A prospective blinded study on emergency pain assessment and therapy

Factors Associated With Delay to Opiate Analgesia in Emergency Departments

Patients presenting to an emergency department (ED) with painful conditions continue to experience significant delay to analgesia. It remains unclear whether demographic and clinical factors are associated with this outcome. The objectives of this study were to determine 1) the proportion of patients that require parenteral opiate analgesia for pain in an ED and who receive the opiate in less than 60 minutes; and 2) whether any factors are predictive for the first dose of analgesia being delayed beyond 60 minutes. A retrospective cohort study with descriptive and comparative data analysis was conducted. Over a 3-month period, the medical record of every patient receiving parenteral opiates in a tertiary emergency department was reviewed and analyzed. Of 857 patients, 451 (52.6%) received analgesia in less then 60 minutes. Multiple demographic and clinical factors are associated with statistically significant delay to analgesia, including age, triage code, seniority of treating doctor, diagnosis, and disposition from the ED.

PERSPECTIVE

A considerable proportion of patients suffer delay to analgesia. Identifiable factors associated with a delay to analgesia exist. There is potential for clinicians to develop strategies to address the population in emergency departments at risk for delay to analgesia.

Visual analog scale of ART adherence: association with 3-day self-report and adherence barriers

BACKGROUND

Brief self-reports of antiretroviral therapy adherence that place minimal burden on patients and clinic staff are promising alternatives to more elaborate adherence assessments currently in use. This research assessed the association between self-reported adherence on visual analog scale (VASs) and an existing, more complex self-reported measure of adherence, the AACTG, and the degree to which each method distinguished optimally and suboptimally adherent patients in terms of reported barriers to adherence.

METHODS

HIV-infected patients (N = 147) at a southeastern US clinic completed a computerized assessment including an antiretroviral therapy adherence VAS, a modified version of the AACTG, and a measure of adherence.

RESULTS

Adherence rates were comparable across the AACTG (81%) and VAS (87%); they significantly correlated (r = 0.585) and produced identical classification of optimal (>90%) or suboptimal (<90%) adherence for 66% of patients. In general, VAS scores tended to be higher than AACTG scores. Suboptimally adherent patients reported more adherence barriers than those classified as optimally adherent, and those so classified by the VAS reported considerably more barriers to adherence than those so classified by the AACTG.

CONCLUSIONS

Results generally support the construct validity of the VAS and its use as an easily administered assessment tool that can identify patients with barriers to adherence who might benefit from adherence support interventions.

Pain management in paediatric trauma patients with long bone fracture

OBJECTIVES

This study was done to review and describe the care of paediatric trauma patients with respect to pain assessment and medication administration.

METHODS

A retrospective review of paediatric trauma patients, age <16 with a long bone fracture and GCS=15, cared for by our paediatric trauma response team (January 1998-August 2002). A single trained abstractor reviewed all records. Data were descriptively analysed.

RESULTS

Fifty-six children were included. All but three received pain medication during resuscitation. The median time to first dose of pain medication after arrival was 20 min (95% CI: 14-29 min). The median pre- and post-treatment pain scores, on a 5-point scale, were 4 and 2, respectively. Vital signs were unaffected.

CONCLUSIONS

As a group, our paediatric trauma resuscitation team did a much better job managing pain, in this segment of the population, than the preponderance of existing literature would predict.

Acute musculoskeletal pain in the emergency department: a review of the literature and implications for the advanced practice nurse

Acute pain assessment and management and their accurate documentation have been identified by The Joint Commission on the Accreditation of Healthcare Organization as significant components of the emergency department experience. Research studies have historically focused on the subjective perception of the physician or nurse for evidence of acute musculoskeletal pain assessment for the patient; however, the lack of interrater reliability between caregivers and patients has illustrated the need to evaluate the patient's perception of pain. A review of the literature for acute musculoskeletal pain in the emergency department shows that a patient's pain experience is often underestimated, and severity of pain often does not predict pain management. Relying on patient satisfaction surveys as a surrogate marker for effectiveness of pain management is inadequate, and factors, such as age, gender, or ethnicity, may contribute to a disparity in pain management. The purpose of this article is to review pain management practices for patients with acute musculoskeletal pain who present to the emergency department and to provide recommendations for advanced practice nurses working with this emergency department patient population. Promising areas for future research include targeting mechanisms of pain with specific medications, identifying vulnerable populations at risk for inadequate pain management, and universal use of a standardized pain rating scale.

The future of pain management in emergency medicine

How have we as a profession, whose number-one goal is to decrease human suffering, made pain control such a poorly discussed issue in training? From day 1 of medical school, pain and suffering need to be discussed. No clinical area should be taught without discussion of this most common and most important symptom. Although we have shown that up to 70% of our patients have pain as a part of their presenting problem, hospitalized patients also have high rates of pain, often unrecognized. Barriers need to be identified and discussed. Alternatives to medications should be as much a part of our armamentarium as caring and compassion. The future of pain control depends on this paradigm shift.

Orofacial pain: patient satisfaction and delay of urgent care

OBJECTIVE

Accomplishing the Healthy People 2010 goal of eliminating disparities in oral disease will require a better understanding of the patterns of health care associated with orofacial pain. This study examined factors associated with pain-related acute oral health care.

