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Original paper
Acupuncture and standard emergency department care for pain and/or nausea and its impact on emergency care delivery: a feasibility study Anthony L Zhang,1 Shefton J Parker,1 De Villiers Smit,2 David McD Taylor,3 Charlie C L Xue1
1
School of Health Sciences, RMIT University, Bundoora, Victoria, Australia 2 Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia 3 Department of Emergency, Austin Health, Heidelberg, Victoria, Australia Correspondence to Professor Charlie Xue, School of Health Sciences, RMIT University, 3083, Melbourne, VIC Australia; [email protected] Received 19 November 2013 Revised 29 January 2014 Accepted 4 February 2014 Published Online First 7 March 2014
To cite: Zhang AL, Parker SJ, Smit DV, et al. Acupunct Med 2014;32:250–256.
250
ABSTRACT Objective To evaluate the feasibility of delivering acupuncture in an emergency department (ED) to patients presenting with pain and/or nausea. Methods A feasibility study (with historical controls) undertaken at the Northern Hospital ED in Melbourne, Australia, involving people presenting to ED triage with pain (VAS 0–10) and/or nausea (Morrow Index 1–6) between January and August 2010 (n=400). The acupuncture group comprised 200 patients who received usual medical care and acupuncture; the usual care group comprised 200 patients with retrospective data closely matched from ED electronic health records. Results Refusal rate was 31%, with ‘symptoms under control owing to medical treatment before acupuncture’ the most prevalent reason for refusal (n=36); 52.5% of participants responded ‘definitely yes’ for their willingness to repeat acupuncture, and a further 31.8% responded ‘probably yes’. Over half (57%) reported a satisfaction score of 10 for acupuncture treatment. Musculoskeletal conditions were the most common conditions treated n=117 (58.5%), followed by abdominal or flank pain n=49 (24.5%). Adverse events were rare (2%) and mild. Pain and nausea scores reduced from a mean±SD of 7.01±2.02 before acupuncture to 4.72±2.62 after acupuncture and from 2.6±2.19 to 1.42±1.86, respectively. Conclusions Acupuncture in the ED appears safe and acceptable for patients with pain and/or nausea. Results suggest combined care may provide effective pain and nausea relief in ED patients. Further high-quality, sufficiently powered randomised studies evaluating the
cost-effectiveness and efficacy of the add-on effect of acupuncture are recommended.
INTRODUCTION In a community setting among Australian GPs, complementary medicine for various health conditions is increasing in popularity.1 In a survey of GPs, 84% described acupuncture potentially as moderately or highly effective and 57% of GPs encourage their patients to use acupuncture.2 Over the last several decades, acupuncture research has identified a number of mechanisms of action related to clinical application, based on measurable responses triggered by acupuncture.3 Studies show that acupuncture enhances the post-stimulation spatial extent of resting brain networks to include anti-nociceptive, memory and affective brain regions, which might explain why acupuncture has an analgesic effect.4 Pharmacotherapy analgesia, although effective for painful conditions, has limitations to its use owing to side effects, allergies and drug interactions. The extended use of some analgesic drugs, such as opioids, places patients at higher risk of developing constipation, cardiovascular disease and/or potential dependence.5 6 Despite the short-term benefit of analgesic drugs, it is not uncommon for a patient’s pain to return once the therapeutic effect has worn off.7 GPs are aware of the limits of pharmacotherapy and are increasingly suggesting complementary medicines such as acupuncture to patients who present with
Zhang AL, et al. Acupunct Med 2014;32:250–256. doi:10.1136/acupmed-2013-010501
Downloaded from http://aim.bmj.com/ on July 3, 2015 - Published by group.bmj.com
