Top

European Journal of Trauma and Emergency Surgery

Published in:

30-03-2023 | Triage | Original Article

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators

Authors: Triinu Keskpaik, Peep Talving, Ülle Kirsimägi, Vladislav Mihnovitš, Anni Ruul, Joel Starkopf

Published in: European Journal of Trauma and Emergency Surgery | Issue 3/2023

Abstract

Background

Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs.

Objectives

The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals.

Methods

This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3.

Results

Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35–105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71–3.40, p = 0.034).

Conclusion

Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.

Available only for authorised users

Bhuiya FA, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS Data Brief. 2010;43:1–8.

Moore BJ (IBM Watson Health), Stocks C (AHRQ), Owens PL (AHRQ). Trends in Emergency Department Visits, 2006–2014. HCUP Statistical Brief #227. September 2017. Agency for Health-care Research and Quality, Rockville MD.

Hansen K, Boyle A, Holroyd B, Phillips G, Benger J, Chartier LB, et al. Updated framework on quality and safety in emergency medicine. Emerg Med J. 2020. https://doi.org/10.1136/emermed-2019-209290.CrossRefPubMed

Schull MJ, Guttmann A, Leaver CA, Vermeulen M, Hatcher CM, Rowe BH, et al. Prioritizing performance measurement for emergency department care: consensus on evidence-based quality of care indicators. CJEM. 2011. https://doi.org/10.2310/8000.2011.110334. (PMID: 21955411).CrossRefPubMed

Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002. https://doi.org/10.1053/ajem.2002.32643.CrossRefPubMed

Karwowski-Soulié F, Lessenot-Tcherny S, Lamarche-Vadel A, Bineau S, Ginsburg C, Meyniard O, et al. Pain in an emergency department: an audit. Eur J Emerg Med. 2006. https://doi.org/10.1097/01.mej.0000217975.31342.13.CrossRefPubMed

Venkat A, Fromm C, Isaacs E, Ibarra J. An ethical framework for the management of pain in the emergency department. Acad Emerg Med. 2013;20:716–23.CrossRefPubMed

Beal J, France J. Management of Pain in Adults. The Royal College of Emergency Medicine Best Practice Guideline. 2021. https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_BPC_Management_of_Pain_in_Adults_300621.pdf. Accessed 01.

Schug SA, Palmer GM, Scott DA, Alcock M, Halliwell R, Mott JF; APM:SE Working Group of the, Australian and New Zealand college of anaesthetists and faculty of pain medicine acute pain management: scientific evidence fifth edition 2020.

10.

Stang AS, Hartling L, Fera C, Johnson D, Ali S (2014) Quality indicators for the assessment and management of pain in the emergency department: a systematic review. Pain Res Manag. 2014. https://doi.org/10.1155/2014/269140.

11.

New Zealand Emergency Medicine Network and The Shorter Stays in Emergency Department National Research Project Group. National audit of the quality of pain relief provided in emergency departments in Aotearoa, New Zealand: The PRiZED 1 Study. Emerg Med Australas. 2017. https://doi.org/10.1111/1742-6723.12714.

12.

Allione A, Melchio R, Martini G, Dutto L, Ricca M, Bernardi E, et al. Factors influencing desired and received analgesia in emergency department. Intern Emerg Med. 2011. https://doi.org/10.1007/s11739-010-0463-9.CrossRefPubMed

13.

Patrick PA, Rosenthal BM, Iezzi CA, Brand DA. Timely pain management in the emergency department. J Emerg Med. 2015. https://doi.org/10.1016/j.jemermed.2014.09.009.CrossRefPubMed

14.

Henneman PL, Nathanson BH, Li H, Smithline HA, Blank FS, Santoro JP, et al. Emergency department patients who stay more than 6 hours contribute to crowding. J Emerg Med. 2010. https://doi.org/10.1016/j.jemermed.CrossRefPubMed

15.

Jones PG, Mountain D, Forero R. Review article: emergency department crowding measures associations with quality of care: a systematic review. Emerg Med Australas. 2021. https://doi.org/10.1111/1742-6723.13743.CrossRefPubMedPubMedCentral

16.

Yiadom MYAB, Napoli A, Granovsky M, Parker RB, Pilgrim R, Pines JM, et al. Managing and measuring emergency department care: results of the fourth emergency department benchmarking definitions summit. Acad Emerg Med. 2020. https://doi.org/10.1111/acem.13978.CrossRefPubMed

17.

Shabbir J, Ridgway PF, Lynch K, Law CE, Evoy D, O’Mahony JB, et al. Administration of analgesia for acute abdominal pain sufferers in the accident and emergency setting. Eur J Emerg Med. 2004. https://doi.org/10.1097/00063110-200412000-00002.CrossRefPubMed

18.

