Article, Emergency Medicine

Quality of care for joint dislocation in 47 US EDs

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 1105-1113

Original Contribution

Quality of care for joint dislocation in 47 US EDs?,??

Chu-Lin Tsai MD, ScD a, Ashley F. Sullivan MS, MPH a, James A. Gordon MD, MPA a, b, Rainu Kaushal MD, MPH c, David J. Magid MD, MPH d, e, f,

David Blumenthal MD, MPP b, g, Carlos A. Camargo Jr. MD, DrPH a, b,?

aDepartment of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA bMongan Institute for Health Policy, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA cWeill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA

dDepartment of Emergency Medicine and Institute for Health Research, Kaiser Permanente Colorado,

University of Colorado Denver, Aurora, CO 80231, USA

eDepartment of Preventive Medicine and Institute for Health Research, Kaiser Permanente Colorado,

University of Colorado Denver, Aurora, CO 80231, USA

fDepartment of Biometrics and Institute for Health Research, Kaiser Permanente Colorado, University of Colorado Denver,

Aurora, CO 80231, USA

gOffice of the National Coordinator for Health information technology, Department of Health and Human Services, Washington, DC 20201, USA

Received 8 June 2011; revised 20 July 2011; accepted 21 July 2011

Abstract

Background: Little is known about emergency department (ED) quality of care for joint dislocation. We sought to determine concordance of ED management of dislocation with Guideline recommendations and to assess whether higher concordance was associated with better patient outcomes.

Methods: We conducted a retrospective chart review study of joint dislocation as part of the National ED Safety Study (www.emnet-usa.org). We identified all charts with a primary ED or hospital discharge diagnosis of joint dislocation in 47 EDs across 19 US states between 2003 and 2005. Concordance with guideline recommendations was evaluated using 5 individual quality measures and composite guideline concordance scores. Concordance scores were calculated as the percentage of eligible patients receiving guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.

Results: The cohort consisted of 1980 ED patients; the patients’ median age was 38 years, and 63% were men. Care for dislocation was excellent, with a concordance score of more than 85 across all quality measures. The median ED composite guideline concordance score was 93 (interquartile range, 90-95). In multivariable analyses, receiving treatment in EDs with the highest (fourth quartile) composite guideline concordance scores was independently associated with a significantly higher likelihood of successful joint reduction (adjusted odds ratio, 3.28; 95% confidence interval, 1.38-7.81), as compared with treatment in EDs with the lowest (first quartile) scores.

? This study was supported by grant R01 HS013099 from the Agency for Healthcare Research and Quality (Rockville, MD).

?? The authors have no conflicts of interest to disclose.

* Corresponding author. Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114. Tel.: +1 617 7265276; fax: +1 617 724 4050.

E-mail address: [email protected] (C.A. Camargo).

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.07.012

Conclusions: Concordance of ED management of joint dislocation with guideline recommendations was high. Greater concordance with guideline-recommended care may increase the likelihood of successful joint reduction.

(C) 2012

Introduction

Each year in the United States, approximately 7 million emergency department (ED) visits are due to musculoskel- etal diseases [1]. Approximately 8% of these visits (555 000) are attributable to joint dislocation [1,2]. Care for joint dislocation in the ED requires adequate analgesia, and for a subset of care involving procedural sedation, careful assessment and monitoring are needed.

Procedural sedation and analgesia (PSA) have received considerable attention in recent years, particularly in the ED setting. It refers to the technique of administering sedatives or dissociative agents with analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardioRespiratory function [3]. There are several guidelines and policies on PSA in the ED. In 2001, the Joint Commission on the Accreditation of Healthcare Organiza- tions (JCAHO) made the assessment and treatment of pain a quality standard in all health care facilities [4]. Subsequently, the American College of Emergency Physicians (ACEP) issued a policy statement on pain management in the ED [5]. The ACEP also has developed a clinical policy on procedural sedation since 1998 [6] and updated its recommendations in 2005 [3].

Despite the abundance of guidelines and policies, to our knowledge, no studies have examined the actual quality of dislocation care delivered in the ED, particularly in those who undergo procedural sedation. Previous studies have focused on pain management for long bone fractures [7-10], safety and efficacy of Sedative agents [11-15], or complica- tions of dislocations [16-18]. The extent to which actual ED management of joint dislocation is concordant with guideline recommendations remains unclear.

The objectives of the present study were (1) to determine concordance of ED management of dislocation with guideline recommendations in patients who undergo proce- dural sedation for closed reduction of a dislocated joint and

(2) to assess whether higher concordance was associated with better patient outcome (Successful reduction of a dislocated joint in the ED).