Original paper uncomplicated painful conditions such as carpal tunnel syndrome.2 8 In the emergency department (ED), the possible advantages of acupuncture compared with pharmacotherapy are relatively unknown and untested. In 2007, the Australian and New Zealand College of Anaesthetists, based on level 1 scientific evidence, recommended that “acupuncture may be effective in some acute pain settings… and acupuncture reduces postoperative pain as well as opioid-related adverse effects”.9 The National Institute of Health (NIH) has concluded that there is sufficient evidence of the value of acupuncture to expand its use into conventional medicine.10 This pilot study was designed to investigate the feasibility, potential efficacy, safety and acceptability to patient and medical staff of acupuncture in an ED. The results were intended to assist in the development of a large-scale RCT of acupuncture in the ED.11 METHODS Human research ethics approval was granted from the Northern Hospital and RMIT University and the protocol conformed to the provisions of the Declaration of Helsinki in 1995 (as revised in Seoul 2008). The study was conducted at the ED of the Northern Hospital, Victoria, Australia, between January and August 2010. Acupuncture was available to patients 10 hours a week, over 2 days, for 8 months. Figure 1 shows the path for patients who were screened and consented to participate in the pilot study. Participants Acupuncture group
Two hundred triaged patients, ≥18 years of age, with symptoms of pain and/or nausea, were identified via the ED information system (EDIS). Patients whose language prevented them providing informed consent, critically ill patients (determined by the treating physician or the consultant in charge) and pregnant women were screened and excluded before an approach for consent was made. Participation was voluntary. If the patient refused, a reason was documented without recording patient identifiers. Usual care group
Two hundred historical patient records were screened and matched 1 week after each comparative case for gender and closest possible match to age, arrival day and time, presenting condition and discharge diagnosis to that of the acupuncture group participant. To limit selection bias, the usual care group patients were screened in the EDIS by a research assistant not associated with the care of patients. No identifying information was collected and no contact with matched patients was necessary. Usual care group data were collected to compare time to medical consultation and discharge with acupuncture group data, to investigate
Zhang AL, et al. Acupunct Med 2014;32:250–256. doi:10.1136/acupmed-2013-010501
Figure 1 Path for patients who were screened and consented to participate in the feasibility study.
if acupuncture caused delays in patient care or extension of their length of stay. Acupuncture protocol
Potential participants were screened chronologically from the earliest to the most recent triage via their EDIS triage notes for conditions of pain and/or nausea, then again by the treating physician or consultant in charge to ensure their suitability for acupuncture. After patient consent had been received, an acupuncturist undertook a short period of discussion with the patient and observation, obtaining a brief history of their condition, patient-reported pain score (VAS) and/or their reported nausea (Morrow Index) score.12 A pragmatic acupuncture treatment prescription was developed for each patient individually (using WHO acupuncture location recommendations),13 based on the acupuncturist’s evaluation. Acupuncture was delivered by emergency medical physicians with medical acupuncture qualifications, registered acupuncturists with the Chinese medicine registration board of Victoria or final year RMIT university acupuncture students under supervision of registered acupuncturists. The supervising acupuncturist held an honorary ED position for the duration of the study. Funding for the equipment was provided by RMIT University with assistance from the 251
Downloaded from http://aim.bmj.com/ on July 3, 2015 - Published by group.bmj.com
Original paper Department of Health, Victoria. Medical acupuncturists were part of the ED staff and delivered acupuncture to patients using study equipment, in addition to their regular roles within the ED. Manual acupuncture was performed at the bedside in an ED cubicle or treatment room using Chinese manufactured, copper-handled, stainless steel singleuse needles, 0.25 mm gauge and either 30 mm or 40 mm in length. For each point, regardless of the treating acupuncturist, the needle was manipulated after insertion until the sensation of de qi (dull ache and possible grabbing sensation of the needle) was experienced. Needles were left for about 20 min before removal by an acupuncturist. Immediately after removal of needles, the acupuncturist recorded patient-reported pain and/or nausea scores, adverse events and the participant’s acceptability of (a) the ED visit, (b) the acupuncture treatment and (c) their willingness to repeat acupuncture again in the future for their condition. The ED doctor was free to assess and consult the patient at any stage before, during or after acupuncture, and pharmacotherapy was permitted as necessary.
