Procedural sedation and analgesia in a C”>American Journal of Emergency Medicine (2011) 29, 1083-1088

Original Contribution

Procedural sedation and analgesia in a Canadian ED: a time-in-motion study^?,??

Jaime Bawden HBSc ^a,b, Cristina Villa-Roel MD, MSc ^b, Mira Singh MA ^b, Gregg Fabris B. Soc. Sc. ^c, Ken Bond BEd, MA ^d, Debbie Boyko RN ^b,

Danielle Anstett HBSc ^a, Konrad Fassbender PhD ^e, Brian H. Rowe MD, MSc ^b,f,?

^aFaculty of Medicine, National University of Ireland Galway, Ireland

^bDepartment of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada ^cDepartment of Economics, Dalhousie University, Halifax, Nova Scotia, Canada ^dDepartment of Pediatrics, University of Alberta, Edmonton, Alberta, Canada ^eDepartment of Oncology, University of Alberta, Edmonton, Alberta, Canada

^fSchool of Public Health, University of Alberta, Edmonton, Alberta, Canada

Received 24 April 2010; revised 24 June 2010; accepted 27 June 2010

Abstract

Introduction: Some patients presenting to emergency departments (EDs) suffer from conditions requiring potentially painful treatment; procedural sedation and analgesia (PSA) are important components of their management. The purpose of this study was to determine the resources used during the administration of PSA.

Methods: This prospective observational study was conducted in a Canadian urban teaching center. Detailed data concerning the dosage of PSA medications, adverse events, and ED times for patients requiring PSA for treatment of fractures, reductions of Joint dislocations, and cardioversion for atrial fibrillation were collected. Descriptive analyses included proportions, means with standard deviations, and medians with interquartile ranges.

Results: Of the 177 PSA cases considered for analysis, 69.5% were Orthopedic manipulations and 30.5% were cardioversions. Propofol alone or combined with fentanyl was the commonest medication, and 27 minor adverse events were documented. The median number of staff used in each PSA was 4 (4, 4). The median time from triage to the start of the procedure was 175 minutes (98, 259). The median time from the end of monitoring to discharge was 186 minutes (104, 316). The median time from the start of PSA administration to the end of patient monitoring was 12 minutes for fractures/dislocations and 7 minutes for cardioversion. The Total ED length of stay was 6.6 hours.

^? Data from this study were presented at the following scientific meeting: Canadian Association of Emergency Physicians Annual Scientific Meeting, Montreal, Quebec, Canada, May 29-June 2 2010.

^?? We appreciate the partial funding provided by the Canadian Agency for Drugs and Technologies in Health and the Department of Emergency Medicine.

Dr Rowe is supported by the Government of Canada as a 21st Century Canada Research Chair (Ottawa, Ontario).

* Corresponding author. Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2B7. Tel.: +1 780 407 6707; fax: +1 780 407 3982.

E-mail address: [email protected] (B.H. Rowe).

0735-6757/$ - see front matter (C) 2011 doi:10.1016/j.ajem.2010.06.036

Conclusion: Procedural sedation and analgesia are potentially time-consuming interventions requiring the coordination of ED staff; delays in procedures represent opportunities to reduce ED overcrowding. Procedural sedation and analgesia guidelines may assist with standardization.

(C) 2011

Introduction

More than 14 million emergency department (ED) visits are made annually by Canadians [1]. Patients presenting to the ED are often suffering from conditions requiring procedures or treatments that induce considerable pain, such as orthopedic manipulations or electrical cardioversion. Proce- dural sedation and analgesia (PSA) are frequently used standard of care in many EDs that involve administering sedatives or dissociative drugs with or without analgesics [2] and are increasingly important components of the manage- ment of these patients. Procedural sedation and analgesia enable patients to undergo painful and unpleasant procedures outside of an operating room setting, while maintaining cardioRespiratory function, allowing ED physicians to per- form these procedures safely, effectively, and humanely [3-7]. Procedures requiring PSA involve a variety of health care professionals; in busy EDs, gathering all the individuals required to perform such procedures can prove difficult and may result in delays in treatment. For example, PSA on a patient presenting to the ED with a joint dislocation often require contributions from 2 physicians, a nurse, a respiratory therapist (RT), and an orthopedic technician (OT). Whereas the physicians and OT are usually in charge of the reduction and drug administration, the RT assists the physician with airway monitoring; and the nurse remains with the patient until he/she no longer requires one-to-one monitoring. To date, the majority of research on PSA performed in EDs has focused solely on the efficacy and safety of PSA. Several studies have been conducted to examine the differences between commonly administered PSA medications, pain and memory recall of patients [4,5], success of procedures using PSA [4,6-8], satisfaction of care [4,6,8,9], and adverse events associated with PSA [4,6,10]. Data focusing on PSA treatment times and the amount of time required by each health care professional involved, however, are quite limited. In the current literature, the most commonly reported time data are restricted to those of PSA administration until patient recovery (patient no longer requires monitoring) [6,8], without considering the amount of time required of each individual health care professional involved or the total amount of time from triage to

admission/discharge from the ED.

