Despite a recent focus on early analgesia, many departments are failing to reach the goal set out by the Royal College of Emergency Medicine for provision of analgesia within 20 min of arrival . Many factors have been shown to impact the provision of adequate analgesia in ED, such as ED waiting times for triage, overcrowding, suboptimal staff numbers and time to access and prepare opioids for IV administration as well as availability of beds in the resuscitation areas. Long waiting times, slow discharge times and overcrowding are affecting almost every ED in the UK, and the situation does not show any signs of significant improvement at present. Provision of adequate analgesia and the overall impact of this on the ED are an area of patient management that is not well studied. In this service evaluation, we aimed to assess whether the introduction of an effective, fast-acting, non-parenterally administered analgesic, namely methoxyflurane, would have an impact on patient length of stay, potentially reducing the numbers of staff involved in individual patient care and the burden on the vital resuscitation area beds.
This evaluation showed that the availability of methoxyflurane significantly reduced ED patient length of stay vs. standard care. There was a reduction of approximately 3 h in patient length of stay for those presenting with shoulder injuries, which was higher than expected. For other upper limb injuries, while the difference was not statistically significant, there was a mean reduction of 72 min. The finding that methoxyflurane use is associated with a significant reduction in patient length of stay is consistent with recent findings in other hospitals [6, 7, 14]. It appears to be primarily due to a reduction in the use of intravenous procedural sedation, which, prior to the introduction of methoxyflurane, was frequently used for relocation of shoulders and manipulation of fractures. Intravenous procedural sedation requires a resuscitation area bed, which is not always immediately available, and requires three or more members of staff to carry out the procedure. Many of the patients administered procedural sedation also exceed the 4-h target for discharge. In comparison, for many patients receiving methoxyflurane, this analgesic alone was sufficient for the patients to be comfortable during assessment and treatment, negating the need for intravenous procedural sedation. Methoxyflurane use also enabled us to treat patients in a regular bay and usually required only two members of staff. However, there were 11 patients where methoxyflurane alone provided insufficient analgesia for the procedure to be completed, and these patients had to be converted to procedural sedation.
The length of stay for patients with hip and other lower limb injuries was not reduced with methoxyflurane, which was not an unexpected outcome. In many cases, patients with pelvic or lower limb fractures will require hospital admission and further treatment. Their time in the department is therefore likely to reflect the wait for an inpatient bed. This evaluation was not designed to determine if there were benefits to this patient group; however, it is reasonable to suggest that the timely provision of analgesia would benefit patients even with no improvement in ED length of stay.
It is difficult to ascertain accurate costing for the provision of analgesia for patient assessment and treatment, as the cost involves not only the drug cost, but also the associated consumables and staff costs. The NICE Guideline  on management of non-complex fractures (NG38) contains detailed costings sourced primarily from the NHS supply chain. This guideline calculated that the overall cost of procedural sedation is £155.47. Utilizing the costings listed, we have calculated that the overall cost of methoxyflurane use is £73.39, which is comprised of staff costs and the cost of methoxyflurane (Penthrox) itself. Therefore, for each patient administered methoxyflurane for upper limb/shoulder injuries, there is a potential saving to the trust of £82.08.