Methods

Study design and setting

This retrospective cohort study was part of the National Emergency Department Safety Study (NEDSS). Details of the NEDSS study design and data collection have been

previously published [19]. Briefly, NEDSS was a large, multicenter study that aimed to characterize system and clinician factors associated with the occurrence of errors in the ED. The NEDSS was coordinated by the Emergency Medicine Network (EMNet) (www.emnet-usa.org). We invited EDs affiliated with EMNet to participate in the study, with additional recruitment through postings on emergency medicine listservs, direct contact with sites, and presentations at national meetings. A total of 59 US EDs in 19 US states completed the joint dislocation component of the NEDSS. The institutional review board at all participat- ing hospitals approved the study.

Inclusion and exclusion criteria

Using International Classification of Diseases, Ninth Revision, Clinical Modification [20], codes from hospital administrative records, each site identified all charts with a primary ED or hospital discharge diagnosis of joint dislocation during a 12-month period. The 5 joint disloca- tions of interest (and their International Classification of Diseases codes) were shoulder (831.00-831.03, 831.05-

831.09, 718.21, 718.31), elbow (832.00-832.09, 718.22,

718.32), hip (835.00-835.03, 718.25, 718.35), knee (836.0-

836.2, 836.50-836.59, 718.26, 718.36), and ankle disloca-

tion (837.00-837.09, 718.27, 718.37).

Trained research personnel at each site used a standard- ized form to abstract data from 70 randomly selected ED visits for dislocation. Sites with less than 70 charts reviewed all eligible charts. Exclusion criteria were (1) 13 years or younger or 90 years or older, (2) acromioclavicular Joint dislocations, or (3) dislocated joints not involving the 5 joints of interest. A limited chart abstraction was performed after applying these 3 exclusion criteria. If more than 1 joint was dislocated, we abstracted data for only 1 joint based on the following rules: (1) we chose the dislocated joint that underwent a reduction procedure and (2) if more than 1 joint underwent a reduction procedure, we chose the joint in the following order of preference: shoulder, elbow, hip, knee, and ankle. In the case of repeat visits, only the first ED visit was included. We further excluded visits at which joint reduction procedures or intravenous/intramuscular sedatives were not involved. The final study population represented ED visits involving procedural sedation for closed reduction of a dislocation, and comprehensive chart abstraction was performed. Finally, to avoid unstable estimates on assess- ment of ED-level performance in this particular analysis, we excluded 7 sites that had less than 20 cases with procedural sedation. The patient flow is illustrated in Fig. 1. The final sample consisted of 1980 visits from 47 EDs.

n = 4,977

59 EDs

n = 3,186

59 EDs

1,072 excluded according to the following sequence

453 did not undergo a joint reduction procedure 619 did not receive IV or IM sedatives

n = 2,114

59 EDs

Less than 20 patients per ED 134 excluded (7 EDs)

n = 1,980

47 EDs

Fig. 1 Patient flow. IV indicates intravenous; IM, intramuscular.

Data collection and processing

From each chart, we abstracted baseline patient charac- teristics, medical history, ED presenting symptoms and signs, ED course and management, ED provider type, and ED disposition. Details on the use of analgesics and sedatives were collected including date/time, dose, and route of administration. The following 9 clinically important adverse events in procedural sedation were collected: vomiting, systolic blood pressure less than 90 mm Hg for greater than

5 minutes, intravenous fluid given for a drop in blood pressure, medications given for a drop of blood pressure, oxygen saturation less than 90% for greater than 5 minutes, use of Bag-mask ventilation, endotracheal intubation, administration of reversal agents, and cardiopulmonary resuscitation. The complete case report form is available as an online data supplement.

Table 1 Description of quality measures for ED care of joint dislocation

We also distributed a key informant survey at each site to collect data on ED characteristics, such as annual visit volume and annual number of visits for dislocation. Geographic regions (Northeast, South, Midwest, and West) were defined according to Census Bureau boundaries [21].

Concordance with guidelines: quality measures

1,791 excluded according to the following sequence 746 Age ? 13 years

24 Age ? 90 years

348 Acromioclavicular joint dislocation 673 Joint dislocation other than

shoulder, elbow, hip, knee, or ankle

Based on contemporaneous pain management standards [4,5] and clinical policies on PSA [6] and in the consensus view of the NEDSS investigators and EMNet Steering Committee, we developed a priori 5 individual quality measures for ED dislocation care. The specifications of these measures, including numerators and denominators, are listed in Table 1.

We also summarized the 5 quality measures by a patient composite guideline concordance score, which was calcu- lated as the number of times a patient received the guideline- concordant care across quality measures, divided by the patient’s total number of eligible opportunities [22,23]. Using the same “opportunity-based” approach, the ED-level composite guideline concordance scores were obtained. These percent scores were rescaled from 0 to 100, with a score of 100 indicating perfect concordance.