The purpose of the current study was to determine the resources and times associated with the administration of PSA to patients requiring treatment of fracture/dislocation reductions and electrical cardioversion in the ED. This study was designed to help provide a more comprehensive understanding of the time required of physicians and other health care workers for the administration of PSA. Secondary

objectives included the adequacy of sedation and the number of adverse events experienced by patients.

Methods

Study design

This was a prospective observational time study of ED health care professionals involved in the care of patients over the course of PSA administration and recovery period between July 19, 2007, and December 11, 2009.

Setting

This study was performed at the University of Alberta Hospital ED, a large urban teaching center with approximately 75 000 patient visits per year. The center is a tertiary referral center with trauma, burns, and pediatric specialization.

PSA process and clinical practice guideline

For documentation purposes, a specific PSA monitoring form is recommended by the Canadian Consensus Guide- lines when performing PSA in Canadian EDs and was used in this study [11]. This form is mandatory at the University of Alberta Hospital (including the ED) and includes documen- tation of the patient’s American Society of Anesthesiolo- gists’ (ASA) Physical Status classification, weight (in kilograms), allergies, and time of last oral intake (solids and liquids) before sedation. In addition, vital signs and oxygen saturation are recorded before drug administration, as well as regularly during the procedure until Full recovery. Also included in the form are drug administration times and doses, as well as an evaluation of any adverse events and adequacy of sedation during the procedure.

The ASA classification has been widely used since its inception in 1941 [12]; it serves as a guide to evaluate the severity of a patient’s condition and assess the degree of a patient’s physical state. The 5 classes are as follows: I = healthy patient, II = mild systemic disease (no Functional limitation), III = severe systemic disease (definite functional limitation), IV = severe systemic disease that is a constant threat to life, and V = moribund patient not expected to survive without the operation [13].

At the University of Alberta Hospital, PSA are performed at the discretion of the treating emergency physician and typically involve 4 qualified staff for electrical cardioversion (eg, a nurse, procedural and sedation physicians, and an RT)

and 5 for orthopedic manipulations (as above with the addition of an OT).

Selection of participants

All adult (>=17 years of age) patients presenting to the ED requiring procedural sedation for the treatment of simple orthopedic injuries (fractures or reduction of major joint dislocation) or cardioversion to treat atrial fibrillation were eligible for study inclusion. Patients were excluded if they were younger than 17 years (Pediatric cases), had a chronic health condition (ASA class >=III), or requirED procedural sedation for the treatment of more than one orthopedic manipulation (eg, bilateral wrist fracture).

Data collection and processing

Before the start of the procedure, the research assistant on

Table 1 Patients requiring PSA at the University of Alberta hospital (N = 177)

Demographics

Age (mean +- SD, y) 53.7 (+-20.3)

Female sex, n (%) 95 (53.7%) Causes of attention/procedures,

n (%)

Fractures and dislocations 123 (69.5%)

Cardioversion 54 (30.5%) ASA classification, n (%)

I 76 (42.9%)

II-III 70 (39.5%)

IV-V 2 (1.1%)

ND 29 (16.4%)

Medication, n (%)

Propofol or propofol +- fentanyl 153 (86.4%) ketamine alone 1 (0.6%)

Ketafol 7 (3.9%)

Fentanyl +- midazolam 1 (0.6%) Outcomes, n (%)

call was notified and attended the procedure. During the

course of the PSA procedure, detailed data on the number and

Accomplished procedure with no difficulty ^a

118 (66.7%)

composition of health professionals involved, dosage of PSA

drugs administered, procedure and Recovery times, procedural

Adverse events 27 (15.2%) Timing

success, adverse events, and the total ED length of stay were collected by trained research assistants using a standardized form. Patient demographics and disposition were recorded from the ED electronic information system. Additional information was obtained from the PSA form including the ASA patient classification for sedation, adequacy of sedation, and postprocedure assessment.

