it may be that as many as 40% of patients leave without effective pain relief [14-18].

Analgesia is clinically important, as uncontrolled pain triggers stress hormone responses that impair cardiac, pulmonary, and endocrine functions [1-4,19,20]. Ineffec- tively managed pain also has important adverse psycholo- gical effects and has financial consequences as a contributor to health care resource use and lost productivity [3].

Analgesic practice is well reported in emergency medicine, emergency medical services, and critical care transport settings. This project evaluates analgesic adminis- tration to trauma patients by specialty CCT teams; it is novel in the use of pooled data from different CCT agencies and for identifying the factors that distinguish the patients to whom analgesia was not offered.

Methods

This is a retrospective review of a pooled population of trauma patients who reported pain during their transport by 1 of 2 specialty critical care transport programs operating in overlapping New England service areas. Institutional review boards at each organization approved the project.

The programs have similar operational profiles and medical practice standards; both are members of the North East Air Alliance, a confederation of critical care programs with a history of collaborative operations. Program A is a multimodal transport entity completing about 3300 annual transports with fixed-wing, rotor-wing, and ground assets. Team members rotate between transport modes, and the practice standards are uniform across all transport modes. Program B provides rotor wing and ground transport to about 1200 patients annually. Each team uses a critical care transport nurse, partnered at program A with a paramedic and with a respiratory therapist at program B.

Both programs administer fentanyl for analgesia to trauma patients under protocols that do not require online medical direction, and patient care at each program is subject to intensive retrospective quality improvement processes. The maximum protocol doses of fentanyl for trauma analgesia in Nonintubated patients at the 2 programs are 5 and 2 ug/kg per hour, respectively, with individual doses and administration frequencies at clinician discretion. Each program also carries morphine, but the practice standards identify fentanyl as the preferred analgesic for trauma patients. At the time of the study, 46 different providers were administering opioid analgesic medications at the 2 programs.

Consecutive transport records from the second quarter of 2005 were reviewed. These records had not been previously reviewed for any analgesia research.

Enrolled patients met the following criteria: transport for traumatic injury, nonintubated, and a complaint of pain noted in the transport record. Records were abstracted by one of the authors, all of whom have at least 5 years of specialty experience. These data points were retrieved: patient age, sex, lowest systolic blood pressure (SBP), lowest Glasgow Coma Scale score, initial pain self-report using the numeric response scale, pain self-report at transfer of care to the receiving facility, analgesic type and dose, site of origin (scene vs hospital), injury type (isolated limb injury vs other injury), and time of day (day shift vs night shift). The information is recorded in the transport chart and was transferred without interpretation into the research database. The 11-point numeric response scale (NRS) anchored with 0 as no pain and 10 as maximal pain is well validated for clinical practice and pain research. The Emergency Medical Services Outcomes Project recommends the NRS for out-of- hospital use because of greater likelihood of completion, minimized cultural and language barriers, and the ability to perform a pain assessment simultaneously with transport- related tasks [1-4,21-25]. The minimum change required for clinical significance on a 11-point 1-dimensional pain scale is 1.3 arbitrary units (AU) [26,27].

Descriptive statistics and frequencies are reported. Analgesic administration was evaluated using an intent-to- treat analysis to account for patients who were offered analgesic but refused administration. Between-group com- parisons are reported with odds ratios (OR) and their associated 95% confidence intervals (CIs). Comparisons by GCS score were made using a priori distinctions of GCS score of 15, representing best function, and scores between 9 and 15, representing mild and moderate brain injury under established guidelines. Grouping for NRS-based compar- isons (NRS b4 vs NRS >=4) was determined a priori from an evident association identified in a pilot study. For analgesia outcomes, mean comparisons were performed on the population of patients who received analgesia and had NRS documentation before and after that treatment. A univariate analysis of variance controlled for differences in initial pain level. The sample size provided 80% power to detect a difference of 1.3 AU with a 2-sided .05 significance level [28]. Statistics were calculated with SPSS for Windows version 10.1.0 (SPSS, Inc, 1999-2000; SPSS, Chicago, Ill).

