Pines JM, Hollander JE Emergency Department Crowding is Associated with Poor Care for Patients with Severe Pain
Refers to article:
Emergency Department Crowding Is Associated With Poor Care for Patients With Severe Pain
, 03 October 2007
Jesse M. Pines, Judd E. Hollander
Annals of Emergency Medicine
January 2008 (Vol. 51, Issue 1, Pages 1-5) Abstract |
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Editor’s Capsule Summary
What is already known on this topic
Emergency department (ED) crowding may result in delays in the administration of medication such as antibiotics for pneumonia.
What question this study addressed
Does crowding cause delays in treatment for pain?
What this study adds to our knowledge
In this retrospective analysis of 13,578 patients treated at a single inner-city ED, patients with severe pain were slightly less likely to receive pain medications quickly when the ED volume increased.
How this might change clinical practice
Crowding may delay the administration of pain medication in some patients. Standing orders for the administration of pain medication might mitigate such delays.
1. The authors performed a retrospective cohort study of all patients with severe pain presenting to their emergency department (ED). Why do you think the authors chose this type of study design? Describe the strengths and weaknesses of this design and contrast these with those of a prospective cohort study. If you were replicating this study prospectively, how might you alter the study design with respect to: a) the assessment of severity of patient pain; b) receipt of pain medication in the ED; and c) the measurement of ED crowding?
2. In Table 1, the authors report the mean age and standard deviation of patients and the median total patient-care hours with the interquartile range. What do the mean and median values of a dataset represent and why might authors choose to report the median value instead of the mean value? What types of graphics can be used to display the distribution of a continuous variable such as age? Why, traditionally, have summary statistics been preferred to graphs?
3. The authors report that only 49% of patients judged by staff to have severe pain received pain medication while in the ED. What factors seemed to be most predictive of not receiving pain medication while in the ED? Why might it be important to know the frequency of these factors in the study population? Based on your own clinical experience, does it seem plausible that nearly half of patients with severe pain received no pain medication in the ED? If not, what might be responsible for this finding? If you were the principal investigator and were concerned about the validity of this finding, how might you verify its accuracy? Define the terms “internal validity” and “external validity” and explain how these terms specifically apply to this study’s conclusions.
4. Pines and Hollander comment in the Discussion that “severity is associated with higher odds of non-receipt of any pain medication, possibly because providers focus more on diagnosis than symptom control.” How might you design a study to test whether physicians prioritize diagnosing the patient’s condition over patient pain control? The CEO of your hospital reads this article and charges you with designing system changes to correct this problem. Describe what you might do to increase the likelihood that a patient with severe pain would promptly receive analgesia.
5. In Table 2, the authors report the odds ratios for time to analgesia based on measures of ED crowding. The odds ratio for waiting room number was 1.03 (95% confidence interval 1.02-1.03) to predict “no analgesia given in the ED.” Why did the authors report odds ratios? What assumptions underlie these estimates of the odds ratio? In this study, the odds ratio of 1.03 is comparing the odds of no analgesia when N patients are in the waiting room with the odds of no analgesia when N+1 patients are there. How much do the odds of no analgesia increase when there are 5, 10, 15, or 20 additional patients in the waiting room? If the authors instead chose to use an increase of 5 additional waiting room patients as their metric how would this alter the odds ratio? What do these values mean to you as an emergency physician? Can you calculate (approximately) the probability of not receiving analgesia as a function of waiting room occupancy?
6. In your opinion, what are the most important conclusions from this paper? How might the limitations mentioned by the authors affect your decision whether to change your clinical practice with regard to administering analgesia to patients during times of ED crowding? What additional information or data analyses would you like the authors to provide in order for you to change your clinical practice?
aVanderbilt University Medical Center, Nashville, TN
bUniversity of California, Los Angeles, Los Angeles, CA
SEE RELATED ARTICLE, P. 1.
Editor’s Note: You are reading the first installment of Annals of Emergency Medicine Journal Club. This bi-monthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers - be they clinicians, academics, residents, or medical students - to critically appraise the literature.
Over a two- to three-year cycle we plan to ask questions that cover the main topics in research methodology and critical appraisal of the literature. To do this we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue but they are articles that serve the mission of covering the clinical epidemiology curriculum.
Journal Club entries will be published in two phases. In the first phase, a list of questions about the article will be published in the issue that the article appears. Questions are rated “novice,” () “intermediate,” () “advanced” (), so that individuals planning a journal club can assign the right question to the right student. The second phase consists of the publication of suggested answers. This will be done 5 months following the publication of the questions. However, residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. Thus, if an actual journal club is conducted within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by both residents and medical students and discourage regurgitation of the published answers.
It is our hope that the Journal Club will broaden Annals of Emergency Medicine’s appeal to residents and medical students. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.
FULL TEXT
The authors performed a retrospective cohort study of all patients with severe pain presenting to their emergency department (ED). Why do you think the authors chose this type of study design? Describe the strengths and weaknesses of this design and contrast these with those of a prospective cohort study. If you were replicating this study prospectively, how might you alter the study design with respect to: a) the assessment of severity of patient pain; b) receipt of pain medication in the ED; and c) the measurement of ED crowding?
The authors report that only 49% of patients judged by staff to have severe pain received pain medication while in the ED. What factors seemed to be most predictive of not receiving pain medication while in the ED? Why might it be important to know the frequency of these factors in the study population? Based on your own clinical experience, does it seem plausible that nearly half of patients with severe pain received no pain medication in the ED? If not, what might be responsible for this finding? If you were the principal investigator and were concerned about the validity of this finding, how might you verify its accuracy? Define the terms “internal validity” and “external validity” and explain how these terms specifically apply to this study’s conclusions.
Pines and Hollander comment in the Discussion that “severity is associated with higher odds of non-receipt of any pain medication, possibly because providers focus more on diagnosis than symptom control.” How might you design a study to test whether physicians prioritize diagnosing the patient’s condition over patient pain control? The CEO of your hospital reads this article and charges you with designing system changes to correct this problem. Describe what you might do to increase the likelihood that a patient with severe pain would promptly receive analgesia.