METHODS

The authors used data on 698 participants in the Florida Dental Care Study, a study of oral health among dentate adults aged 45 years and older at baseline.

RESULTS

Fifteen percent of the respondents reported having had at least one dental visit as the result of orofacial pain. The majority of the respondents reportedly delayed contacting a dentist for at least one day; however, there was no difference between respondents reporting pain as the initiating symptom and those with other problems. Once respondents decided that dental services were needed, those with a painful symptom were nearly twice as likely as those without pain to want to be seen immediately. Rural adults were more likely than urban adults to report having received urgent dental care for a painful symptom. When orofacial pain occurred, those who identified as non-Hispanic African American were more likely than those who identified as non-Hispanic white to delay care rather than to seek treatment immediately, and women were more likely then men. Having a pain-related oral problem was associated with significantly less satisfaction with the services provided; non-Hispanic African American respondents were less likely than non-Hispanic white respondents to report being very satisfied, and rural residents were less likely than urban residents. Furthermore, men were more likely than women to suffer with orofacial pain without receiving either scheduled dental care or an urgent visit.

CONCLUSIONS

Barriers to care are complex and likely to be interactive, but must be understood before the goals of Healthy People 2010 can be accomplished.

Complementary and Alternative Pain Therapy in the Emergency Department

One primary reason patients go to emergency departments is for pain relief. Understanding the physiologic dynamics of pain, pharmacologic methods for treatment of pain, as well CAM therapies used in treatment of pain is important to all providers in emergency care. Asking patients about self-care and treatments used outside of the emergency department is an important part of the patient history. Complementary and alternative therapies are very popular for painful conditions despite the lack of strong research supporting some of their use. Even though evidenced-based studies that are double blinded and show a high degree of interrater observer reliability do not exist, patients will likely continue to seek out CAM therapies as a means of self-treatment and a way to maintain additional life control. Regardless of absolute validity of a therapy for some patients, it is the bottom line: "it seems to help my pain." Pain management distills down to a very simple endpoint, patient relief, and comfort. Sham or science, if the patient feels better, feels comforted, feels less stressed, and more functional in life and their practices pose no health risk, then supporting their CAM therapy creates a true wholistic partnership in their health care.CAM should be relatively inexpensive and extremely safe. Such is not always the case, as some patients have discovered with the use of botanicals. It becomes an imperative that all providers be aware of CAM therapies and informed about potential interactions and side effects when helping patients manage pain and explore adding CAM strategies for pain relief. The use of regulated breathing, meditation, guided imagery, or a massage for a pain sufferer are simple but potentially beneficial inexpensive aids to care that can be easily employed in the emergency department. Some CAM therapies covered here, while not easily practiced in the emergency department, exist as possibilities for exploration of patients after they leave, and may offer an improved sense of well-being and empowerment in the face of suffering and despair. The foundations of good nutrition, exercise, stress reduction, and reengagement in life can contribute much to restoring the quality of life to a pain patient. Adding nondrug therapies of physical therapy, cognitive-behavioral therapy, TENS, hypnosis, biofeedback, psychoanalysis, and others can complete the conventional picture. Adding in simple mind/body therapies, touch therapies, acupuncture, or others may be appropriate in select cases, and depending on the circumstances, may effect and enhance a conventional pain management program. Armed with an understanding of pain dynamics and treatments, practitioners can better meet patient needs, avoid serious side effects, and improve care when addressing pain management in the emergency department.

Pain management and regional anaesthesia in the trauma patient

PURPOSE OF THE REVIEW

Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. This update reviews recent publications related to pain relief in the trauma patient.

RECENT FINDINGS

Although recent publications suggest that the assessment and treatment of pain in trauma have improved, most studies still document inadequate analgesia. We discuss the use of different analgesia strategies in the prehospital and emergency room settings.

SUMMARY

Educating the emergency room staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma. Peripheral nerve block techniques should be practised by emergency room staff. If simple techniques are chosen, competence can be achieved with short, focused training sessions. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient.

Clinical guidelines and policies: can they improve emergency department pain management?

The prevalence of pain in patients presenting to Emergency Departments (ED) has been well documented by both Cordell and Johnston. Equally well documented has been the apparent failure to adequately control that pain. In 1990 Selbst found that patients with long bone fractures received little analgesia in the ED, and Ngai, et al., showed that the under-treatment of pain continued after discharge. In a prospective study, Ducharme and Barber found that up to one third of patients presented with severe pain and were often unrelieved at discharge. Even though specific patient subgroups appear to be at greater risk, all patients are potential victims of oligoanalgesia - the under-treatment of pain. Despite an ever increasing volume of research about pain in emergency medicine, dissemination of relevant information with widespread change in practice patterns has not been witnessed. Recent studies continue to affirm that pain management in the ED is suboptimal.

