Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands

doi:10.5847/wjem.j.1920-8642.2020.02.001

Abstract

Abstract:

BACKGROUND: Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians.

METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire.

RESULTS: The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients.

CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.

Key words: Procedural sedation and analgesia, Emergency departments, Emergency physicians

Maybritt I. Kuypers, Adinda Klijn, Nieke E. Mullaart-Jansen, Frans B. Plötz. Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands[J]. World Journal of Emergency Medicine, 2020, 11(2): 69-73.

Figures/Tables 3

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References 12

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Variables	Adult		Children
Variables	n	Percent	n	Percent
Do you perform PSA procedures? (Yes)	84/148	56.8	30/148	20.4
Two to four times a week	11/84	13.1	-
Once a week	21/84	25.0	-
Once per two weeks	17/84	20.2	3/30	10.0
Once per month	17/84	20.2	7/30	23.3
< Once per month	18/84	21.4	17/30	56.7
Is this frequency enough to maintain your skills? Strongly disagree Disagree Neutral Agree Strongly agree	1/84 19/84 17/84 43/84 3/84	1.2 22.6 20.2 51.2 3.6	2/30 7/30 14/30 5/30 2/30	6.7 23.3 46.7 16.7 6.7
Your first choice sedative used for PSA
Propofol	17/84	20.2	5/30	16.7
Midazolam	48/84	57.1	15/30	50.0
Esketamine	12/84	14.3	1/30	3.3
Diazepam	2/84	2.4	2/30	6.7
Nitrous oxide 50:50	1/84	1.2	3/30	10.0
Ketanest/propofol	1/84	1.2	0/0
Your first choice analgesic medication used for PSA
Fentanyl	30/84	35.7	3/30	10.0
Sufentanil	0/0		0
Remifentanil	1/84	1.2	0
Morphine	15/84	17.9	2/30	6.7
Paracetamol	17/84	20.2	15/30	50.0
NSAID	2/84	2.4	0/0
Esketamine	9/84	10.7	2/30	6.7
Nitrous oxide 50:50	0/0		2/30	6.7
Local (for example: lidocaine)	3/84	3.6	1/30	3.3
None	1/84	1.2	1/30	3.3
Other	2/84	2.4	2/30	6.7
Indications for PSA in your ED¹
Dislocation	77/84	91.7	18/30	58.1
Dislocated fracture	69/84	82.1	25/30	83.3
Cardioversion	25/84	29.8	0/0
Wound management	7/84	8.3	12/30	40.0
CT scan	4/84	4.8	1/30	3.3
Chest tube Intubation Other Is the executor of the procedure also the provider of PSA? (Yes)	10/84 2/84 5/84 51/84	11.9 2.4 6.0 60.7	0/0 1/30 3/30 15/30	3.3 10.0 50.0

Variables	Strongly agree		Agree		Neutral		Disagree		Strongly disagree
Variables	n	Percent	n	Percent	n	Percent	n	Percent	n	Percent
I am capable and competent in performing PSA in adults	6	7.1	48	57.1	15	17.9	12	14.3	2	2.4
I am able to perform ALS appropriately	32	38.1	49	58.3	0	0.0	2	2.4	0	0.0
I am aware of the indications, contra-indications and precautions for PSA	9 4 8	10.7 4.8 9.5	64 52 66	76.2 61.9 78.6	7 19 1	8.3 22.6 1.2	1 5 2	1.2 6.0 2.4	0 0 0	0.0 0.0 0.0
I am able to recognize and treat the most common adverse events and/ or complications’ The number of PSA I provide is adequate to be capable and competent I use the protocol that is available in the hospital I work in PSA in the ED is always provided in short painful procedures	6 6 3 13 1	7.1 7.1 3.6 15.5 1.2	70 64 43 46 32	83.3 76.2 51.2 54.8 38.1	3 6 17 16 18	3.6 7.1 20.2 19.0 21.4	1 2 19 2 28	1.2 2.4 22.6 2.4 33.3	0 0 1 1 2	0.0 0.0 1.2 1.2 2.4

Variables	Strongly agree		Agree		Neutral		Disagree		Strongly disagree
Variables	n	Percent	n	Percent	n	Percent	n	Percent	n	Percent
I am capable and competent in performing paediatric PSA	0	0.0	10	33.3	13	43.3	4	13.3	3	10.0
I am able to perform APLS appropriately	10	33.3	12	40.0	5	16.7	3	10.0	0	0.0
I am able to inform the patient, parents and/or a legal guardian about the indications, contra-indications, possible adverse events, sedation techniques and alternatives	5 1 2 3 3	16.7 3.3 6.7 10.0 10.0	19 18 16 17 14	63.3 60.0 53.3 56.7 46.7	3 6 6 5 7	10.0 20.0 20.0 16.7 23.3	1 3 4 3 4	3.3 10.0 13.3 10.0 13.3	1 1 1 1 1	3.3 3.3 3.3 3.3 3.3
The number of PSA I provide is adequate to be capable and competent	1	3.3	5	16.7	14	46.7	7	23.3	2	6.7
The age of the patient determines if I perform PSA or not	2	6.7	15	50.0	8	26.7	3	10.0	1	3.3
I only apply PSA in paediatric patients in the direct presence of another specialist	8	26.7	9	30.0	5	16.7	6	20.0	0	0.0
I use the protocol that is available in the hospital I work in PSA in the ED is always provided in short painful procedures	5 0	16.7 0.0	15 9	50.0 30.0	7 7	23.3 23.3	1 12	3.3 40.0	0 1	0.0 3.3

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