Results

Characteristics of study subjects

The 209 study subjects were nearly equally distributed between the 2 programs: 52.6% (n = 110) and 47.4% (n = 99), respectively. Male patients predominated: 154 males

absence of pain scale documentation, and transport program. The relationship between treatment and GCS score approached significance (P = .06). Table 1 reports treatment rates, ORs, and 95% CIs for each of the test factors.

Table 1 Differences in analgesic treatment rate (N = 209

for all)

Factor

(% of patients offered analgesia)

Initial pain self-report NRS b4 (57.9%)

NRS >=4 (91.3%)

Pain scale documentation

NRS documentation absent (67.2%) NRS documentation present (86.9%) Transport program

Program B (72.7%)

Program A (88.2%) Nadir GCS score

Less than 15 (67.5%)

15 (81.1%)

Patient origin Scene (77.0%)

Health care facility (86.2%) Limb injury

Other system injury (77.8%) Limb injury only (84.8%) Time

Day shift (79.2%)

Night shift (85.5%) Patient sex

Female (76.4%)

Male (82.5%)

Nadir SBP

Less than 90 mm Hg (77.8%)

90 mm Hg or higher (81.0%) Age

16 years and older (80.7%)

Younger than 16 years (81.8%)

OR for analgesic administration (95% CI)

0.13 (0.04-0.40)

0.31 (0.15-0.60)

0.36 (0.17-0.74)

0.49 (0.23-1.04)

0.54 (0.26-1.13)

0.63 (0.31-1.29)

0.65 (0.28-1.51)

0.69 (0.33-1.45)

0.82 (0.16-4.10)

0.93 (0.30-2.92)

Analgesia was measured by analysis of the 114 patients (54.5%) who received analgesic and had NRS pain reports documented both before and after medication administration. From an original mean pain report of 6.8 +- 2.8 AU, pain self- report at the end of transport decreased significantly to 3.3 +-

2.4 AU (range, 0-10; P <= .001). Two statistically significant

differences in analgesia effect were identified: patient origin and nadir GCS score. Neither represented a Clinically significant change. Mean Analgesic dose variation was not a significant cofactor in the groups with different analgesia outcomes. Table 2 reports the NRS and dose information for these groups. Patient sex, patient age, time of transport, long bone injury only, and nadir SBP had no association with analgesia effect in these patients.

Most patients (95.9%, n = 141) who received analgesic received fentanyl; the rest received morphine. Mean fentanyl dose was 1.7 +- 1.0 ug/kg (range, 0.37-5.6 ug/kg), and dose correlated poorly with analgesic effect (r = 0.23). Similarly, although mean fentanyl dose differed between the 2 transport programs, there was not a significant difference in analgesia effect between the two (see Table 2).

3.3. Limitations

We acknowledge limitations in our project. The study was completed with information from 2 specific and similar critical care transport teams. Caution is indicated in

(73.7%) and 55 females (26.3%). The mean age was 37.2 +-

Table 2 Differences in analgesia effect (patients with

analgesic administration, pretreatment NRS, and posttreatment NRS; n = 114)

Factor Analgesia effect (AU)

Age

GCS nadir Origin Patient sex Program

SBP nadir

Older than 16: 4.0 +- 2.2

Younger than 16: 5.9 +- 1.5

15: 4.4 +- 2.2 ?

Less than 15: 3.3 +- 2.3

Scene: 3.8 +- 2.2 ?

Interfacility: 4.7 +- 2.2

Male: 4.2 +- 2.3

Female: 4.1 +- 2.3

Program A: 4.4 +- 2.1

Program B 3.8 +- 2.5 More than 90 mm Hg:

4.2 +- 2.3

Less than 90 mm Hg:

4.5 +- 1.9

Day shift: 4.3 +- 2.3

Night shift: 4.1 +- 2.2

Mean fentanyl dose (ug/kg)

1.7 +- 0.9

1.5 +- 1.1

1.7 +- 1.1

1.6 +- 0.7

1.7 +- 1.1

1.8 +- 1.0

1.7 +- 0.9

1.9 +- 1.4

2.0 +- 1.2 ?