Outcome measure

The primary outcome measure was successful closed reduction of dislocated joint in the ED, which was confirmed clinically or with a postreduction radiograph. The secondary outcome was frequency of adverse events.

Statistical analysis

Summary statistics at both the patient and the ED level are presented as proportions (with 95% confidence intervals

Measure

Numerator

Denominator

pain assessment Pain medication

Assessment of neurovascular status in the limb of a dislocated joint

Assessment of vital signs after procedural sedation

Successful reduction

At least 1 assessment of pain documented in the chart, by either verbal description or numerical scale Administration of any pain medication during the ED stay or before ED arrival

Neurologic or vascular status documented at least once during the ED stay

Full vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation) documented at least once after IV/IM sedatives given

Successful joint reduction confirmed clinically or with a postreduction x-ray

All patients presenting to the ED with a joint dislocation

Dislocation patients reporting moderate level of pain and above (or rated >=5/10 or >=3/5 on numerical scale)

All patients presenting to the ED with a joint dislocation

Dislocation patients who receive procedural sedation with IV/IM sedatives

Dislocation patients who receive procedural sedation and are sent home

IV indicates intravenous; IM, intramuscular.

Table 2 Emergency department and patient characteristics

ED characteristic n = 47

No. of ED visits per year, median (IQR) 58 215 (43 000-75 000)

No. of ED visits for joint dislocation per year, median (IQR) 150 (106-200)

No. of ED beds, median (IQR) 40 (28-51)

Residency affiliated, % 83

Census region, %

Northeast 40

Midwest 26

South 11

West 23

Urban location, % 100

Patient characteristic n=1,980

demographic factors

Age, y, median (IQR) 38 (25-58)

Male, % 63

Race/ethnicity, % a

White 56

Black 29

Hispanic 10

Other 5

Medical history, %

Congestive heart failure 1

Chronic obstructive pulmonary disease 1

Liver disease 1

Chronic renal insufficiency 1

ED presentation Dislocated joint, %

Shoulder 73

Elbow 10

Hip 13

Knee 2

Ankle 2

pain level, %

Moderate pain and above (or rated >=5/10 or >=3/5 on numerical scale) 82

Severe pain and above (or rated >=7/10 or >=4/5 on numerical scale) 72

Initial ED systolic blood pressure, mm Hg, median (IQR) 140 (126-153)

Initial ED heart rate, beats per minute, median (IQR) 83 (72-95)

Initial ED respiratory rate, breaths per minute, median (IQR) 18 (18-20)

Initial ED oxygen saturation, %, median (IQR) b 98 (97-100)

ED course

ED consultation, % 22

Anesthesiologists involved, % 3

Sedatives used for procedural sedation, %

Midazolam, fentanyl, or both 46

Single use of propofol 21

Single use of etomidate 14

Other single use or combinations 19

N1 attempt to reduce dislocation, % 15

Successful reduction of dislocated joint, % 94

ED length of stay, min, median (IQR) 249 (180-349)

ED disposition, %

Sent home 87

Admit to hospital ward or observation unit 8

Admit to intensive care unit 0.3

Transfer to a second hospital 0.6

Other (eg, operating room, jail, or nursing home) 4

a Documented for 1297 patients.

b Documented for 1723 patients.

[CI]) or means (with SD or medians [with interquartile ranges {IQR}]). Bivariate associations were examined using the Student t tests, Wilcoxon rank sum tests, and ?2 tests, as appropriate.

Multivariable logistic regression modeling was performed to assess the association between ED and patient character- istics (predictors) and successful reduction of dislocated joint (outcome). Model variables were selected a priori [24], based on review of the medical literature [25,26], or from variables associated with the outcome at P b .10 in univariable analyses [27]. Model variables included ED characteristics (ED-level composite guideline concordance scores and region) and patient characteristics (age, sex, dislocated joint, severe pain at presentation, anesthesiologist involve- ment, single use of propofol, and N1 attempt to reduce dislocation). To assess the link of care processes and patient outcome, the ED-level composite guideline concordance scores for this particular multivariable analysis were derived from 4 process-of-care measures omitting the outcome measure of successful joint reduction.

To determine the functional form used for continuous predictors (ie, ED-level composite guideline concordance scores), we grouped the predictor into quartiles and checked if log odds increased or decreased linearly [28]. Because more than 1 attempt to reduce dislocation may be a close proxy for the outcome variable [24], we presented models with and without this potential proxy variable. The model was fit using generalized estimating equations to account for the effects of clustering of patients within EDs [29]. Because Shoulder dislocations may be more reflective of ED quality of care (eg, less dependent on other services), we repeated the multivariable model restricting to shoulder dislocations. In addition to modeling successful joint reduction, we also assessed the relationship between guideline concordance and frequency of adverse events using a multivariable Poisson model. Model variables included the same variables as in the joint reduction model, plus hypotension (systolic blood pressure b90 mm Hg) at presentation, desaturation (oxygen saturation b90%) at presentation, and a history of chronic

Table 3 Performance on quality measures at the patient and ED level

obstructive pulmonary disease. All odds ratios (ORs) and Incidence rate ratios (IRRs) are presented with 95% CIs. All analyses were performed using Stata 10.0 software (Stata- Corp, College Station, TX).

