Background

Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders.

Objective

A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes.

Research design

A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009.

Subjects

A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included.

Measures

The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity.

Results

On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357).

Discussion

In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.

Background

Emergency department (ED) clinicians often lack training and resources to conduct advance care planning (ACP) conversations. The use of technology for health education is increasing, yet little is known if it can be used to engage older ED patients in ACP.

Objective

To determine the feasibility of using tablets to provide ACP education ( www.prepareforyourcare.org )(PREPARE) to older ED patients.

Design

A feasibility study conducted in late 2014 and early 2015.

Setting/subjects

Subjects were recruited from a parent cohort of older adults enrolled in a survey about Geriatric ED care. Inclusion criteria were ≥65 years age and English speaking; exclusions were hearing or vision impairment or if clinically unstable.

Measurements

Primary outcome was completion of ≥1 of 5 PREPARE modules. Secondary outcomes were ease of use (10-point scale; 1 = very hard, 10 = very easy) and the reasons for refusal to participate.

Results

Sixty-one subjects were approached; 24 (39%) were interested in viewing PREPARE after the Geriatric ED survey. Mean age was 75 years (standard deviation [SD] 9); 67% were female and 54% were nonwhite. Seventy-one percent of participants completed ≥1 module. Participants rated the website as easy to use for themselves (mean 8.4, SD 2.39) and for others (mean 7.3, SD 2.31). Of the subjects who declined, top reasons cited were fatigue (26%), already feeling prepared (13%), and technology limitations (11%).

Conclusion

PREPARE has the potential to engage older adults who are not acutely ill in ACP during their ED visits. Further studies should explore optimal approaches for ED implementation.

Objectives

To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients.

Design

Secondary analysis of retrospective cohort study.

Setting

Five EDs (four academic, one community) in the United States.

Participants

Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]).

Measurements

Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type.

Results

A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P  < 0.001) and higher opioid-doses (parameter estimate = 0.268; 95 CI = 0.239 to 0.297; P  < 0.001). When LBF were examined separately, older-patients had a trend to longer analgesic wait-times (99 [55-163] vs. 76 [35-149] minutes, P  = 0.057), but no other differences in process outcomes were found.

Conclusion

Long bone fractures were associated with more aggressive pain care than SBF. When fracture types were examined separately, older patients did not appear to receive more aggressive pain care. This difference should be accounted for in further research.