Quarterly EJEM Research Round-up
Welcome to the quarterly EJEM research round-up, where we present our top picks from the last three months of EJEM editions.
Barbra Backus
With an increasing aging population, the amount of elderly patients at the emergency department (ED), increases accordingly. In most countries elderly account for 20% of the ED attendees. In a recent published study Bloom et al. investigated the association between age and the provision of pain care for ED patients presenting with abdominal pain [1]. This retrospective cohort study focused on two primary endpoints: time to initial analgesia and the selection of opioid analgesia. Data were drawn over four months of electronic health record (EHR) data within a single UK National Health Service (NHS) trust, spanning visits from December 2022 to March 2023. The study included 4231 patients presenting with abdominal pain. Demographic data analysed were age, sex and ethnicity, complemented with pain scores using a 0–10 scale.
The primary endpoint, time to initial analgesia, showed a median delay of 110 minutes (95% CI: 104-120), with substantial variability (IQR: 55-229 minutes). Univariate analysis revealed that age was significantly associated with delayed analgesia, with each decade increase in age resulting in a median delay of approximately 10.5 minutes (95% CI: 6.1-14.9, P < 0.001). Patients aged 70-79 had a median time to initial analgesia of 159 minutes (95% CI: 114–189), compared to 97 minutes (95% CI: 85–104) for patients aged 18-29. Sex and ethnicity did not show significant associations with delayed analgesia. Multivariable analysis confirmed that age and initial pain score were significant predictors, with older patients and those with higher pain scores receiving analgesia later. Operational factors, including referral from other facilities and time of day, also influenced time to analgesia, with evening shifts associated with longer delays. Initial pain score had a positive and significant (P < 0.001) association with time to initial analgesia. Univariate results indicated that each one-point increase on a 0–10 scale was associated with lowering time to initial analgesia of 12.2 min (95% CI, 9.7–14.7) and 11.1 (95% CI; −8.6 to −13.6) minutes the multivariate model. Regarding the secondary endpoint, the selection of opioid analgesia, no association was found between opioid selection and age group (P = 0.127), sex (P = 0.285) or ethnicity (P = 0.237).
Overall, the findings suggest that age is influencing delays in receiving initial analgesia, with older patients experiencing significant delays compared to younger patients. Despite previous studies highlighting potential racial or ethnic biases in pain care, this study did not find significant associations between ethnicity and either time to analgesia or opioid selection. Age-related delays in pain management may contribute to adverse outcomes, particularly in older patients. This analysis is consistent with existing literature, which underscores the vulnerability of older adults to inadequate pain management, suggesting a need for targeted interventions to mitigate these disparities in acute care settings. Onderkant formulier
Another study assessing how patient criteria influence our care at the ED was the study conducted by dr Vromant et al. This recently published European case-based survey-study investigated whether patient gender influences decisions of emergency physicians (EPs) regarding tracheal intubation in critically ill patients with acute respiratory distress [2]. A total of 3423 physicians participated, of which 91.6% were emergency physicians (46% women). Participants were presented with a randomized vignette of a 75-year-old patient, varying only by gender (male or female) and functional status (high, moderate, or low independence). The primary outcome measured was the recommendation for intubation.
The results showed a significant gender difference in decision-making. Overall, 67.9% of female patients were recommended for intubation, compared to 71.7% of male patients, a difference of 3.81% (95% CI, 0.74–6.88%, p = 0.017). Multivariable logistic regression confirmed that female gender was independently associated with a lower likelihood of intubation (adjusted OR = 0.80; 95% CI, 0.69–0.93, p = 0.004). Functional status also influenced decision-making; intubation rates were 79.9% for high-functioning patients, 72.4% for those with moderate impairment, and 57.4% for those with low functional status.
In subgroup analysis, female physicians were also less likely to recommend intubation (adjusted OR = 0.85; 95% CI, 0.73–0.99, p = 0.04), while Franch physicians were more likely to recommend intubation compared to other physicians, especially compared to physicians from Southern Europe (adjusted OR = 0.44; 95% CI, 0.36–0.54, p < 0.0001). Intubation was slightly more likely among physicians from academic versus non-academic hospitals (adjusted OR = 1.18; 95% CI, 1.01–1.38, p = 0.04).
Additionally the patients’ desire not to suffer was taken into account. When patients expressed a desire to avoid aggressive treatment, the decision to intubate was limited in 55.2% of cases. Female patients were more likely to undergo limited care then male patients (adjusted OR = 1.25; 95% CI, 1.05–1.49, p = 0.01).
These findings highlight a gender-based inequality in the decision-making process for intubation, with female patients being less likely to be intubated than male patients. This study suggests the presence of implicit gender bias in emergency care decisions. However, as also recognized by the authors the results of the study are limited by the survey-based design data and the hypothetical nature of the case scenarios. Further research and interventions addressing gender bias in clinical decision-making are recommended.
Another study discussing our provided care at the ED is the study by dr Coste et al on the accuracy of humeral intraosseous punctures [3]. This observational study examined the accuracy of anatomical landmarking for intraosseous punctures at the humeral site, a handling that can be crucial in emergent situations. The ideal puncture site, with the lowest risk of complications to tendons and veins, is located at the centre of the greater humeral tuberosity (an area of approximately 25 mm in diameter). Five orthopaedic surgeons identified the ideal puncture point, around which a 10mm "green" zone (ideal) and a 10-20mm "orange" zone (acceptable) were defined, with anything beyond 20mm considered the "red" zone, associated with higher risk of injury to nerves and blood vessels. The study included 67 operators (47 doctors, 20 nurses) across five centres, who performed 97 punctures on humeral models. Of the punctures analysed, 23 (24%) were located in the green zone, 67 (69%) in the orange zone, and 7 (7%) in the red zone, with no significant difference between the left and right sides. In order to increase the chance of reaching the medullary cavity a 45° angle would be desirable. Angulation was considered acceptable (45°±10°) in 56 cases (58%). Left-sided punctures had acceptable angulation in 49 cases (91%), compared to only 7 cases (16%) on the right, showing a significant lateralization effect. The study revealed that while 24% of punctures were in the ideal green zone, fortunately only 7% fell into the dangerous red zone. However, the majority of punctures were outside the ideal zone, particularly in the orange zone, where the risk of damage to structures like the biceps tendon, subscapularis tendon, and cephalic vein exists. These findings suggest that anatomical landmarking for humeral intraosseous puncture may be insufficient and calls for improved training protocols. Perhaps the lower accuracy of correct puncture at the humerus counterbalance the reported limitations of tibial intraosseous access.
1. Older age and risk for delayed abdominal pain care in the emergency department. Bloom, Ben; Fritz, Christie L; Gupta, Shivani; Pott, Jason; Skene, Imogen; Astin-Chamberlain, Raine; Ali, Mohammad; Thomas, Sarah A; Thomas, Stephen H. European Journal of Emergency Medicine 31(5):p 332-338, October 2024.
2. Effect of patient gender on the decision of ceiling of care: an European study of emergency physicians’ treatment decisions in simulated cases. Vromant, Amélie; Alamé, Karine; Cassard, Clémentine; Bloom, Ben; Miró, Oscar; Freund, Yonathan. European Journal of Emergency Medicine 31(6):p 423-428, December 2024.
3. Accuracy of humeral intraosseous puncture: direct analysis of humeral head models. Coste, Ophélie; Souayah, Ahmed; Occelli, Céline; Lapostolle, Frédéric. European Journal of Emergency Medicine 31(6):p 440-441, December 2024.