Results

ED and patient characteristics

The final cohort comprised 1980 patients who presented to 47 EDs between 2003 and 2005, with 92% of the visits made in 2004. The median number of charts abstracted per ED was 39 (IQR, 30-55). Table 2 shows the ED and patient characteristics. Participating EDs had high annual visit volumes (median, 58 215) and cared for many dislocation patients annually (median, 150). Eighty-three percent of the EDs were affiliated with an emergency medicine residency program. Participating EDs were all urban and located in different geographic regions of the country.

The median age of the patients was 38 years (IQR, 25-58), and 63% were men. Long-term comorbidities were uncom- mon. Most of the patients presented to the ED with shoulder dislocations and had at least moderate levels of pain. Twenty- two percent of the dislocation care involved consultation; 3% involved anesthesiologists. The most commonly used sedatives were midazolam, fentanyl, or both (46%), followed by single use of propofol (21%). Although 15% required more than 1 attempt to reduce dislocation, most of the patients underwent successful reduction. The median ED length of stay was about 4 hours, and most of the patients were sent home. Only 15 patients (0.8%) were sent to the operation room for failed reduction.

Quality of ED dislocation care

Table 3 shows the item-by-item guideline-recommended care as well as the composite guideline concordance scores.

Quality measure

No. of

patients eligible

No. of times recommended care was delivered

% of eligible patients who received recommended care (95% CI)

Median ED performance (IQR)

Pain assessment

1980

1797

91 (90-92)

93 (86-98)

Pain medication

1621

1404

87 (85-88)

88 (79-93)

Assessment of neurovascular status in

1980

1938

98 (97-99)

99 (96-100)

the limb of a dislocated joint

Assessment of vital signs

1980

1779

90 (89-91)

91 (83-96)

after procedural sedation

Discharge with successful reduction

1708

1653

97 (96-98)

98 (96-100)

Composite score

Patient-level median

ED-level median

score (IQR)

score (IQR)

Composite guideline concordance score

100 (80-100)

93 (90-95)

Fig. 2 Distribution of composite guideline concordance score at the ED level. The scores are slightly negatively skewed, with more extreme values to the left.

Overall, care for dislocation was excellent, with a concor- dance score of more than 85 across all quality measures. Fig. 2 shows the distribution of the ED composite guideline concordance scores. The median ED concordance score was 93 (IQR, 90-95), with scores ranging from 78 to 99.

Table 4 details the frequency of the 9 adverse events. Overall, 6.3% of the patients experienced at least 1 adverse event. The most common adverse event was administration of reversal agents (2.3%), followed by use of bag-mask ventilation (2.0%) and then vomiting (1.3%). Six patients (0.3%) were intubated during or after procedural sedation. Neither cardiopulmonary resuscitation nor death was documented.

Multivariable analyses of ED care and patient outcome

The ED and patient characteristics associated with successful joint reduction are shown in Table 5. In model 1, after adjusting for several ED characteristics and patient mix, treatment in EDs with the highest (fourth quartile) composite guideline concordance scores was independently

Adverse event n (%)

Vomiting 25 (1.3)

SBP b90 mm Hg for N5 min 8 (0.4)

IV fluid given for a drop in BP 13 (0.7)

Medications given for a drop in BP 2 (0.1)

SaO2 b90% for N5 min 10 (0.5)

Bag-mask ventilation 39 (2.0)

Endotracheal intubation 6 (0.3)

Reversal agent administered 46 (2.3)

CPR administered 0 (0)

SBP indicates systolic blood pressure; BP, blood pressure; IV, intravenous, Sao2, oxygen saturation; CPR, cardiopulmonary resuscitation.

associated with a significantly higher likelihood of success- ful joint reduction (adjusted OR, 3.36; 95% CI, 1.48-7.62), as compared with treatment in EDs with the lowest (first quartile) scores. The finding persisted after adjusting for more than 1 attempt to reduce dislocation (adjusted OR, 3.28; 95% CI, 1.38-7.81). When evaluated as a continuous function, every 10-pont increase in ED composite concor- dance was associated with a more than 2-fold increase in the likelihood of successful reduction (adjusted OR, 2.60; 95% CI, 1.49-4.52; P = .001). There were no Regional variations in ED quality of dislocation care.

