Prescription Of analgesia in Emergency Medicine (POEM): a multicentre observational survey of pain relief in patients presenting with an isolated limb fracture and/or dislocation

Background: Acute pain is one of the most commonly cited reasons for attendance to the emergency department (ED), and the Royal College of Emergency Medicine (RCEM) Best Practice Guideline (2014) acknowledged that the current management of acute pain in UK EDs is inadequate and has a poor evidence base. Methods: The Prescription Of analgesia in Emergency Medicine (POEM) survey is a cross-sectional observational survey of consecutive patients presenting to 12 National Health Service (NHS) EDs with limb fracture and/or dislocation in England and Scotland and was carried out between 2015 and 2017. The primary outcome was to assess the adequacy of pain management in the ED against the recommendations in the RCEM Best Practice Guidelines. Results: In all, 8346 patients were identified as attending the ED with a limb fracture and/or dislocation but adherence to RCEM guidelines could only be evaluated for the 4160 (49.8%) patients with a recorded pain score. Of these, 2409/4160 (57.9%) patients received appropriate pain relief, but only 1347 patients were also assessed within 20 minutes of their arrival in the ED. Therefore, according to the RCEM guidelines, only 16.1% (1347/8346) of all patients were assessed and had satisfactory pain management in the ED. Conclusions: The POEM survey has identified that pain relief for patients with an isolated limb fracture remains inadequate when strictly compared to the RCEM Best Practice Guidelines. However, we have found that some patients receive analgesia despite having no pain score recorded, while other analgesic modalities are provided that are not currently encompassed by the Best Practice Guidelines. Future iterations of these guidelines may wish to encompass the breadth of available modalities of pain relief and the whole patient journey. In addition, more work is needed to improve timely and repeated assessment of pain and its recording, which has been better achieved in some EDs than others.

背景：急性疼痛是急诊科（ED）就诊最常见的原因之一，英国皇家急诊医学院（RCEM）的最佳实践指南（2014年）承认，英国急诊科目前对急性疼痛的管理是不充分的，且证据基础薄弱。 方法：急诊医学镇痛处方（POEM）调查是一项对2015年至2017年间在英格兰和苏格兰12家国民医疗服务体系（NHS）急诊科就诊的四肢骨折和/或脱位连续患者进行的横断面观察性调查。主要结果是根据RCEM最佳实践指南中的建议评估急诊科疼痛管理的充分性。 结果：总共有8346名患者被确定因四肢骨折和/或脱位而到急诊科就诊，但只有4160名（49.8%）有记录疼痛评分的患者能够评估对RCEM指南的依从性。在这些患者中，2409/4160（57.9%）的患者得到了适当的疼痛缓解，但只有1347名患者在到达急诊科20分钟内也进行了评估。因此，根据RCEM指南，所有患者中只有16.1%（1347/8346）在急诊科得到了评估且疼痛管理令人满意。 结论：POEM调查发现，与RCEM最佳实践指南严格比较时，单纯四肢骨折患者的疼痛缓解仍然不充分。然而，我们发现一些患者尽管没有记录疼痛评分却接受了镇痛治疗，同时还提供了一些最佳实践指南目前未涵盖的其他镇痛方式。这些指南的未来版本可能希望涵盖现有疼痛缓解方式的范围以及患者的整个就医过程。此外，还需要更多的工作来改进对疼痛的及时和反复评估以及记录，在一些急诊科这方面做得比其他急诊科更好。