1.2 +- 0.7

1.8 +- 1.2

1.7 +- 1.0

Time of transport

1.7 +- 1.1

1.6 +- 1.0

* Significant at P b .5.

19.6 years (range, 3-91 years). There were 58.4% scene patients (n = 122), and 41.6% (n = 87) were transported between hospitals. The nadir SBP in transport ranged between 59 and 193 mm Hg (mean, 121.8 +- 20.9 mm Hg); the mean GCS score was 14.7 +- 0.9 (range, 11-15). For patients on whom a NRS pain self-report was documented (n = 145, 69.4%), initial pain was 6.8 +- 2.8 AU on a 0 to

10 scale (range, 1-10).

Main results

Interrater reliability for the data abstraction was measured with Cohen ? statistic (r = 0.99). Of the 209 enrolled patients, the transport teams administered analgesia to 147 (70.3%). An additional 22 (10.5%) patients were offered analgesic but declined, resulting in an 80.9% analgesic treatment rate (95% CI, 75.6%-86.2%). There were sig- nificant relationships between analgesic absence and 3 evaluated factors: initial pain self-report of less than 4,

extrapolating these results to other transport programs or practice environments, particularly those with dissimilar transport and treatment characteristics.

Structurally, the descriptive design allows demonstration of associations in this group of patients but it is not a randomized, controlled experimental design that would infer any causality. The enrollment of a consecutive number of patients is not a true randomization of enrollees, but the study group is representative of the general trauma population seen in this environment. The transport decision is made by the physician or scene provider, independent of transport program involvement until their arrival at the patient’s side. Accordingly, there is no selection bias in the sample, but trauma care systems with different CCT entry or use criteria might present with different patient population traits. Our study did not evaluate for differences between patients with blunt and penetrating mechanisms of traumatic injury. Although that distinction may not be significant, an evaluation of that hypothesis in this article would have been helpful [17]. Historical data from the study CCT programs suggests that more than 80% of trauma patients transported

have Blunt traumatic injury.

Some of our subgroups were small, which coupled with low nonIntervention rates, resulted in wide CIs for some variables. A study with greater enrolment, from either a longer time horizon or the inclusion of more sites, would help clarify our results. The effect of a relatively small number of patients with both analgesia administration and both pre- and posttreatment NRS documentation particularly limits our insight into analgesia effectiveness.

Finally, this project was not designed to identify the root causes giving rise to those associations. Subsequent confirmation and evaluation of these associations would be helpful.

Discussion

These results validate earlier reports that CCT teams find trauma patients in significant pain at both scene and interhospital locations, that those teams have high interven- tion rates, and that they achieve significant pain reduction for patients [5,11-13].

We have identified factors associated with non-admin- istration of analgesics. Although our data pool is a relatively unique group of patients, those undergoing specialty critical care transport, the existing analgesia literature describes those patients as being cared for by providers with some of the highest reported analgesic intervention rates. In that light, the identification of these factors in the CCT setting may indicate some merit in evaluating these factors in other settings.

The importance of pain scale documentation on analgesic treatment rates is previously well documented, and it is not surprising that such influence extends to the care of patients during critical care transport. It is clear that improving documentation to improve analgesia care is low-hanging fruit for organizational performance improvement [1-3,14- 19,29-31].

Education about the nature of the information achieved from pain assessment may also be helpful. Pain at 2 or 3 on the NRS scale is clinically significant pain, the relief of which is a key out-of-hospital patient outcome [1-4,21,25].A relationship between increasing ED analgesic administration rates and increasing pain self-report magnitude has been reported [18]. We confirm the existence of such a relation- ship and find that it persists in 3 unique circumstances: an environment with higher overall administration rates, patient treatment exclusively with intravenous analgesics, and in the critical care transport environment (see Fig. 1).