With respect to patient characteristics, dislocations of hip, knee, and ankle were less likely to be successfully reduced, compared with dislocations of shoulder. More than 1 attempt to reduce dislocation also was associated with a lower likelihood of successful reduction. Single use of propofol may be associated with a higher likelihood of successful reduction; however, this finding did not persist in the fully adjusted model. Anesthesiologist involvement was not associated with a higher likelihood of successful reduction. Restricting to a subset of patients with a shoulder dislocation, the multivariable results did not change materially. Emergency departments with the highest com- posite guideline concordance scores were still associated with a significantly higher likelihood of successful joint

reduction (adjusted OR, 6.83; 95% CI, 2.27-20.55).

For the secondary outcome measure, we found that ED guideline concordance was not associated with the frequency of adverse events. However, 2 patient-level factors, female sex (adjusted IRR, 1.65; 95% CI, 1.12- 2.42), and a history of chronic obstructive pulmonary disease (adjusted IRR, 3.13; 95% CI, 1.28-7.65) predicted higher frequency of adverse events.

Discussion

In this study of 1980 patients presenting with joint dislocations who underwent procedural sedation in 47 US EDs, we found that overall concordance of emergency care with guideline recommendations was high. We also found that higher guideline concordance was positively associated with better patient outcomes (ie, successful reduction). In these urban, academic EDs, emergency physicians appear to have adopted the use of ultrashort-acting sedatives (eg, propofol and etomidate) with rare involvement of anesthe- siologists and to perform procedural sedation safely without major complications.

Table 4 Frequency of adverse events of 1980 patients

The high rates of pain assessment and pain medications among ED dislocation patients are encouraging. In studies before 2001, the time when JCAHO implemented the pain assessment quality standard, the rates of pain assessment and analgesic administration rarely exceed 70% [30,31]. A recent analysis of the National Hospital Ambulatory Medical Care Survey data found increasing pain assessment among ED

Variable

Unadjusted OR (95% CI) a

Model 1 adjusted OR (95% CI) a,b

Model 2 adjusted OR (95% CI) a,b

ED characteristic

ED composite guideline concordance score c

First (lowest) quartile

1.00 (reference)

1.00 (reference)

1.00 (reference)

Second quartile

1.63 (0.78-3.39)

1.97 (0.996-3.89)

2.04 (0.97-4.25)

Third quartile

1.44 (0.77-2.70)

1.48 (0.82-2.68)

1.45 (0.79-2.65)

Fourth (highest) quartile

2.12 (0.94-4.80)

3.36 (1.48-7.62)

3.28 (1.38-7.81)

Census region

Northeast

1.00 (reference)

1.00 (reference)

1.00 (reference)

Midwest

1.83 (0.85-3.96)

1.89 (0.95-3.74)

1.99 (0.97-4.07)

South

0.84 (0.51-1.37)

1.03 (0.57-1.83)

1.09 (0.56-2.10)

West

0.71 (0.35-1.42)

0.55 (0.30-1.03)

0.61 (0.32-1.15)

Patient characteristic

Age, per 10-y increase

0.87 (0.81-0.94)

0.92 (0.83-1.01)

0.93 (0.84-1.04)

Female sex

0.74 (0.50-1.07)

0.95 (0.62-1.46)

0.95 (0.61-1.47)

Dislocated joint

Shoulder

1.00 (reference)

1.00 (reference)

1.00 (reference)

Elbow

0.54 (0.30-0.99)

0.54 (0.29-1.02)

0.51 (0.26-1.02)

Hip

0.29 (0.17-0.49)

0.31 (0.17-0.54)

0.29 (0.16-0.53)

Knee

0.27 (0.10-0.73)

0.26 (0.09-0.72)

0.20 (0.07-0.52)

Ankle

0.28 (0.12-0.63)

0.29 (0.13-0.65)

0.26 (0.12-0.56)

Severe pain at presentation

1.42 (1.02-1.98)

0.97 (0.65-1.44)

1.02 (0.68-1.54)

Anesthesiologist involvement

1.70 (0.57-5.06)

1.02 (0.29-3.61)

1.05 (0.29-3.78)

Single use of propofol

1.12 (0.63-2.00)

1.95 (1.05-3.61)

1.77 (0.92-3.43)

N1 attempt to reduce dislocation

0.25 (0.16-0.40)

0.23 (0.14-0.38)

a Model was fit using generalized estimating equations to account for the effects of clustering of patients within EDs.

b Model adjusting for all variables shown in the table.

c The composite guideline concordance scores were derived from 4 quality measures: pain assessment, pain medication, assessment of neurovascular status, and assessment of vital signs after procedural sedation.

patients with a long bone fracture after implementation of the JCAHO’s standards, an increase from 57% in 1998 to 2000 to 74% in 2001 to 2003 [7]. The use of pain medications also increased from 56% to 76% in this national sample [7]. Our results are consistent with these improvements in ED pain management over time, further suggesting the possibility of using perfection (100%) as a future benchmark. As shown in several ED quality improvement studies [32-35], education programs and guidelines implementation can potentially eliminate ED oligoanalgesia.