Measurements
Demographic data, triage presenting symptoms and discharge diagnosis were recorded as well as times for triage, initial medical consultation, approach for acupuncture, start of acupuncture, completion of acupuncture and discharge. Adverse events reported by patients, ED staff or acupuncturist were recorded after acupuncture treatment. Willingness to repeat acupuncture for a similar condition in the future and satisfaction with the acupuncture was measured using 10-point ordinal scale, and pain was measured (VAS 0–10) at triage, before acupuncture and immediately
Figure 2 Acupuncture treatment before or after medical consultation and historically matched controls.
252
after acupuncture.14 If applicable, nausea was measured using the Morrow Index (range 1–6) at triage, before acupuncture and immediately after acupuncture. Staff time required to manage patients was calculated by subtracting the time from ‘triage to intervention’ (acupuncturist or physician consultation) from the ‘triage to discharge time’ (min). Data analysis
No a priori power calculation was performed for sample size as this was a feasibility study, designed to guide the development of a full size RCT. The sample size was based on enrolling available cases over an 8-month period. Statistical Package for Social Sciences for Windows (SPSS) V.19.0 was used to analyse the data. The data for the two groups were compared using the independent t test, χ2 test and the Mann–Whitney U test, where applicable. A value of p ≤0.05 was considered statistically significant. Post-recruitment phase discussions were held between researchers and hospital management to evaluate and report the impacts of the pilot acupuncture study on the ED, grouping similar participant data and evaluating the various pathways by which participants were recruited, treated and discharged throughout the study. RESULTS A total of 290 ED patients were approached about acupuncture treatment, 200 (69.0%) consented and completed treatment. The acupuncture group consisted of two participant subgroups: acupuncture given before (n=55) or after (n=145) medical consultation (figure 2). Participants were not allocated to the groups; inclusion in a group was dependent on whether the treating physician or acupuncturist saw the patient first after triage. Common reasons for declining acupuncture were (1) symptoms were under control owing to medical treatment before acupuncture (n=36, 40%); (2) preference for medical treatment (n=13, 14.4%); (3); not interested in acupuncture (n=10, 11.1%) and (4) needle phobia (n=8, 8.9%). Overall, 98.5% of respondents reported a satisfaction score of between 5 and 10. More than half (52.5%) of participants responded ‘definitely yes’ for their willingness to repeat acupuncture, and a further 31.8% responded ‘probably yes’. Over half (57%) reported a satisfaction score of 10. Overall, 222 women and 178 men were included in the study. The acupuncture group was well matched for age and gender, and was representative of the ED usual care population in their diagnostic category and waiting time (table 1). More than half of the participants presented with musculoskeletal back or limb pain (58.5% and 59.5% for the acupuncture and control groups, respectively). Most participants had an Australasian Triage Scale (ATS) rating of ≥3 (1, most urgent; 5, least urgent).15
Zhang AL, et al. Acupunct Med 2014;32:250–256. doi:10.1136/acupmed-2013-010501
Downloaded from http://aim.bmj.com/ on July 3, 2015 - Published by group.bmj.com
Original paper Table 1 Demographics, diagnosis, waiting time and staff time required of patient groups Acupuncture (N=200) Gender, N (%): Female 115 (57.5) Male 85 (42.5) Age, N (% within group): 18–39 87 (43.5) 40–59 64 (32.0) 60–79 48 (24.0) 80–99 1 (0.5) Western medicine diagnosis, N (% within group): Musculoskeletal pain 117 (58.5) Pain in abdominal or flank region 49 (24.5) Headache or vertigo 15 (7.5) Other conditions 19 (9.5) Waiting time between triage and initial consultation (min), mean (SE) 85 (5) Waiting time between triage and initial medical or acupuncture consultation (min), mean (SE): Acupuncture before consultation 66 (10) (N=55) Acupuncture after consultation 134 (5) (N=145) Staff time managing patients (min): Acupuncture before consultation 182 (99) (N=55) Acupuncture after consultation 273 (152) (N=145)
Overall, there was no gender or age difference between patients who received acupuncture before or after medical consultation. In the acupuncture group, there was significant difference between the patient-reported pain scores before (mean=7.01, SD=2.02) and after acupuncture (mean=4.72, SD=2.62) [t (193)=14.81, p
Original paper
Acupuncture and standard emergency department care for pain and/or nausea and its impact on emergency care delivery: a feasibility study Anthony L Zhang,1 Shefton J Parker,1 De Villiers Smit,2 David McD Taylor,3 Charlie C L Xue1
1
School of Health Sciences, RMIT University, Bundoora, Victoria, Australia 2 Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia 3 Department of Emergency, Austin Health, Heidelberg, Victoria, Australia Correspondence to Professor Charlie Xue, School of Health Sciences, RMIT University, 3083, Melbourne, VIC Australia; [email protected] Received 19 November 2013 Revised 29 January 2014 Accepted 4 February 2014 Published Online First 7 March 2014
To cite: Zhang AL, Parker SJ, Smit DV, et al. Acupunct Med 2014;32:250–256.