Mandated pain scales improve frequency of ED analgesic administration

A retrospective study design was used to determine the effect of introducing a mandated verbal numeric pain scale on the incidence and timing of analgesic administration in the ED. Consecutive patients presenting with renal colic, extremity trauma, headache, ophthalmologic trauma, and soft tissue injury were included. 521 encounters were reviewed before and 479 encounters after the introduction of the pain scale. Groups were similar in baseline characteristics. Analgesic use increased from 25% to 36% (p < 0.001), and analgesics were administered more rapidly after the scale was introduced (113 minutes vs. 152 minutes, p = 0.09). Analgesic use correlated with pain severity. Patients undergoing diagnostic testing were less likely to receive analgesics, especially when presenting with a headache (p < 0.001). We conclude that use of a pain scale at triage significantly increases use of analgesia, and shortens the time till its administration. Patients undergoing diagnostic workups were less likely to receive analgesia.

Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial

STUDY OBJECTIVE

Nasogastric tube insertion is a common emergency department (ED) procedure that is associated with considerable patient discomfort. The safety and efficacy of nebulized lidocaine for upper airway anesthesia have previously been demonstrated. We determine whether nebulized lidocaine administered before nasogastric tube insertion significantly reduces patient discomfort.

METHODS

A double-blind, placebo-controlled, randomized clinical trial of adult patients was conducted in the EDs of 2 university hospitals. Twenty-nine participants were administered nebulized lidocaine (4 mL 10%), and 21 participants received nebulized normal saline solution. Patient discomfort was measured using a 100-mm visual analog scale. The difficulty of nasogastric tube insertion was evaluated using a 5-point Likert scale.

RESULTS

There was a clinical and statistical significant difference in patient discomfort associated with the passage of the nasogastric tube between nebulized lidocaine and placebo groups (mean visual analog scale score 37.7 versus 59.3 mm, respectively; difference between group means 21.6 mm; 95% confidence interval [CI] 5.3 to 38.0 mm). There was not a detectable difference in difficulty with the passage of the nasogastric tube between the 2 groups (median 2 versus 2; median difference 0; 95% CI -1 to 1). Epistaxis occurred more frequently in the lidocaine group (17% versus 0%; difference 17%; 95% CI 3.5% to 31%).

CONCLUSION

Nebulized lidocaine decreases the discomfort of nasogastric tube insertion and should be considered before passing a nasogastric tube. An increased frequency of epistaxis, however, may be associated with its use.

A prospective study of nurse initiated panadeine forte: expanding pain management in the ED

INTRODUCTION

This study describes an innovative pain management strategy that aimed to improve the efficiency and effectiveness of timely analgesia for those patients in moderate pain and who experienced significant delay prior to medical assessment.

METHOD

A 12-week prospective exploratory study was conducted to evaluate the introduction of a triage nurse initiated schedule 4 drug. A panadeine forte policy was developed and a data tool formulated to evaluate the effectiveness and frequency of nurse initiated panadeine forte.

RESULTS

The average pre-pain score reported by patients was 68 mm and the median was 70 mm. The average post-pain score was 37 mm and the median was 35 mm. The average post-pain score reduced by 31 mm demonstrating a clinically significant change. A statistically significant (Wilcoxon signed rank test < 0.001) reduction in post-pain scores was also identified.

CONCLUSION

We identified a statistically and clinically significant reduction in post-analgesic pain scores for patients. Improving pain management can have a positive impact on patients in moderate pain who experience extended waiting times prior to medical assessment.

Patient expectations for pain relief in the ED

The objective of the study was to assess patient expectations for pain relief in the ED. A convenience sample of 522 patients with pain and 144 patients without pain were enrolled in a prospective observational study at a university ED. Patients reported a mean expectation for pain relief of 72 % (95% CI 70-74). Eighteen percent expected complete (100%) pain relief in the ED. Patient expectations for pain relief were poorly correlated (r = 0.150) with initial pain intensity. Patients without pain reported a mean expectation for pain relief of 74% (95% CI 71-77) if they had presented with pain. There were no differences in patient expectations for pain relief based on age or gender. Patients expect a large percentage of their pain to be relieved in the ED, and many expect complete analgesia. Patient expectations for pain relief do not vary based on age, gender or pain intensity.

Variability in emergency physician decisionmaking about prescribing opioid analgesics

STUDY OBJECTIVE

The purpose of this study is to determine what factors influence emergency physicians' decisions to prescribe an opioid analgesic for 3 common, painful conditions.

METHODS

We developed items thought to influence the decision to prescribe an opioid analgesic through a review of the literature, expert consultation, and interviews with practicing emergency physicians. We developed a baseline vignette and items expected to influence the decision for each of the 3 conditions: migraine, back pain, and ankle fracture. We surveyed 650 physicians randomly selected from the American College of Emergency Physicians. The influence of individual items was explored through a univariate analysis of the response distribution. Patterns were assessed by analytically creating scales.

RESULTS

We received responses from 398 (63%) of the 634 eligible physicians. Physicians' likelihoods of prescribing an opioid showed marked variability, with at least 10% of physicians saying they were unlikely and 10% of physicians saying they were likely to prescribe for each condition. Physician responses to individual pieces of clinical information, such as the patient requesting "something strong" for the pain, were also highly variable, with at least 10% of physicians saying they would be negatively influenced by this request and at least 10% saying they would be positively influenced by it.