Table 5 Unadjusted and multivariable-adjusted predictors of successful reduction among ED patients with joint dislocations

Another encouraging note from our study is the strong link between ED guideline-concordant care and improved patient outcomes. The 4 individual process measures— encompassing better pain management, meticulous neuro- vascular assessment, and careful monitoring during proce- dural sedation–all contributed to a higher likelihood of successful joint reduction. This important finding tightens the link between processes and outcomes of dislocation care and lends support to both JCAHO pain management standards [4] and ACEP clinical policies/statements on ED PSA [3,5,6]. The EDs with lower concordance with guideline recommendations should strive to improve their quality of dislocation care, bearing in mind that this improvement may translate into a 3-fold increase in the chance of successful joint reduction among their patients.

Our study also provides important data on overall dislocation care in the ED and effectiveness and safety of ED sedative use. Consistent with the literature [18,36], our study showed that the shoulder was the most frequently dislocated joint in the ED. Furthermore, the dislocated shoulder was far more likely to be reduced compared with other dislocated joints in our study. This could be explained by the lower rates of factures associated with shoulder dislocations [18,36]. With respect to sedative use in the ED, our study indicates that many emergency physicians had already started to use new sedative agents for procedural sedation, such as propofol and etomidate [37], earlier in this decade, despite the historical and/or political barriers to emergency physicians’ use of potent sedatives [38]. Recently, the Centers for Medicare & Medicaid Services issued a policy stating that deep sedation can only be administered by an anesthesiologist, a certified registered nurse anesthetist, or a trained medical doctor or a doctor of osteopathy not involved in the performance of a medical procedure [39]. The restricted use and associated high costs remain a concern [39]. Our real- world large multicenter study, along with data from other single-center studies [40,41] and patient registries [42], showed that emergency physicians were capable, with rare involvement of anesthesiologists, to perform safe procedural sedation with a low incidence of adverse events.

Our study has some potential limitations. First, because most EDs participating in our study are urban academic centers, our results may not be generalizable to other settings (eg, community-based practice). Second, our study was not designed to address other important issues in PSA research, such as preprocedural fasting and equipment/supplies issues [43,44]. Third, we did not collect data on a few factors that might be related to successful joint reduction, such as presence of concomitant fractures, numbers of previous dislocation episodes, and mechanisms of injury [18,25,26]. Fourth, we did not collect data on the 619 patients who underwent joint reduction without conscious sedation (Fig. 1). They might have a successful joint reduction with a joint block or other procedures and, thus, represent an important patient population when studying quality of ED dislocation care. Future work could examine care within various subgroups of the larger population that we focused on in our study. Last, because this was a chart review study, body weight was either not documented (50%) or without mention of unit (kilograms or pounds, 8%). Thus, we cannot include meaningful dosage information (dose per kilogram) in our multivariable analysis.

In summary, in a sample composed of mostly academic EDs, care of dislocation was highly concordant with guideline recommendations. Greater concordance with guideline-recommended care processes in PSA may increase the likelihood of successful joint reduction. Emergency physicians should continue to provide effective and safe procedural sedation to ED patients and work with colleagues from other specialties to advance knowledge in this field.

Supplementary materials related to this article can be found online at doi:10.1016/j.ajem.2011.07.012.

Acknowledgments

The authors thank the participating site investigators for their ongoing dedication to emergency medicine and patient safety research. We also thank numerous EMNet staff for their important contributions throughout the study.

EMNet Steering Committee

Carlos A. Camargo, Jr, MD, DrPH (Chair); Sunday Clark, ScD; Adit A. Ginde, MD, MPH; Robert A. Lowe, MD, MPH; Jonathan M. Mansbach, MD; Ashley F. Sullivan, MPH, MS; and Scott T. Wilber, MD, MPH.

EMNet Coordinating Center

Carlos A. Camargo, Jr, MD, DrPH (Director); Erica Eagan; Janice A. Espinola, MPH; Tate Forgey, MA; Kathryn M. Niro; Susan A. Rudders, MD; Anne P. Steptoe; Ashley F. Sullivan, MS, MPH; Chu-Lin Tsai, MD, ScD; and Milo F. Vassallo, MD, PhD–all at Massachusetts General Hospital, Boston.

