The ACTTION-APS-AAPM Pain Taxonomy (AAAPT) Multidimensional Approach to Classifying Acute Pain Conditions.

Objective: With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (e.g., pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain. Setting: Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM). Methods: As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions. Perspective: The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Conclusions: Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

Reviewing recommendations of root cause analyses

Objective: To determine the opinion of medical and nursing clinicians of recommendations arising from root cause analyses (RCAs) conducted between 1 April 2003 and 30 September 2004 in one Sydney Area Health Service. Methods: Twelve doctors (response rate 86%) and 17 nurses (response rate 100%) reviewed 328 recommendations arising from 59 RCAs and completed a self-administered survey. Results: Nurses were significantly more likely than doctors to rate recommendations made by the original RCA team as "relevant to the causal statement", "understandable", "measurable" and "achievable". Doctors and nurses involved in the original RCA were significantly more likely to state that recommendations would "eliminate" or "control" the risk of a similar event occurring in the future. Conclusions: This is one of the first studies to analyse RCA data at the area health service level. That nurses reviewed recommendations more favourably may have implications for successful adoption of recommendations at the clinical level. We recommend further detailed analyses of recommendations arising from RCAs in order to determine their usefulness to inform strategies for improved patient safety

Administration of medications by enrolled nurses: perceptions of metropolitan and non-metropolitan registered nurses and nursing unit managers

The objective of this study was to investigate the views and current practices of registered nurses (RNs) and nurse unit managers (NUMs) working in metropolitan and non-metropolitan health facilities relating to medication administration by enrolled nurses (ENs). The advanced scope of practice role relating to medication administration is one area currently challenging Registered and Enrolled Nurses from the perspectives of the education, knowledge and skills required to support competence in this area of practice. A self-administered survey comprising questions on participant demographics, their perceptions and their current practices relating to ENs administering medications was completed by 272 RNs and NUMs from metropolitan and non-metropolitan health care facilities within Australia. There were statistically significant differences among metropolitan and non-metropolitan based RNs relating to their views on the various routes by which ENs should be allowed to administer medications. Significantly more RNs from metropolitan hospitals indicated that they asked ENs to administer S3, S4 and S4D medications. Overall, a large proportion of RNs were opposed to ENs administering injectable medications. This study describes the current practices and view points of RNs relating to administration of medications by ENs. While the findings suggest that practice change could be slow, appropriate ongoing education for and consultation with RNs will support change of practice at the clinical level. Further formalising a medication administration role for ENs that acknowledges current practice will have potential organisational and patient safety benefits

Administration of medications by enrolled nurses : perceptions of metropolitan and non-metropolitan registered nurses and nursing unit managers

Objective: The objective of this study was to investigate the views and current practices of registered nurses (RNs) and nurse unit managers (NUMs) working in metropolitan and non-metropolitan health facilities relating to medication administration by enrolled nurses (ENs). Background: The advanced scope of practice role relating to medication administration is one area currently challenging Registered and Enrolled Nurses from the perspectives of the education, knowledge and skills required to support competence in this area of practice. Method: A self-administered survey comprising questions on participant demographics, their perceptions and their current practices relating to ENs administering medications was completed by 272 RNs and Nums from metropolitan and non-metropolitan health care facilities within Australia. Results: There were statistically significant differences among metropolitan and non-metropolitan based RNs relating to their views on the various routes by which ENs should be allowed to administer medications. Significantly more RNs from metropolitan hospitals indicated that they asked ENs to administer S3, S4 and S4D medications. Overall, a large proportion of RNs were opposed to ENs administering injectable medications. Conclusion: This study describes the current practices and view points of RNs relating to administration of medications by ENs. While the findings suggest that practice change could be slow, appropriate ongoing education for and consultation with RNs will support change of practice at the clinical level. Further formalising a medication administration role for ENs that acknowledges current practice will have potential organisational and patient safety benefits