Statistical analysis

Data analyses were performed using Stata Statistical

Procedure physician time (mean +- SD; n = 174; min) Sedation physician time (mean +- SD; min)

Nursing time

(mean +- SD; n = 102; min) Respiratory therapist time (mean +- SD; n = 175; min) Orthopedic technician time (mean +- SD; n = 92; min) Time triage-start meds (median [IQR], h)

13.8 (+-6.4)

15.7 (+-6.0)

12.7 (+-7.7)

18.4 (+-7.1)

16 (+-7.4)

2.8 (1.6, 4.2)

Software Release 10.0 (Stata Corporation, College Station,

Admitted (n = 78, hrs) 2.8 (1.5, 4.4)

Discharged (n = 99, hrs) 2.8 (1.6, 4.1)

Time start meds-start procedure (median [IQR], min)

Time involving procedure and end monitoring

(median [IQR], min)

Time start meds-end monitoring (median [IQR], min)

Time end monitoring-ED departure (median [IQR], h)

4 (2.5, 6.0)

9 (6.9, 13)

14 (11.0, 18)

3.1 (1.7, 5.3)

Admitted (n = 78, h) 5.1 (3.5, 7.3)

Discharged (n = 99, h) 2.1 (1.4, 3.4)

Time start meds-discharge/admitted (median [IQR], h)

3.3 (2.0, 5.4)

Admitted (n = 78, h) 5.3 (3.6, 7.5)

Discharged (n = 99, h) 2.4 (1.6, 3.4)

Total ED LOS (median [IQR], h)

6.6 (4.9, 8.7)

Fig. 1 Patient flow.

Admitted (n = 77, h) 8.2 (6.4, 11.1)

Discharged (n = 99, h) 5.3 (4.0, 7.7)

ND = not documented.

^a Available for 129 patients.

TX). Descriptive analyses include proportions for cate- gorical variables, and means with standard deviations (+-SDs) or medians with interquartile ranges (IQRs) for continuous variables.

Ethics

The protocol for this study was approved by the Health Research Ethics Board of the University of Alberta. Patient consent was not required for this study.

Results

Demographics

A total of 184 eligible study patients presented to the ED during the study. Exclusions occurred as follows: more than one orthopedic manipulation (n = 4), reduction of minor joint dislocation (n = 2), and complex orthopedic procedure (Hip fracture requiring Steinmann pin insertion [n = 1]) (Fig. 1). Of the 177 PSA considered for analysis, 123 (69.5%) were orthopedic manipulations and 54 (30.5%) were cardioversions. The mean age of patients was 54 years, and

54% were female.

Medication

Propofol alone or combined with fentanyl was the most commonly administered medication (86%); and the median dosages administered were 100 mg (60, 140) and 100 ug (50, 100), respectively. Self-limited and minor adverse events were documented in 27 patients (15%). No serious adverse events occurred.

Fig. 2 ED times for patients presenting with fractures and dislocations.

Fig. 3 ED times for patients requiring cardioversion.

Resources and ED times

The median number of staff used in each PSA was 4 (4, 4). Details on staff’s timing are summarized in Table 1. The median time from triage to the start of the procedure was 175 minutes (98, 259), the median time involving procedure and monitoring was 9 minutes, and the median time from the end of monitoring to discharge was 186 minutes (104, 316). The total ED LOS was 6.6 hours. Specific ED times for orthopedic procedures and cardioversion are presented in Figs. 2 and 3.

Discussion

This prospective observational study collected valid, accurate, and comprehensive data on the time and resources required to perform PSA on common ED procedures. We found that propofol alone or combined with fentanyl was the most commonly used PSA medication (86%) and that only self-limited and minor adverse events were associated with their administration. Overall, 4 staff were required during the procedures; and the median time involving procedure and monitoring was 9 minutes (with approximately 3 hours elapsing between triage and start of the PSA and the end of monitoring to discharge; totaling an approximate ED LOS of 6-7 hours). Although these times varied significantly according to the type of intervention, these LOS statistics clearly contribute to ED overcrowding and patient dissatis- faction with care.

These results provide valuable information for costing and health economic evaluation of various PSA agents and approaches (eg, propofol vs ketafol) and will assist decision makers in planning for ED resources in the future. Although PSA have the potential to reduce hospital admissions, relieve

pain and suffering, and address ED overcrowding, they must be resourced appropriately, founded upon evidence-based protocols, and subjected to continuous quality improvement. Without data like those presented here, evaluations of the cost-effectiveness of these interventions can be inaccurate and misleading [14]. Finally, the results identified serious delays at either end of the PSA that contribute to ED overcrowding and point to areas where entry to and exit from PSA procedures can be improved.

In most Tertiary ED centers, PSA are now common events. Despite the focus on efficacy and safety of PSA, little has been done on the economic evaluation of the PSA agents and/or the procedures themselves. A systematic review and health technology assessment performed in 2007 for the Canadian Agency for Drugs and Technologies in Health [14] identified 41 studies relating to the cost-effectiveness of ED PSA agents, only 2 of which compared the costs and health consequences of short-acting agents for ED PSA [15,16]. Both of these studies compared propofol and midazolam for adult PSA of painful procedures in the ED; significant cost differences between the 2 sedation strategies were found, with propofol being the more cost-effective of the 2 [15,16]. Because of the limited data available on the economic evaluation of PSA agents and procedures, Bond et al [14] addressed the cost-effectiveness of PSA drugs compared with each other and with conventional opioid and benzodiazepine agents for adult patients requiring PSA for orthopedic manipulations or nonelective cardiover- sions in the ED. The costs associated with each PSA event- from the time of ED admission until discharge/hospitalization

-were calculated according to the Canadian Guidelines for Economic Evaluation [17]. Cost-minimization analysis com- paring different PSA strategies included costs associated with sedative medications, personnel, procedural success, adverse events, hospitalization, and treatment times. Using preliminary data from the study reported here, Bond et al determined that propofol yielded the greatest cost savings per procedure ($335.70 CAD) compared with other PSA drugs and conventional therapy. Ultimately, the ability to examine the utility of PSA agents in the ED relies on valid efficacy, safety, and cost data.