Principal Investigators at the 47 Participating Sites

HJ Alter (Highland General Hospital, Oakland, CA); JM Basior (Buffalo General Hospital, Buffalo, NY); SL Bernstein (Montefiore Medical Center, Bronx, NY); JM

Caterino (Ohio State University Hospital, Columbus, OH); RK Cydulka (MetroHealth Medical Center, Cleveland, OH); LC Degutis (Yale-New Haven Medical Center, New Haven, CT); DB Diercks (UC Davis Medical Center, Sacramento, CA); SK Epstein (Beth Israel Deaconess Medical Center, Boston, MA); RJ Fairbanks (University of Rochester Medical Center, Rochester, NY); GM Gaddis (Saint Luke’s Hospital of Kansas City, Kansas City, MO); K Gebreyes (Washington Hospital Center, Washington, DC); RO Gray (Hennepin County Medical Center, Minneapolis, MN); M Griffin (Sinai-Grace Hospital, Detroit, MI); JW Hafner, Jr (OSF Saint Francis Medical Center, Peoria, IL); FP Harchelroad, Jr (Allegheny General Hospital, Pittsburgh, PA); JS Haukoos (Denver Health Medical Center, Denver, CO); DS Huckins (Newton-Wellesley Hospital, Newton, MA); M Huston (Franklin Square Hospital Center, Balti- more, MD); KA Jones (Detroit Receiving Hospital, Detroit, MI); S Key (Cape Canaveral Hospital, Cocoa Beach, FL); H Kilgannon (Cooper University Hospital, Camden, NJ); E Lashley (Maimonides Medical Center, Brooklyn, NY); MJ Leber (Brooklyn Hospital Center, Brooklyn, NY); S Liu (Massachusetts General Hospital, Boston, MA); BL Lopez (Thomas Jefferson University Hospital, Philadelphia, PA); F LoVecchio (Maricopa Medical Center, Phoenix, AZ); EL Lynch (Loma Linda University Medical Center and Children’s Hospital, Loma Linda, CA); DJ Magid (Saint Joseph Hospital, Denver, CO); JS Myslinski (Palmetto Richland Memorial Hospital, Columbia, SC); NW Naviaux (University of Colorado Hospital, Aurora, CO); DJ Pallin (Brigham and Women’s Hospital, Boston, MA); A Papa (Doylestown Hospital, Doylestown, PA); SK Polevoi (UCSF Medical Center, San Francisco, CA); MS Radeos (Lincoln Medical Center, Bronx, NY); S Reingold (Advocate Christ Medical Center, Oak Lawn, IL); DJ Robinson (Memorial Hermann Hospital, Houston, TX); A Sacchetti (Our Lady of Lourdes Medical Center, Camden, NJ); M Sigal (Salem Hospital, Salem, MA); HA Smithline (Baystate Medical Center, Springfield, MA); BK Snyder (UCSD Medical Center-Hillcrest, San Diego, CA); LA Starke (Kettering Medical Center, Kettering, OH); E Thallner (Cleveland Clinic Hospital, Cleveland, OH); KH Todd (Beth Israel Medical Center, New York, NY); TP Tran (University of Nebraska Medical Center, Omaha, NE); DR Vinson (Kaiser Permanente Roseville Medical Center, Roseville, CA); E Wang (Stanford University Medical Center, Stanford, CA); and ST Wilber (Akron City Hospital, Akron, OH).