CONCLUSION

Even when faced with identical case scenarios, physicians' decisions to prescribe opioid analgesics are highly variable. Moreover, the same clinical information, such as a patient requesting a strong analgesic, changes the likelihood of prescribing opioids in opposite directions for different physicians.

Patient preference for route of pain medication delivery

We sought to determine Emergency Department (ED) patient preference for oral (p.o.), intramuscular (i.m.), or intravenous (i.v.) pain medication and patient expectations of time to medication effect by route. A prospective, observational study of 1276 patients presenting with painful illness or injury was performed in a university ED. Patient preferences were 66% p.o., 15% i.m., and 19% i.v. pain medication. Patients aged greater than 55 years were more likely to prefer parenteral medication than younger patients. Patients in severe pain were also more likely to prefer parenteral medication than those with less severe pain. Despite these differences, a majority of patients in all groups preferred oral medications. There were no differences in preference based on ethnicity or gender. Patient expectations for time to pain medication effect were 27 min p.o. (95% CI 26-28), 12 min i.m. (95% CI 11-13), and 7.5 min i.v. (95% CI 6.9-8.0).

Accuracy of emergency nurses in assessment of patients’ pain

Pain is a common complaint in Emergency Departments. Inpatient studies have shown discrepancies between patients' and nurses' pain assessments. The accuracy of emergency nurse assessments of their patients' pain has not been well investigated. Using a 0 to 10 numeric rating scale (NRS), researchers asked patients to rate their pain intensity in triage. Separately, the triage nurse was asked to rate the patient's pain. This process was repeated with the same patients but different nurses after patients were taken back to a clinical area within the Emergency Department. At triage, patients' average pain intensity score was 7.5 +/- 2.2. The triage nurses' ratings were significantly lower at 5.1 +/- 2.4 (p <.001). In the clinical area, patients' scores were also significantly higher than nurses' at 7.7 +/- 2.2 and 4.2 +/- 2.3, respectively (p <.001). Differences between nurses' and patients' pain intensity scores depended on the patient's chief complaint. Considerable underestimation of patient's pain occurred in both triage and in the clinical area. Underestimation of patient's pain can have negative effects if appropriate treatment is withheld. Minimizing patient-nurse discrepancies in pain intensity ratings through careful evaluations and acceptance of the patient's self report of pain are important first steps in improving pain management in the Emergency Department.

Pain medication use before ED arrival

The objective of this study was to determine the frequency and types of pain medications taken before ED arrival based on pain intensity, duration of pain, chief complaint, gender, age, and race. A convenience sample of patients in pain was enrolled in this university hospital-based prospective, observational study. A total of 1233 patients were enrolled. Five hundred thirty-nine of 1233 (44%) patients took pain medication before arrival. Two hundred three (38%) took ibuprofen, 147 of 539 (27%) took oral opioids, and 135 of 539 (25%) took acetaminophen, which were the most frequently used medications. Severity of pain, age, duration of pain, and chief complaint were associated (chi-squared P <.05) with variations in prior medication use. Race and gender were not associated (chi-squared P >.05) with differences in medication use before arrival. Many patients (44%) take medication before arrival in the ED. Age, severity and duration of pain, as well as chief complaint are associated with differences in frequency of self-administered medication.

How reliable are pain scores? A pilot study of 20 healthy volunteers

INTRODUCTION

Pain scales such as the 100-MM Visual Analog Scale and the 10-point Numeric Rating Scale are used to describe pain intensity. The Visual Analog Scale and the Numeric Rating Scale provide accurate descriptors for a patient's perceived level of pain. But how accurate or reliable is a patient's perception of pain?

METHODS

To test the relationship between the intensity of the pain stimulus and pain perception, we devised an experiment using a convenience sample of 20 healthy adult volunteers. A cutaneous nerve stimulator delivered a series of shocks of increasing intensity to the individual via a pediatric EKG electrode. The participants indicated their threshold for "intolerable pain." With use of this same level of stimulus in subsequent shocks, the participants, blinded to the amount of stimulus, were then asked to rate each shock as either "the same," "a little less," or "a little more" than the baseline stimulus. They then recorded their VAS score for each stimulus.

RESULTS

"Intolerable pain" varied widely between 8 mm to 73 mm; likewise, the level of stimulus that produced this pain ranged from 4 to 9. Once a person's threshold of "intolerable pain" had been reached, 49% of the subsequent shocks were perceived as different, even though the stimulus was exactly the same.

DISCUSSION

This experiment showed that (1) given the same intensity of pain stimulus, different persons have different perceptions of pain; and (2) the same intensity of pain stimulus, given to the same person repeatedly, does not result in the same self-report of pain intensity.