Fig. 1 Analgesia administration rate by initial pain report.

We acknowledge that, in addition to lower observed intervention rates, patients in the low NRS group were also more likely to refuse analgesic (63.6%) than those with a pain self-report of 4 or more (13.0%; OR, 11.1; 95% CI, 3.03-50.0). This may illuminate the complexity of the psychosocial dynamics of pain perception and management and would be interesting to evaluate more deeply. It does not diminish, however, the identification of a significant decline in the rate at which analgesia was offered to patients who had reported pain.

It is not particularly surprising that patients with an abnormal GCS score had less analgesia from intervention and approached a significantly lower intervention rate. Presumably, clinicians exercise caution with the use of central nervous system depressant agents in patients whose central nervous system examination is already abnormal, and the National Association of EMS Physicians specifi- cally addresses that caution in their analgesia guidelines [32]. Interestingly, however, the dose of analgesia adminis- tered did not differ between patients with normal and abnormal GCS score during transport. In addition, the analyzed patients with low GCS score and pain documenta- tion had almost exclusively mild brain injuries (95.5% with GCS score 13 or 14). These facts make the differences in treatment and effectiveness less intuitive. We are not able to illuminate further these findings. The impact of GCS score change and the magnitude of GCS score depression on analgesia practice and outcomes would be a worthy future study.

We found an interesting suggestion of an organizational or cultural effect on analgesic administration. The surveyed transport programs serve geographically overlapping areas, have similar medical Treatment protocols, and are members of a regional CCT confederation. Both treated patients at rates among the highest reported in the literature. Still, there were significant dose and administration frequency differ- ences between the 2 otherwise similar programs. Other analgesia literature has documented clear interactions between pain management practices, organizational educa- tion, and quality measures. There are reported successes in altering analgesic administration practices through system- wide educational, informational, and quality improvement initiatives, with improvements in pain assessment, the meaning of pain, pain documentation, and intervention rates [1-3,18-21,29-31]. Such concepts are logically applic- able to critical care transport operations. However, as compelling as the suggestion of the role of organizational culture on analgesic treatment is, we cannot completely exclude the possibility of a clinical influence that was not evaluated in our investigation.

Another interesting suggestion is that organizations could most easily improve analgesic outcomes by simply offering analgesia to more patients. Our projeCT reports very high rates of analgesic treatment for patients who self-report pain, but providers still left 19.1% of those patients untreated. In treated patients, we did not detect any

clinically significant outcome differences, perhaps indicat- ing that clinical factors have a limited affect on analgesia once treatment is begun. Similarly, although the 2 transport programs administered significantly different amounts of analgesic, there were no measurable outcome differences between the two. It may be that, in the hands of expert providers, only the decision to initiate treatment plays a significant role in the amount of pain relief achieved in the CCT environment. A descriptive study of expert practice judgment has similarly suggested that clinical experts administering analgesia are dissatisfied with anything other than complete pain relief as an outcome once treatment is begun [33].

Factors that increase analgesic administration rates, such as increased pain scale documentation rates, provider education programs, and organizational prioritization may be, accordingly, the most beneficial analgesic performance improvement strategies. For example, simply offering analgesia to the untreated patients in this sample who had a documented initial NRS pain level of less than 4 would increase the overall treatment rate by 4.7%.

Conclusion

Specialty critical care transport teams administer narcotic analgesic medication to trauma patients frequently and with significant effect. Non-administration is associated with initial pain report of 3 or lower on scale from 0 to 10, the transporting agency, and the absence of NRS pain scale documentation. We did not detect any clinically significant analgesic Outcome changes between groups of treated patients. Critical care transport teams may be able to optimize the number of patients to whom analgesia is offered by focusing on their consideration of patient pain reports, documentation, and organizational culture.

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