Procedural sedation and analgesia guidelines often necessitate the presence of multiple health care professionals during procedures involving PSA. As previously mentioned, our ED requires 4 qualified staff for electrical cardioversion and 5 for orthopedic manipulations. In busy teaching EDs, such as the one involved in this study, gathering all individuals required to perform these procedures can prove difficult and potentially lead to delays in treatment. Moreover, shifting busy health care workers within the demanding environment of the ED could result in patient neglect-both of the patient involved in the PSA and of those left briefly while health care workers attend the PSA procedure. For this reason, interventions designed to reduce delays seem appropriate in this setting.

Triage liaison physicians (TLPs) have been introduced into some overcrowded EDs and represent a potential for

reducing pre-PSA delays. The TLPs are responsible for facilitating patient flow through the ED to help expedite patient care and reduce overall LOS [18]. In addition, the TLPs act to support Triage nurses, answer incoming physician calls, liaise with ED physicians, and assess Ambulance patients at presentation. Emergency departments should explore using the TLP in lieu of a second ED physician during PSA procedures. As well, to speed up the process, TLPs could request radiographs for patients before seeing the treating physician if they are likely to require orthopedic manipulation. Further research evaluating the impact of TLP use to reduce delays in patient care should be completed.

Other options to reduce delays include focusing on the staff and procedures required to complete a PSA procedure. For example, studies have shown that PSA can be performed effectively and safely in the ED by a single ED physician with a nurse present for patient monitoring [19,20]. Moreover, Sacchetti and colleagues [20] demonstrated that, in a community setting, there is no difference in the occurrence of complications with a single ED physician performing both the sedation and procedure compared with having 2 ED physicians each being responsible for performing only one task. In addition, Campbell et al found that specially trained Advanced Care Paramedics (ACPs), under the supervision of an ED physician, could effectively assist with drug administration and patient monitoring [10]. The use of ACPs was deemed appropriate during PSA because they are proficient in patient monitoring and airway management. Advanced Care Paramedics would eliminate the need for a sedation physician and possibly RTs. Finally, for orthopedic manipulations, delays could be reduced by performing reductions without pre- and/or postreduction imaging [21].

Limitations

Although data for this study were recorded prospectively on a standardized form, it was subject to many of the limitations commonly encountered with retrospective chart reviews. For example, documentation on the PSA forms routinely used in our ED was not always complete, such as the ASA patient classification for sedation and the adequacy of sedation during the PSA event, resulting in missing data. Further research is clearly required on compliance with clinical practice guidelines in the ED setting.

This study was limited to one tertiary care ED center; PSA protocol in this center requires multiple staff members (4 for electrical cardioversion and 5 for orthopedic manipulations). In a nontertiary ED (ie, community or rural centers), single- coverage ED physician staffing is common; and RTs and/or OTs are not always available [14]. We appreciate that these differences in staffing may influence the applicability of results of this study to smaller centers.

Furthermore, this study excluded prolonged or complex procedures (eg, complex lacerations, incision and drainage of

abscesses, orthopedic pinning, and endotracheal intubation), as well as most high-risk patients (ASA class NIII). The results of the study, therefore, may not be entirely generalizable to the ED patient population requiring PSA for the previously mentioned procedures. In addition, as this study was limited to adults (N17 years of age), these results need to be replicated in a sample of children.

For practical reasons, a convenience sample was used, wherein a patient was only included if Research staff were available when the patient presented. This precluded patients who mainly presented overnight or on weekends for PSA when research staff were less often available; these patients may differ with respect to reasons for presentation, resources available, and their ability to comply with instruction. Finally, the definitions of several adverse events on the PSA form used in the ED were not well described (eg, hypotension); however, because this study was not examin- ing efficacy, we do not believe this introduced a bias.

Conclusions

Procedural sedation and analgesia are potentially time- consuming interventions that require the coordination of a variety of ED staff; delays in procedures are common and represent opportunities to reduce ED overcrowding. Varia- tions in practice within and among hospitals suggest guidelines may assist clinicians and institutions with standardization of procedures.

Acknowledgments

The authors are grateful to Virginia Willis for coordinat- ing the time-in-motion study.

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