250
ABSTRACT Objective To evaluate the feasibility of delivering acupuncture in an emergency department (ED) to patients presenting with pain and/or nausea. Methods A feasibility study (with historical controls) undertaken at the Northern Hospital ED in Melbourne, Australia, involving people presenting to ED triage with pain (VAS 0–10) and/or nausea (Morrow Index 1–6) between January and August 2010 (n=400). The acupuncture group comprised 200 patients who received usual medical care and acupuncture; the usual care group comprised 200 patients with retrospective data closely matched from ED electronic health records. Results Refusal rate was 31%, with ‘symptoms under control owing to medical treatment before acupuncture’ the most prevalent reason for refusal (n=36); 52.5% of participants responded ‘definitely yes’ for their willingness to repeat acupuncture, and a further 31.8% responded ‘probably yes’. Over half (57%) reported a satisfaction score of 10 for acupuncture treatment. Musculoskeletal conditions were the most common conditions treated n=117 (58.5%), followed by abdominal or flank pain n=49 (24.5%). Adverse events were rare (2%) and mild. Pain and nausea scores reduced from a mean±SD of 7.01±2.02 before acupuncture to 4.72±2.62 after acupuncture and from 2.6±2.19 to 1.42±1.86, respectively. Conclusions Acupuncture in the ED appears safe and acceptable for patients with pain and/or nausea. Results suggest combined care may provide effective pain and nausea relief in ED patients. Further high-quality, sufficiently powered randomised studies evaluating the
cost-effectiveness and efficacy of the add-on effect of acupuncture are recommended.
INTRODUCTION In a community setting among Australian GPs, complementary medicine for various health conditions is increasing in popularity.1 In a survey of GPs, 84% described acupuncture potentially as moderately or highly effective and 57% of GPs encourage their patients to use acupuncture.2 Over the last several decades, acupuncture research has identified a number of mechanisms of action related to clinical application, based on measurable responses triggered by acupuncture.3 Studies show that acupuncture enhances the post-stimulation spatial extent of resting brain networks to include anti-nociceptive, memory and affective brain regions, which might explain why acupuncture has an analgesic effect.4 Pharmacotherapy analgesia, although effective for painful conditions, has limitations to its use owing to side effects, allergies and drug interactions. The extended use of some analgesic drugs, such as opioids, places patients at higher risk of developing constipation, cardiovascular disease and/or potential dependence.5 6 Despite the short-term benefit of analgesic drugs, it is not uncommon for a patient’s pain to return once the therapeutic effect has worn off.7 GPs are aware of the limits of pharmacotherapy and are increasingly suggesting complementary medicines such as acupuncture to patients who present with
Zhang AL, et al. Acupunct Med 2014;32:250–256. doi:10.1136/acupmed-2013-010501
Downloaded from http://aim.bmj.com/ on July 3, 2015 - Published by group.bmj.com
Original paper uncomplicated painful conditions such as carpal tunnel syndrome.2 8 In the emergency department (ED), the possible advantages of acupuncture compared with pharmacotherapy are relatively unknown and untested. In 2007, the Australian and New Zealand College of Anaesthetists, based on level 1 scientific evidence, recommended that “acupuncture may be effective in some acute pain settings… and acupuncture reduces postoperative pain as well as opioid-related adverse effects”.9 The National Institute of Health (NIH) has concluded that there is sufficient evidence of the value of acupuncture to expand its use into conventional medicine.10 This pilot study was designed to investigate the feasibility, potential efficacy, safety and acceptability to patient and medical staff of acupuncture in an ED. The results were intended to assist in the development of a large-scale RCT of acupuncture in the ED.11 METHODS Human research ethics approval was granted from the Northern Hospital and RMIT University and the protocol conformed to the provisions of the Declaration of Helsinki in 1995 (as revised in Seoul 2008). The study was conducted at the ED of the Northern Hospital, Victoria, Australia, between January and August 2010. Acupuncture was available to patients 10 hours a week, over 2 days, for 8 months. Figure 1 shows the path for patients who were screened and consented to participate in the pilot study. Participants Acupuncture group