Documentation of ED patient pain by nurses and physicians

The purpose of this study was to evaluate ED documentation of patient pain in light of the Joint Commission of Accreditation of Healthcare Organization's emphasis on pain assessment and management. A prospectively designed pain management survey was offered to patients on ED discharge. Documentation of pain intensity by ED nurses and physicians was retrospectively reviewed. Of 302 patients surveyed, 261 (86%) complete charts were available for review. Initial pain assessments were noted on 94% of the charts, but a pain scale was used for only 23% of the patients. Documentation of pain subsequent to therapy was noted on 39% of the charts, but a pain scale was used only 19% of the time. Subsequent to therapy, nurses were 2.2 x more likely to document pain assessments than physicians (30% vs 16%, P <.001). Patients with severe pain on arrival (46% vs 31%, odds ratio [OR] = 1.9, P <.02), chest pain (72% vs 32%, OR = 5.4, P <.001), or those receiving powerful analgesics (62% vs 32%, 3.5, P <.001) were more likely to receive a documented subsequent pain assessment than other patients. Pain severity is not consistently documented in ED patients, especially after therapy has been provided. Patients with severe pain and those receiving powerful analgesics were more likely to have a pain assessment subsequent to ED therapy.

Management and relief of pain in an emergency department from the adult patients' perspective

To estimate the prevalence of pain in adult patients attending an emergency department (ED) and to identify risk markers for insufficient pain relief, a cross-sectional survey was conducted for 16 days, 24 hours each day, in the ED of a Paris university hospital. A structured questionnaire was used to collect characteristics of pain and its management from patients. Pain intensity was evaluated both on arrival and before discharge using two scales (a numerical descriptor scale or a verbal pain intensity scale). On arrival, 78% of the patients complained of pain; among them, 54% complained of intense pain and 47% suffered procedural pain. Insufficient pain relief was assessed in 289 (77%) patients. We identified the following risk markers for insufficient pain relief: moderate or low pain intensity, no intervention in the ED before the medical examination, and no use of medication before arrival.

The epidemiology of pain in the prehospital setting

OBJECTIVE

To develop national estimates of the epidemiology of pain in the prehospital setting.

METHODS

Cross-sectional data on a probability sample of 21,103 emergency department (ED) visits from the 1999 National Hospital Ambulatory Medical Care Survey were analyzed. For patients arriving by ambulance, the frequencies (95% confidence intervals) of patients presenting with no level of pain reported (data unknown or missing) and those reporting no, mild, and moderate or severe pain were determined. The reasons for visit among those with moderate or severe pain, and the ED narcotic analgesic use among those with pain information reported and not reported, were also determined.

RESULTS

Of the 102.8 million patients visiting the ED in 1999, 14.5 million arrived by ambulance. Fifty-three percent (49-58%) were female. Seven million six hundred thousand [52% (48-56%)] had no information on presenting level of pain reported, 2.0 million [14% (2-25%)] had no pain, 2.0 million [14% (3-25%)] had mild pain, and 2.9 million 120% (12-29%)] had moderate or severe pain. Among those with moderate or severe pain, the most common reasons for visit were injuries 27% (11-43%) and non-injury musculoskeletal symptoms 18% (0-39%). Narcotic analgesics were ordered or continued in 13% (0-29%) of those with no presenting level of pain recorded and 21% (9-34%) of those for whom the presenting level of pain was recorded.

CONCLUSION

Pain is a common condition among prehospital patients: 20% reported moderate to severe pain. Given the use of narcotic analgesics among those for whom pain information was not reported, this is likely a conservative estimate.

Acute pain management after surgery or in the emergency room in Switzerland: a comparative survey of Swiss anaesthesiologists and surgeons

The treatment of acute pain remains unsatisfactory despite advances in pain research and the publication of numerous guidelines. The aim of this study was to survey postoperative and emergency room acute pain treatment in Switzerland, particularly regarding compliance with practice guidelines on therapeutic responsibility, treatment algorithms, pain documentation, quality control and education.A representative sample of anaesthesiologists and surgeons (general and orthopaedic) was selected from all Swiss hospitals with regular surgical activity and sent a 256 point questionnaire on acute pain management. Five hundred and seventy five doctors were contacted in 98 hospitals, 44% of doctors (covering 89% of hospitals) returned fully completed questionnaires. Half the respondents work in a hospital with an acute pain service. For postoperative pain management, only 10% of prescription is by algorithm, less than a third of respondents regularly determine pain scores, only 15% perform any statistical analysis of pain management, less than one third regularly meet to discuss management problems, and half claim not to have received-or be receiving-formal (i.e. structured/accredited) pain education. The situation is even less satisfactory for emergency room analgesia. Respondents accept the contribution of postoperative and emergency room analgesia to reduced costs and improved medical outcomes. Asked to highlight their major concerns in acute pain management, lack of education and inadequate organisation are listed in first and second positions. This survey suggests that compliance with published practice guidelines for acute pain management can be improved, and highlights the need for continuing organisational and educational development in acute analgesia, particularly for the emergency room.

Emergency Medical Services Outcomes Project (EMSOP) IV: pain measurement in out-of-hospital outcomes research

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. In prior work (EMSOP I), discomfort had the highest weighted score among outcome categories for the top 3 adult conditions (ie, minor trauma, respiratory distress, chest pain) and the first and third highest rankings for children's conditions (ie, minor trauma, respiratory distress). In this fourth article in the EMSOP series, we discuss issues relevant to the measurement of pain in the out-of-hospital setting, recommended pain measures that require evaluation, and implications for outcomes research focusing on pain. For adults, adolescents, and older children, 2 verbal pain-rating scales are recommended for out-of-hospital evaluation: (1) the Adjective Response Scale, which includes the responses "none," "slight," "moderate," "severe," and "agonizing," and (2) the Numeric Response Scale, which includes responses from 0 (no pain) to 100 (worst pain imaginable). The Oucher Scale, combining a visual analog scale with pictures, seems most promising for out-of-hospital use among younger children. Future research in out-of-hospital care should be conducted to determine the utility and feasibility of these measures, as well as the effectiveness of interventions for pain relief.

