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Objectives: This study characterizes the association between pain score documentation and analgesic administration among pediatric emergency department patients., Methods: This is a secondary analysis of a prospectively collected research database from an academic emergency department. Records of randomly sampled pediatric patients seen between August 2005 and October 2006 were reviewed. Pain scores from age-appropriate 0 to 10 numeric pain rating scales were abstracted (≥ 7 considered severe). Descriptive statistics and 95% confidence intervals (CIs) were calculated., Results: An initial pain score was documented in 87.4% of 4514 patients enrolled, 797 (17.7%) with severe pain. Of these, 63.1% (95% CI, 59.7%-66.5%) received an analgesic, and 16.7% (95% CI, 14.2%-19.5%) received it parenterally. Initial pain score documentation was similar across age groups. Patients younger than 2 years with severe pain were less likely to receive analgesics compared with teenaged patients with severe pain (32.1%; 95% CI, 15.9%-52.3%) versus 67.6% (95% CI, 63.2%-71.7%). Of 502 patients with documented severe pain who received analgesic, 23.3% (95% CI, 19.7%-27.3%) had a second pain score documented within 2 hours of the first. Documentation of a second pain score was associated with the use of parenteral analgesic and a second dose of analgesic., Conclusions: In this population, initial pain score documentation was common, but severe pain was frequently untreated, most often in the youngest patients. Documentation of a second pain score was not common but was associated with more aggressive pain management when it occurred. Further study is needed to investigate causation and to explore interventions that increase the likelihood of severe pain being treated.

Background: Exemplary teachers have been shown to use teaching scripts, ways of organizing the content and instructional approach for commonly encountered teachable moments. This study describes a busy hospitalist unit's early experience with the collaborative development of teaching scripts., Methods: In 2010, during monthly workshops, 10 faculty members each prepared and presented a teaching script for a different commonly encountered diagnosis. Open-ended surveys assessing the impact on faculty were analyzed using an iterative approach. Changes in faculty self-efficacy, and the frequency and applicability of teaching were measured., Results: The program required 10 hours of attendance time and a mean of 4.3 hours for each faculty member who prepared a teaching script. No significant differences in quantity or applicability of teaching were detected, but faculty self-efficacy improved significantly. In addition, faculty described beneficial effects in their individual professional development, development of a shared mental model of professional responsibility, and interpersonal relationships. A majority of comments were positive; negative comments focused on the time required to prepare scripts, and apprehension about presenting to peers., Conclusions: The program was an efficient approach to improve self-rated teaching skills, enhance professional development, and build collegiality among clinician-teachers., (Copyright © 2012 Society of Hospital Medicine.)

Objective: We observed that parenteral morphine is routinely prescribed in doses that are quite low in relation to doses of alternative parenteral opioids and in comparison with published effective doses and guidelines. The present study was undertaken to determine: 1) whether different parenteral opioids are dosed equivalently; 2) which patient factors affect equianalgesic dose; and 3) which patient factors affect opioid choice., Design: At a 750-bed tertiary care, teaching hospital in Rochester, NY, patients on the medical and surgical floors and in the emergency department who received one or more doses of parenteral morphine, hydromorphone, or meperidine were identified using computerized pharmacy records. A detailed chart review was performed for each patient, recording a variety of patient variables, which were then correlated separately with opioid dose and choice., Results: Of the 293 patients treated with boluses of a parenteral opioid, 75% received morphine at a median dose of only 2 mg. Patients prescribed hydromorphone or meperidine received median equianalgesic doses that were 6.7 and 3.4 times higher, respectively. A prescriber's choice of opioid affected the equianalgesic dose more significantly than any of the patient variables studied, including active home opioid use., Conclusions: At our institution, parenteral morphine boluses are routinely given at relatively low doses compared with: 1) other opioids; 2) patient-controlled analgesic dosing; 3) usual doses required for analgesia from previous studies; and 4) a historical control in the same hospital. The reasons for this pattern are largely unexplained by patient variables. Inadequate bolus dosing of morphine may be a barrier to appropriate patient analgesia.