Two hundred triaged patients, ≥18 years of age, with symptoms of pain and/or nausea, were identified via the ED information system (EDIS). Patients whose language prevented them providing informed consent, critically ill patients (determined by the treating physician or the consultant in charge) and pregnant women were screened and excluded before an approach for consent was made. Participation was voluntary. If the patient refused, a reason was documented without recording patient identifiers. Usual care group
Two hundred historical patient records were screened and matched 1 week after each comparative case for gender and closest possible match to age, arrival day and time, presenting condition and discharge diagnosis to that of the acupuncture group participant. To limit selection bias, the usual care group patients were screened in the EDIS by a research assistant not associated with the care of patients. No identifying information was collected and no contact with matched patients was necessary. Usual care group data were collected to compare time to medical consultation and discharge with acupuncture group data, to investigate
Zhang AL, et al. Acupunct Med 2014;32:250–256. doi:10.1136/acupmed-2013-010501
Figure 1 Path for patients who were screened and consented to participate in the feasibility study.
if acupuncture caused delays in patient care or extension of their length of stay. Acupuncture protocol
Potential participants were screened chronologically from the earliest to the most recent triage via their EDIS triage notes for conditions of pain and/or nausea, then again by the treating physician or consultant in charge to ensure their suitability for acupuncture. After patient consent had been received, an acupuncturist undertook a short period of discussion with the patient and observation, obtaining a brief history of their condition, patient-reported pain score (VAS) and/or their reported nausea (Morrow Index) score.12 A pragmatic acupuncture treatment prescription was developed for each patient individually (using WHO acupuncture location recommendations),13 based on the acupuncturist’s evaluation. Acupuncture was delivered by emergency medical physicians with medical acupuncture qualifications, registered acupuncturists with the Chinese medicine registration board of Victoria or final year RMIT university acupuncture students under supervision of registered acupuncturists. The supervising acupuncturist held an honorary ED position for the duration of the study. Funding for the equipment was provided by RMIT University with assistance from the 251
Downloaded from http://aim.bmj.com/ on July 3, 2015 - Published by group.bmj.com
Original paper Department of Health, Victoria. Medical acupuncturists were part of the ED staff and delivered acupuncture to patients using study equipment, in addition to their regular roles within the ED. Manual acupuncture was performed at the bedside in an ED cubicle or treatment room using Chinese manufactured, copper-handled, stainless steel singleuse needles, 0.25 mm gauge and either 30 mm or 40 mm in length. For each point, regardless of the treating acupuncturist, the needle was manipulated after insertion until the sensation of de qi (dull ache and possible grabbing sensation of the needle) was experienced. Needles were left for about 20 min before removal by an acupuncturist. Immediately after removal of needles, the acupuncturist recorded patient-reported pain and/or nausea scores, adverse events and the participant’s acceptability of (a) the ED visit, (b) the acupuncture treatment and (c) their willingness to repeat acupuncture again in the future for their condition. The ED doctor was free to assess and consult the patient at any stage before, during or after acupuncture, and pharmacotherapy was permitted as necessary.