Patterns of analgesic use in trauma patients in the ED

The objective was to describe patterns of analgesic use for trauma patients treated in our emergency department (ED). We reviewed analgesic use in consecutive patients meeting American College of Surgeons (ACS) Trauma Center Guidelines. A comprehensive database was abstracted from this institution's Trauma Registry and medical records of each patient. A total of 38% (95% CI: 31-46%) of patients received analgesics. Time to administration of first dose of analgesia was 109 minutes (95% CI: 85-133). Women, patients with long bone and pelvic fractures, and those with a longer ED stay were most likely to receive analgesics. Patients with head trauma and those admitted to the intensive care unit were least likely to receive analgesics. Morphine was the most frequent analgesic used with an average total dose of 14 milligrams. A majority of patients meeting ACS Trauma Center Guidelines did not receive analgesics in the ED.

The high prevalence of pain in emergency medical care

Although there is a widely held belief that pain is the number 1 complaint in emergency medical care, few studies have actually assessed the prevalence of pain in the emergency department (ED). We conducted an analysis of secondary data by using explicit data abstraction rules to determine the prevalence of pain in the ED and to classify the location, origin, and duration of the pain. This retrospective cross-sectional study was conducted at an urban teaching hospital in Indianapolis, IN. Charts from 1,665 consecutive ED visits during a 7-day period were reviewed. Pain was defined as the word pain or a pain equivalent word (including aching, burning, and discomfort) recorded on the chart. Of the 1,665 visits, 61.2% had pain documented anywhere on the chart, 34.1% did not have pain, and 4.7% were procedures. Pain was a chief complaint for 52.2% of the visits. This high prevalence of pain has important implications for the allocation of resources as well as educational and research efforts in emergency medical care.

Adult patients' perceptions of pain management at triage: a small exploratory study

Research studies reveal that pain management in Accident and Emergency (A&E) is often sub-optimal. The administration of simple oral analgesics at triage in a large teaching hospital provided the rationale to explore pain management in A&E from the patient's perspective in a small-scale exploratory study using a broadly qualitative approach. Structured interviews using open-ended questions and lasting no longer than 20 minutes explored patients' experiences and opinions of pain assessment, and pain management at triage. A sample of convenience produced a group of 65 patients from which 18 patients; 9 males and 9 females participated. Analysis of the data revealed that 16 patients presented in pain. Triage nurses trained to administer analgesics were available for 7 patients; 2 patients received analgesia. Six patients did not receive a pain assessment and in 3 cases the triage nurse was trained to administer analgesia. Sixteen patients considered pain management at triage to be important. The study reinforces the subjective and complex nature of pain, raises pragmatic questions regarding triage, the need for sustained education and training with any advance in nursing practice and further research regarding patients' perceptions of pain management in A&E.

Patient expectations for pain medication delivery

The purpose of this study was to evaluate emergency department (ED) patient expectations for the delivery of pain medication and correlation of satisfaction with meeting patient needs for pain relief. In this prospective survey of 458 ED patients with pain, the patients reported a mean of 23 minutes as a reasonable wait for pain medication versus 78 minutes for the actual delivery of pain medication. Forty-five percent of patients received pain medication and 70% had their needs for pain relief met. Mean satisfaction for patients who had their needs for pain relief met was 83 mm versus 51 mm for patients whose needs for pain relief were not met (P <.001). Patients expect rapid delivery of pain medication after arrival in the ED. Time to delivery of pain medication in this ED does not meet patient expectations. Patients who had their needs for pain relief met were more satisfied with ED care.

Adequacy of pain assessment and pain relief and correlation of patient satisfaction in 68 ED fast-track patients

INTRODUCTION

The new standards of the joint commission on accreditation of healthcare organizations specify the patient's right to appropriate assessment and management of pain. With this impetus, we looked at our own practice to see how well we assess and manage patients with pain.

METHODS

Patients who presented with minor nonemergent pain were interviewed on arrival, and then again before discharge, with use of a structured questionnaire. A total of 68 completed pain surveys were analyzed.

RESULTS

With use of a visual analog scale, patients rated their pain on arrival and at discharge; they also rated pain they were willing to accept when it was time for discharge. Sixty percent of the patients went home with more pain than they were willing to accept. Fifty-one percent of the patients were offered something for pain, and only half of them said the pain relief was adequate. The median time from arrival to administration of pain medication was 104 minutes. Surprisingly, the median patient satisfaction rating for overall care was "very good."

DISCUSSION

This survey revealed that acute pain conditions are underevaluated and undertreated in one fast-track setting, suggesting that ED staff need more education about the management of acute pain. It also showed that relying on patient satisfaction surveys as surrogate markers for how well we manage pain is erroneous.

Patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal pain rating at discharge, or change in VAS score in the Emergency Department

The aim of this study was to correlate patient satisfaction with pain management in the Emergency Department (ED) with initial and discharge visual analog scale (VAS) pain score, verbal pain rating at discharge, and change in VAS pain score between presentation and discharge. It was conducted as a prospective observational study of patients who presented to an urban, adult ED experiencing pain and who were later discharged. Fifty-four patients completed the study of whom 70% rated the management of their pain as 'good' or 'very good.' There was no correlation between patient satisfaction with pain management initial VAS pain score, discharge VAS pain score, verbal rating of pain at discharge, or change in VAS pain score between presentation and discharge. The study suggests that patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal rating of pain at discharge or change in pain score in the ED. Therefore, information about the quality of analgesia provided in an ED cannot be inferred from patient satisfaction surveys.

Acute pain and pain control: state of the art

Recognition and treatment of pain in the emergency department has undergone an evolution in the past decade. Emergency clinicians, educators, and researchers have begun to address the undertreatment of pain as well as challenge the long-standing dogmas concerning pain treatment. Well-described barriers, both psychological and educational, contribute to our providing inadequate pain relief. This state-of-the-art update describes the current perception of our practice with regard to pain relief and how it can be modified. Pain and pain control is such a broad and complex topic that only new advances and important principles relevant to the practice of emergency medicine are presented. Headache, pediatric pain, and procedural sedation and analgesia are not covered in this article as they will be addressed in future state-of-the-art articles.

Ethnicity and analgesic practice

STUDY OBJECTIVE

We previously reported that Hispanic ethnicity was an independent risk factor for inadequate analgesic administration among patients presenting to a single emergency department. We then attempted to generalize these findings to other ethnic groups and EDs. Our current study objective is to determine whether black patients with extremity fractures are less likely to receive ED analgesics than similarly injured white patients.

METHODS

We conducted the following retrospective cohort study at an urban ED in Atlanta, GA. All black and white patients presenting with new, isolated long-bone fractures over a 40-month period were studied. After abstracting demographic information from the medical record and subsequently removing ethnic identifiers, we submitted the medical record to a physician who recorded characteristics of the patients' injury and treatment. We then submitted the records to a nurse, again blinded to ethnicity, who recorded analgesic administration. We used multiple logistic regression to determine the independent effect of ethnicity on analgesic use while controlling for multiple potential confounders. Our main outcome measure was the proportion of black versus white patients receiving ED analgesics.

RESULTS

The study group consisted of 217 patients, of whom 127 were black and 90 were white. White patients were significantly more likely than black patients to receive ED analgesics (74% versus 57%, P =.01) despite similar records of pain complaints in the medical record. The risk of receiving no analgesic while in the ED was 66% greater for black patients than for white patients (relative risk 1.66, 95% confidence interval, 1.11 to 2.50). This effect persisted after controlling for multiple potential confounders.

CONCLUSION

Black patients with isolated long-bone fractures were less likely than white patients to receive analgesics in this ED. No covariate measured in this study could account for this effect. Our findings have implications for efforts to improve analgesic practices for all patients.

The patient vs. caregiver perception of acute pain in the emergency department

The assessment and management of acute pain is an essential part of care received in the emergency department (ED). This study was undertaken to measure how ED caregivers interpret and treat acute pain. A convenience cohort of 71 patients in a tertiary care teaching hospital were asked to rate their pain on arrival to the ED using a visual analog scale (VAS) and numerical rating scale (NRS). These ratings were compared with those given by their nurse and physician. Both physicians and nurses gave statistically significantly lower NRS and VAS pain ratings than those reported by the patients. Nurses' NRS pain ratings were found to be lower than physicians' ratings of the same patients. On chart review, no pain scale assessments were employed, and only one chart noted that a patient's pain had been relieved after treatment. Approximately half the patients (49%, n = 35) felt on discharge from the ED that their pain had not been relieved. Pain assessment and treatment in the ED appears to be inadequate. The integration of pain assessment before and after treatment is essential in monitoring the effectiveness of pain management in the ED.

A prospective study of ED pain management practices and the patient's perspective

OBJECTIVE

This study was conducted to describe the prevalence of pain in the emergency department and to identify factors that may contribute to its treatment.

METHODS

Interviews were conducted with 203 patients who entered the emergency department during the study period. Patients were interviewed regarding various aspects of their pain. Medical records were reviewed to determine what treatments were provided.

RESULTS

One hundred sixty of the 203 patients came to the emergency department with a chief complaint related to pain, indicating a prevalence rate of 78%. Approximately 58% of all patients received either medication or an intervention. An average of 74 minutes elapsed from the time of arrival in the emergency department to the time of treatment with pharmacologic agents. Various independent variables were examined to determine their ability to predict the treatment of pain. Chest pain was most often treated with medication, and abdominal pain was least often treated with medication. Despite high pain ratings, only 15% of the sample received an opioid.

