Analgesic use in the emergency department

Drug seeking behavior

CONCEPT

Drug seeking behavior (DSB) is often mixed in illicit drug diversion confounding legitimate attempts to control acute and chronic pain.

OBJECTIVE

To review the literature of acute and chronic pain control against the medical and legal context of DSB.

DESIGN

Retrospective literature review from National Library of Medical Computerized Data Base 1990--2004.

PATIENTS

Preference to human prospective on retrospective clinical trials.

RESULTS

Drug use and abuse have significant adverse consequences. Pain control is desirable and necessary with chronic pain syndromes more prone to DSB. This behavior can be accurately profiled and information used to assist recovery.

CONCLUSION

It is desirable to address DSB stressing acceptance and a multidisciplinary approach to recovery.

Chronic pain and aberrant drug-related behavior in the emergency department

Pain is the single most common reason patients seek care in the emergency department. Given the prevalence of pain as a presenting complaint, one might expect emergency physicians to assign its treatment a high priority; however, pain is often seemingly invisible to the emergency physician. Multiple research studies have documented that the undertreatment of pain, or oligoanalgesia, is a frequent occurrence. Pain that is not acknowledged and managed appropriately causes dissatisfaction with medical care, hostility toward the physician, unscheduled returns to the emergency department, delayed return to full function, and potentially, an increased risk of litigation. Failure to recognize and treat pain may result in anxiety, depression, sleep disturbances, increased oxygen demands with the potential for end organ ischemia, and decreased movement with an increased risk of venous thrombosis.

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.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Whether a component of a disease process, the result of acute injury, or a product of a diagnostic or therapeutic procedure, pain should be relieved and stress should be decreased for pediatric patients. Control of pain and stress for children who enter into the emergency medical system, from the prehospital arena to the emergency department, is a vital component of emergency care. Any barriers that prevent appropriate and timely administration of analgesia to the child who requires emergency medical treatment should be eliminated. Although more research and innovation are needed, every opportunity should be taken to use available methods of pain control. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can have a positive effect on providing comfort to children in the emergency setting.

Quality control programme for acute pain management in emergency medicine: a national survey

OBJECTIVE

This national survey was carried out to evaluate the quality programme for acute pain management in the emergency department (ED) and in pre-hospital emergency medical services (EMS).

METHODS

Two types of questionnaires were sent to the chief consultant and the chief nurse of all ED and EMS. Data collected were: the type of structure, quality programme organization, acute pain management, and the training needs to initiate a pain quality programme.

RESULTS

A total of 363 questionnaires were recorded (198 from chief consultants) with 98% of questionnaires being usable. A pain management committee existed in 71% of cases, a quality committee in 83%. A complete quality control procedure existed in 53% of units. An audit on pain management was carried out in only 23% of cases. Training in quality was performed for 64% of physicians and 68% of nurses. Training specifically for pain management was carried out for physicians in 56% of cases and for nurses in 68% of cases. Pain therapeutics protocols existed in 69% of cases. Pain intensity was evaluated 'systematically or often' in 64% at the beginning of patient management, and in 56% at the end of patient management. The staff was 'not very motivated' for a pain management quality programme in less than 3% of responses. A total of 61% of chief consultants and 58% of chief nurses requested advice.

CONCLUSION

Most ED and EMS units seem to master the quality control programme methodology. Units are highly motivated to initiate a quality control programme on pain. Nevertheless, its implementation could benefit from some external support.

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.

Pain management after discharge from the ED

Pain is an important but understudied and often overlooked aspect of emergency medical care. This study examined the management of pain after discharged of patients from the emergency department (ED). We hypothesized that pain management after discharge would be adequate, and that patients would use their medications as prescribed. We surveyed 144 patients by telephone after they had been treated in the ED for common orthopedic complaints. We used a standardized questionnaire to assess prescription-filling practices, side effects of medications, interventions by other health-care professionals, and adequacy of pain relief. Most patients discharged from the ED with a prescription for medication were satisfied with their pain relief (77%). Of those who did not fill their prescription, only 67% were satisfied. Although 26% of the patients reported side effects, most were minor. Thirteen percent of patients with prescribed medications did not fill their prescriptions. Of patients for whom narcotic analgesics were prescribed, 7% drove vehicles while taking these medications. The patients in the study were quite satisfied with their pain control. Most filled their prescriptions and did so in a timely manner. Those who did not fill prescriptions for medications reported the least satisfaction with pain control.

Inadequate analgesia in emergency medicine

Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.

Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients

OBJECTIVE

To determine if there are actual differences between pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians in the management of pain in pediatric patients with fractured extremities.

METHOD

Retrospective chart review of children seen with a forearm or lower extremity fracture over a 2-year period at 3 emergency departments (1 staffed by PEM physicians and 2 staffed by GEM physicians). A severe fracture was defined as a closed fracture with the presence of angulation or displacement. Procedural sedation was defined as the administration of medicine (sedative, analgesic, or dissociative anesthetic) at the time of reduction and/or immobilization of a fracture.

RESULTS

Of the 718 charts reviewed, PEM physicians managed 428 patients, and GEM physicians managed 290 patients. There were no significant differences between the patients managed by PEM physicians and GEM physicians with regard to age, sex, site of fracture, and proportion of severe fractures. There were no differences in the administration of analgesic-related medicines between PEM physicians and GEM physicians in the management of all fractures [40% (95% CI 35-45%) vs. 43% (95% CI 37-49%)] or severe fractures [58% (95% CI 51-64%) vs. 66% (95% CI 58-73%)]. In the management of all fractures, procedural sedation was used by PEM physicians in 100 [23% (95% CI 19-27%)] patients and by GEM physicians in 52 [18% (95% CI 14-23%)] patients. When procedural sedation was used, PEM physicians were more likely to use a sedative agent than GEM physicians [94% (95% CI 88-97%) vs. 46% (95% CI 33-59%)], fentanyl as opposed to morphine or meperidine [62% (95% CI 52-71%) vs. 19% (95% CI 33-59%)] and a combination of sedative and analgesic [90% (95% CI 83-94%) vs. 44% (95% CI 31-57%)]. For all fractures, GEM physicians documented recommending pain medications on discharge more often than PEM physicians [66% (95% CI 60-71%) vs. 45% (95% CI 40-50%)], and they prescribed significantly more prescription analgesics than PEM physicians [13% (95% CI 10-17%) vs. 2% (95% CI 1-4%)].

CONCLUSIONS

In our study, most children with an extremity fracture and greater than one-third of children with a severe fracture did not receive pain medications in the emergency department. Overall, both PEM physicians and GEM physicians have similar practices of analgesic administration for fracture reduction, with a notable exception in the types of agents used during procedural sedation. GEM physicians documented discharge pain medications and prescribed prescription analgesics more often than PEM physicians.

Pain scores improve analgesic administration patterns for trauma patients in the emergency department

OBJECTIVE

To determine the efficacy of pain scores in improving pain management practices for trauma patients in the emergency department (ED).

METHODS

A prospective, observational study of analgesic administration to trauma patients was conducted over a nine-week period following educational intervention and introduction of verbal pain scores (VPSs). All ED nursing and physician staff in an urban Level I trauma center were trained to use the 0-10 VPS. Patients younger than 12 years old, having a Glasgow Coma Scale score (GCS) <8, or requiring intubation were excluded from analysis. Demographics, mechanism of injury, vital signs, pain scores, and analgesic data were extracted from a computerized ED database and patients' records. The staff was blinded to the ongoing study.

RESULTS

There were 150 patients studied (183 consecutive trauma patients seen; 33 patients excluded per criteria). Pain scores were documented for 73% of the patients. Overall, 53% (95% confidence interval [CI] = 45% to 61%) of the patients received analgesics in the ED. Of the patients who had pain scores documented, 60% (95% CI = 51% to 69%) received analgesics, whereas 33% (95% CI = 18% to 47%) of the patients without pain scores received analgesics. No patient with a VPS < 4 received analgesics, whereas 72% of patients with a VPS > 4 and 82% with a VPS > 7 received analgesics. Mean time to analgesic administration was 68 minutes (95% CI = 49 to 87).

CONCLUSIONS

Pain assessment using VPS increased the likelihood of analgesic administration to trauma patients with higher pain scores in the ED.

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 assessment in the paediatric Emergency Department: whose view counts?

OBJECTIVES

To compare patient, guardian and professional assessment of acute pain in children presenting to an Emergency Department, and to examine whether there was a correlation between the scores obtained using the Faces and linear scales for each group.

METHODS

A prospective, observational cohort study of 73 children aged 4-14 years attending a paediatric hospital Emergency Department between March and April 2002 with pain caused by an acute injury. The child's pain on admission, as estimated by the child, their guardian and a healthcare professional (nurse/doctor/emergency nurse practitioner) was recorded using a Faces scale and a linear scale.