Measurements
Demographic data, triage presenting symptoms and discharge diagnosis were recorded as well as times for triage, initial medical consultation, approach for acupuncture, start of acupuncture, completion of acupuncture and discharge. Adverse events reported by patients, ED staff or acupuncturist were recorded after acupuncture treatment. Willingness to repeat acupuncture for a similar condition in the future and satisfaction with the acupuncture was measured using 10-point ordinal scale, and pain was measured (VAS 0–10) at triage, before acupuncture and immediately
Figure 2 Acupuncture treatment before or after medical consultation and historically matched controls.
252
after acupuncture.14 If applicable, nausea was measured using the Morrow Index (range 1–6) at triage, before acupuncture and immediately after acupuncture. Staff time required to manage patients was calculated by subtracting the time from ‘triage to intervention’ (acupuncturist or physician consultation) from the ‘triage to discharge time’ (min). Data analysis
No a priori power calculation was performed for sample size as this was a feasibility study, designed to guide the development of a full size RCT. The sample size was based on enrolling available cases over an 8-month period. Statistical Package for Social Sciences for Windows (SPSS) V.19.0 was used to analyse the data. The data for the two groups were compared using the independent t test, χ2 test and the Mann–Whitney U test, where applicable. A value of p ≤0.05 was considered statistically significant. Post-recruitment phase discussions were held between researchers and hospital management to evaluate and report the impacts of the pilot acupuncture study on the ED, grouping similar participant data and evaluating the various pathways by which participants were recruited, treated and discharged throughout the study. RESULTS A total of 290 ED patients were approached about acupuncture treatment, 200 (69.0%) consented and completed treatment. The acupuncture group consisted of two participant subgroups: acupuncture given before (n=55) or after (n=145) medical consultation (figure 2). Participants were not allocated to the groups; inclusion in a group was dependent on whether the treating physician or acupuncturist saw the patient first after triage. Common reasons for declining acupuncture were (1) symptoms were under control owing to medical treatment before acupuncture (n=36, 40%); (2) preference for medical treatment (n=13, 14.4%); (3); not interested in acupuncture (n=10, 11.1%) and (4) needle phobia (n=8, 8.9%). Overall, 98.5% of respondents reported a satisfaction score of between 5 and 10. More than half (52.5%) of participants responded ‘definitely yes’ for their willingness to repeat acupuncture, and a further 31.8% responded ‘probably yes’. Over half (57%) reported a satisfaction score of 10. Overall, 222 women and 178 men were included in the study. The acupuncture group was well matched for age and gender, and was representative of the ED usual care population in their diagnostic category and waiting time (table 1). More than half of the participants presented with musculoskeletal back or limb pain (58.5% and 59.5% for the acupuncture and control groups, respectively). Most participants had an Australasian Triage Scale (ATS) rating of ≥3 (1, most urgent; 5, least urgent).15
Zhang AL, et al. Acupunct Med 2014;32:250–256. doi:10.1136/acupmed-2013-010501
Downloaded from http://aim.bmj.com/ on July 3, 2015 - Published by group.bmj.com
Original paper Table 1 Demographics, diagnosis, waiting time and staff time required of patient groups Acupuncture (N=200) Gender, N (%): Female 115 (57.5) Male 85 (42.5) Age, N (% within group): 18–39 87 (43.5) 40–59 64 (32.0) 60–79 48 (24.0) 80–99 1 (0.5) Western medicine diagnosis, N (% within group): Musculoskeletal pain 117 (58.5) Pain in abdominal or flank region 49 (24.5) Headache or vertigo 15 (7.5) Other conditions 19 (9.5) Waiting time between triage and initial consultation (min), mean (SE) 85 (5) Waiting time between triage and initial medical or acupuncture consultation (min), mean (SE): Acupuncture before consultation 66 (10) (N=55) Acupuncture after consultation 134 (5) (N=145) Staff time managing patients (min): Acupuncture before consultation 182 (99) (N=55) Acupuncture after consultation 273 (152) (N=145)
Overall, there was no gender or age difference between patients who received acupuncture before or after medical consultation. In the acupuncture group, there was significant difference between the patient-reported pain scores before (mean=7.01, SD=2.02) and after acupuncture (mean=4.72, SD=2.62) [t (193)=14.81, p