DISCUSSION

This study revealed a very high prevalence of pain among patients in the emergency department and showed that, overall, pain was poorly treated. The findings suggest that chest pain is the only type of pain routinely relieved in the emergency department. An anecdotal finding was that 31 patients said they would refuse pain medications if such medications were offered. Twenty-five patients reported fear of addiction as their reason for this refusal.

Do patients receive adequate pain control after discharge from the ED?

Studies on the effectiveness of pain management have uniformly concluded that health care providers underestimate or undertreat pain. In the emergency department (ED) in which this study was conducted, physicians receive formal didactic and bedside teaching on pain recognition and management in order to heighten the awareness of patients' need for pain control. The purpose of this study was to determine if this outpatient pain management of patients with acute, painful conditions is better than that reported in the medical literature. In this prospective study, 110 adult patients who had an acute, painful diagnosis were telephoned 48 hours after discharge from the ED and asked if they felt their pain at home was well controlled. Patient satisfaction with pain control was higher (91%) than that reported in the medical literature. Also, pain medication was provided more frequently by this study's ED (95%). Education on pain awareness and treatment is a way to improve pain management.

A method for assessing emergency department performance using patient outcomes

OBJECTIVE

To determine the rates of correct patient disposition after an ED evaluation.

METHODS

In a university pediatric hospital, a 25% random sample of ED patients for 4 consecutive months was reviewed, after exclusion of minor injuries and patients triaged to the nonurgent clinic. Patients were categorized into one of 4 outcomes on the basis of inpatient resource use: appropriate admission, inappropriate admission, appropriate release, or inappropriate release. A 10% random sample of released patients was contacted by telephone to detect patients who sought care elsewhere after ED release.

RESULTS

642 of 2,682 ED patients (23.9%) were admitted; 159 (24.7%) were inappropriately admitted, and 26 (1.3%) were inappropriately released. The correct identification of the need for hospitalization (sensitivity) was 94.9%, and for release (specificity) 92.7%. Overall, the correct classification rate was 93.1%. Inappropriate admissions were associated with diagnoses of trauma, seizures, and burns.

CONCLUSION

Inappropriate admissions occur at a substantial rate and occur more commonly than inappropriate releases. The correct disposition of patients is a practical and meaningful outcome-based measure of the quality of ED care. This methodology is suitable for use in other EDs.

Do quantitative changes in pain intensity correlate with pain relief and satisfaction?

OBJECTIVE

To correlate measured pain intensity (PI) changes with pain relief and satisfaction with pain management.

METHODS

A prospective single-group repeated-measures design study. A heterogeneous group of patients were asked to record their levels of PI at initial presentation and at ED release using a numerical descriptor scale (NDS) and a visual analog scale (VAS). At release, a 5-point pain relief scale and a pain management satisfaction survey were also completed.

RESULTS

A convenience sample of 81 patients were enrolled over the study period. The average reduction in PI for all patients was 33%. A 5%, 30%, and 57% reduction in PI correlated with "no," "some/partial," and "significant/complete" relief, respectively (p < 0.001). However, when patients were divided into 2 groups based on their initial PI scores, patients with moderate/severe pain (NDS > 5) required a reduction of 35% and 84% in PI to achieve "some/partial" and "significant/complete" relief, respectively. Patients in less pain (NDS < or = 5) needed 25% and 29% reductions in PI for the same categories (p=0.8). Patients were generally satisfied with their pain management. There was a positive association between pain relief and satisfaction with pain management.

CONCLUSION

There is a significant association between changes in PI and pain relief. Greater reductions in PI are required for patients presenting with more severe initial pain to achieve relief compared with those who have lesser initial PI. While there is a linear relationship between increasing pain relief and satisfaction, relief of pain appears to only partially contribute to overall satisfaction with pain management.

One-week survey of pain intensity on admission to and discharge from the emergency department: a pilot study

The purpose of this pilot study was to determine the incidence and severity of pain intensity in patients 4 years of age and older presenting to the noncritical ward of the emergency department (ED). All patients presenting to the ED of two university hospitals (one general, one pediatric) who were triaged to the noncritical ward during 12 h/day for 1 week were asked to report their pain intensity on admission and again asked just prior to discharge home. The chromatic analogue scale with a range of 0-10 was used as the measure of pain intensity. Pain reports were obtained from half of all patients (58% of adults, 47% of children) admitted during the study week. Approximately one-third (29% of adults and 31% of children) reported no pain on admission, but half of both age groups (52% of adults, 48% of children) reported pain 4/10 or higher. On discharge, one-third of both groups reported pain 4/10 or higher. Eleven percent of both adults and children reported pain 1.5/10 or higher on discharge than on admission. Adult patients with musculoskeletal complaints had the highest pain intensities (mean score admission-discharge, 5.6-4.7/10; other categories, <5). For children, neurological complaints, exclusively headaches, were highest (mean score admission-discharge, 4.8-5.2/10; other categories, <5). Children accompanied by their mothers alone had poorer pain improvement (no change) than children accompanied by their fathers alone or both parents (score improvement of 1). It thus appears that pain is a problem for the majority of patients presenting to the ED. An important percentage of patients leave the ED with more pain than when they arrived. Further investigation is warranted to determine factors predicting poor pain resolution during an ED visit.