References

  1. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep 2008:1-38.
  2. HCUPnet. National statistics on all ED visits. Available at: http://hcupnet. ahrq.gov/HCUPnet.jsp?Id=273488E31C705B52&Form=Help&JS= Y&Action=%3E%3ENext%3E%3E&GoTo=MAINSEL. Accessed July 9, 2011.
  3. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005;45:177-96.
  4. Joint Commission on Accreditation of Healthcare organizations. Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace (Ill): Joint Commission on Accreditation of Healthcare Organizations; 2001.
  5. American College of Emergency Physicians. Pain management in the emergency department. Ann Emerg Med 2004;44:198.
  6. Clinical policy for procedural sedation and analgesia in the emergency department. American College of Emergency Physicians. Ann Emerg Med 1998;31:663-77.
  7. Ritsema TS, Kelen GD, Pronovost PJ, Pham JC. The national trend in quality of emergency department pain management for Long bone fractures. Acad Emerg Med 2007;14:163-9.
  8. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993;269:1537-9.
  9. Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11-6.
  10. Bijur P, Berard A, Esses D, Calderon Y, Gallagher EJ. Race, ethnicity, and management of pain from Long-bone fractures: a prospective study of two academic urban emergency departments. Acad Emerg Med 2008;15:589-97.
  11. Green S.M., Roback M.G., Krauss B., et al. Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009;54:171-80 e1-4.
  12. Green S.M., Roback M.G., Krauss B., et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009;54:158-68 e1-4.
  13. Miner JR, Danahy M, Moch A, Biros M. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 2007;49:15-22.
  14. Willman EV, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analge- sia in the emergency department. Ann Emerg Med 2007;49:23-30.
  15. Miner JR, Biros M, Krieg S, Johnson C, Heegaard W, Plummer D. Randomized clinical trial of propofol versus methohexital for procedural sedation during fracture and dislocation reduction in the emergency department. Acad Emerg Med 2003;10:931-7.
  16. Perron AD, Ingerski MS, Brady WJ, Erling BF, Ullman EA. Acute complications associated with shoulder dislocation at an academic emergency department. J Emerg Med 2003;24:141-5.
  17. Beeson MS. Complications of shoulder dislocation. Am J Emerg Med 1999;17:288-95.
  18. Newton EJ, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am 2007;25:763-93 ix-x.
  19. Sullivan AF, Camargo Jr CA, Cleary PD, et al. The National Emergency Department Safety Study: study rationale and design. Acad Emerg Med 2007;14:1182-9.
  20. McClellan M, McNeil BJ, Newhouse JP. Does more intensive treatment of acute myocardial infarction in the elderly reduce mortality? Analysis using instrumental variables. JAMA 1994;272: 859-66.
  21. United States Bureau of the Census. Census regions and divisions of the United States. Available at: http://www.census.gov/geo/www/ us_regdiv.pdf. Accessed October 9, 2009.
  22. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348: 2635-45.
  23. Reeves D, Campbell SM, Adams J, Shekelle PG, Kontopantelis E, Roland MO. Combining multiple indicators of clinical quality: an evaluation of different analytic approaches. Med Care 2007;45: 489-96.
  24. Tsai CL, Camargo Jr CA. Methodological considerations, such as directed acyclic graphs, for studying “acute on chronic” disease epidemiology: chronic obstructive pulmonary disease example. J Clin Epidemiol 2009;62:982-90.
  25. Emond M, Le Sage N, Lavoie A, Moore L. Refinement of the Quebec decision rule for radiography in shoulder dislocation. CJEM 2009;11: 36-43.
  26. Emond M, Le Sage N, Lavoie A, Rochette L. Clinical factors predicting fractures associated with an Anterior shoulder dislocation. Acad Emerg Med 2004;11:853-8.
  27. Greenland S. Modeling and variable selection in epidemiologic analysis. Am J Public Health 1989;79:340-9.
  28. Greenland S. Dose-response and trend analysis in epidemiology: alternatives to categorical analysis. Epidemiology 1995;6:356-65.
  29. Liang KY, Zeger SL. Longitudinal data analysis using Generalized linear models. Biometrika 1986;73:13-22.
  30. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency depart- ment. Am J Emerg Med 1989;7:620-3.
  31. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med 2003;42:197-205.
  32. Decosterd I, Hugli O, Tamches E, et al. Oligoanalgesia in the emergency department: short-term beneficial effects of an education program on acute pain. Ann Emerg Med 2007;50:462-71.
  33. Yanuka M, Soffer D, Halpern P. An interventional study to improve the quality of analgesia in the emergency department. CJEM 2008;10: 435-9.
  34. Campbell P, Dennie M, Dougherty K, Iwaskiw O, Rollo K. Implementation of an ED protocol for pain management at triage at a busy level I trauma center. J Emerg Nurs 2004;30:431-8.
  35. Stalnikowicz R, Mahamid R, Kaspi S, Brezis M. Undertreatment of acute pain in the emergency department: a challenge. Int J Qual Health Care 2005;17:173-6.
  36. Tintinalli JE, Kelen GD, Stapczynski JS. American College of Emergency Physicians Emergency medicine: a comprehensive study guide. 6th ed. New York: McGraw-Hill, Medical Pub. Division; 2004.
  37. Miner JR, Krauss B. Procedural sedation and analgesia research: state of the art. Acad Emerg Med 2007;14:170-8.
  38. Green SM, Krauss B. Barriers to propofol use in emergency medicine. Ann Emerg Med 2008;52:392-8.
  39. Rex DK. Effect of the centers for medicare & medicaid services policy about deep sedation on use of propofol. Ann Intern Med 2011;154:622-6.
  40. McGrane O, Hopkins G, Nielson A, Kang C. Procedural sedation with propofol: a retrospective review of the experiences of an emergency medicine residency program 2005 to 2010. Am J Emerg Med 2011 [Epub ahead of print].
  41. Senula G, Sacchetti A, Moore S, Cortese T. Impact of addition of propofol to ED formulary. Am J Emerg Med 2010;28:880-3.
  42. Hogan K, Sacchetti A, Aman L, Opiela D. The safety of single- physician procedural sedation in the emergency department. Emerg Med J 2006;23:922-3.
  43. Green SM. Research advances in procedural sedation and analgesia. Ann Emerg Med 2007;49:31-6.
  44. Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med 2007;49: 454-61.

Leave a Reply

Your email address will not be published. Required fields are marked *