Vazirani J, Knott JC. Mandatory pain scoring at triage reduces time to analgesia. Ann Emerg Med. 2012. https://doi.org/10.1016/j.annemergmed.2011.08.007.CrossRefPubMed

19.

Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. J Am Geriatr Soc. 2010. https://doi.org/10.1111/j.1532-5415.2010.03152.x.CrossRefPubMedPubMedCentral

20.

Daoust R, Paquet J, Lavigne G, Sanogo K, Chauny JM. Senior patients with moderate to severe pain wait longer for analgesic medication in EDs. Am J Emerg Med. 2014. https://doi.org/10.1016/j.ajem.2013.12.012.CrossRefPubMed

21.

Royal College of Emergency Medicine. Emergency Medicine Briefing: Making the Case for the FourHour Standard. https://www.politicshome.com/news/article/emergency-medicine-briefing-making-the-case-for-the-fourhour-standard. Accessed 28 Aug 2022.

22.

Ministry of Health. 2016. Emergency Department Use 2014/15. Wellington: Ministry of Health. https://www.health.govt.nz/publication/emergency-department-use-2014-15. Accessed 9 Aug 2021.

23.

Choi W, Woo SH, Kim DH, Lee JY, Lee WJ, Jeong S, et al. Prolonged length of stay in the emergency department and mortality in critically Ill elderly patients with infections: a retrospective multicenter study. Emerg Med Int. 2021. https://doi.org/10.1155/2021/9952324.CrossRefPubMedPubMedCentral

24.

Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario. Canada BMJ. 2011. https://doi.org/10.1136/bmj.d2983.CrossRefPubMed

25.

Zhang Z, Bokhari F, Guo Y, Goyal H. Prolonged length of stay in the emergency department and increased risk of hospital mortality in patients with sepsis requiring ICU admission. Emerg Med J. 2019. https://doi.org/10.1136/emermed-2018-208032.CrossRefPubMed

26.

Diercks DB, Roe MT, Chen AY, Peacock WF, Kirk JD, Pollack CV Jr, et al. Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007. https://doi.org/10.1016/j.annemergmed.2007.03.033.CrossRefPubMed

27.

Chang AM, Lin A, Fu R, McConnell KJ, Sun B. Associations of emergency department length of stay with publicly reported quality-of-care measures. Acad Emerg Med. 2017. https://doi.org/10.1111/acem.13102.CrossRefPubMedPubMedCentral

28.

Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS ONE. 2018. https://doi.org/10.1371/journal.pone.0203316.CrossRefPubMedPubMedCentral

29.

Driesen BEJM, van Riet BHG, Verkerk L, Bonjer HJ, Merten H, Nanayakkara PWB. Long length of stay at the emergency department is mostly caused by organisational factors outside the influence of the emergency department: a root cause analysis. PLoS ONE. 2018. https://doi.org/10.1371/journal.pone.0202751.CrossRefPubMedPubMedCentral

30.

Vegting IL, Alam N, Ghanes K, Jouini O, Mulder F, Vreeburg M, et al. What are we waiting for? Factors influencing completion times in an academic and peripheral emergency department. Neth J Med. 2015.

31.

Dadeh AA, Phunyanantakorn P. Factors affecting length of stay in the emergency department in patients who presented with abdominal pain. Emerg Med Int. 2020. https://doi.org/10.1155/2020/5406516.CrossRefPubMedPubMedCentral

32.

Brouns SH, Stassen PM, Lambooij SL, Dieleman J, Vanderfeesten IT, Haak HR. Organisational factors induce prolonged emergency department length of stay in elderly patients–a retrospective cohort study. PLoS ONE. 2015. https://doi.org/10.1371/journal.pone.0135066.CrossRefPubMedPubMedCentral

Title: Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators
Authors: Triinu Keskpaik
Peep Talving
Ülle Kirsimägi
Vladislav Mihnovitš
Anni Ruul
Joel Starkopf
Publication date: 30-03-2023
Publisher: Springer Berlin Heidelberg
Keywords: Triage
Key Symptom
Abdominal Pain
Published in: European Journal of Trauma and Emergency Surgery / Issue 3/2023
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-023-02263-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators

Abstract

Background

Objectives

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Objectives

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 3/2023

Burn injury characteristics, referral pattern, treatment (costs), and outcome in burn patients admitted to a hospital with or without a specialized Burn Centre (BURN-Pro)

Traumatic brain injury: the research continues with higher data quality evolving!

Outcome of functional treatment with a Lucerne Cast in patients with hand fractures: a retrospective case series

External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful?

The diagnostic and prognostic value of glial fibrillary acidic protein in traumatic brain injury: a systematic review and meta-analysis

Cardiovascular parameters on computed tomography are independently associated with in-hospital complications and outcomes in level-1 trauma patients