RESULTS

Professionals consistently score pain lower [median linear scale score 3.1; interquartile range (IQR) 1.6-5.3] than do patients (6.6; 4.9-7.4) or guardians (6.0; 3.9-7.1) using both linear and Faces scales. There is a significant correlation between pain scores obtained using the two scales for professionals [Spearman R value 0.88; 95% confidence interval (CI) 0.82-0.93], guardians (0.83; 0.74-0.89) and patients (0.42; 0.21-0.59).

CONCLUSION

Professionals score pain lower than do children or guardians. Similar pain scores are obtained using both a Faces and a linear scale. This study offers no support for the introduction of a uniform pain assessment tool in a paediatric Emergency Department setting.

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.

Emergency department analgesia for fracture pain

STUDY OBJECTIVES

We analyze records of all emergency department (ED) patients with extremity or clavicular fractures to describe analgesic use, compare analgesia between adults and children, and compare analgesia between the subset of these adults and children with documented moderate or severe pain. Among children, we compare treatment between pediatric and nonpediatric facilities.

METHODS

Analysis of the ED component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 was conducted. The proportion of patients with closed extremity and clavicular fracture that received any analgesic and narcotic analgesic medications was determined for each age category. Survey-adjusted regression analyses compared pain and narcotic medications by age and ED type (pediatric versus other). Analyses were repeated for the subset of patients with moderate or severe pain severity scores.

RESULTS

Of 2,828 patients with isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Pain severity scores were recorded for 59% of visits overall, 47% of children younger than 4 years, and 34% of children younger than 1 year. Among patients with documented moderate or severe pain, 73% received an analgesic and 54% received a narcotic analgesic. Compared with adults, a lower proportion of children (< or = 15 years) received either any analgesic or a narcotic analgesic (P <.001). After adjustment for confounders and survey design, the proportion of patients aged 0 to 3, 4 to 8, 9 to 15, 16 to 29, 30 to 69, and 70 years and older who received any analgesic was 54% (95% confidence interval [CI] 41% to 67%), 63% (95% CI 57% to 68%), 60% (95% CI 57% to 64%), 67% (95% CI 62% to 73%), 68% (95% CI 64% to 72%), and 58% (95% CI 52% to 65%), respectively; the proportion who received a narcotic analgesic was 21% (95% CI 11% to 31%), 30% (95% CI 22% to 37%), 27% (95% CI 23% to 32%), 47% (95% CI 40% to 54%), 51% (95% CI 46% to 56%), and 41% (95% CI 35% to 48%), respectively. Compared with children treated in other EDs, children treated in pediatric EDs were about as likely to receive any analgesia (adjusted relative risk [RR] 1.1; 95% CI 0.9 to 1.3) or narcotic analgesia (adjusted RR 0.9; 95% CI 0.6 to 1.2).

CONCLUSION

In pediatric and adult patients, pain medications were frequently not part of ED treatment for fractures, even for visits with documented moderate or severe pain. Pain severity scores were often not recorded. Pediatric patients were least likely to receive analgesics, especially narcotics.

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.

Effect of ethnicity and race on the use of pain medications in children with long bone fractures in the emergency department

STUDY OBJECTIVES

We characterize the use of analgesics among children of different race and ethnicity who had isolated long bone fractures that were treated in emergency departments (EDs) across the United States.

METHODS

According to ED survey data from the National Hospital Ambulatory Medical Care Survey for 1992 through 1998, patients younger than 19 years and visiting EDs with isolated long bone fractures were identified by International Classification of Diseases, Ninth Revision codes. Analgesic-prescribing rates were examined for children of different racial and ethnic groups. Multivariate logistic regression was used to determine the independent effect of race and ethnicity on analgesic use and on opioid use while other potential confounders were controlled.

RESULTS

One thousand thirty records representing approximately 3.9 million children were identified. Seven hundred ninety-two records were of non-Hispanic white patients, 111 were of black patients, and 127 were of Hispanic white patients. No significant difference was noted among the different racial and ethnic groups for receipt of analgesic medications or of opioid analgesic medications. Children with long bone fractures who visited the ED in the South (adjusted odds ratio [OR] 1.91; 95% confidence interval [CI] 1.19 to 3.09) and the West (adjusted OR 1.78; 95% CI 1.07 to 2.96) received opioid analgesic medications more often than children in the Northeast. Children in the South also received any analgesics more often (adjusted OR 1.61; 95% CI 1.01 to 2.56).

CONCLUSION

No difference in analgesic prescription or opioid analgesic prescription was found between black and Hispanic children compared with non-Hispanic white children with long bone fractures in EDs. There are, however, previously unreported regional differences in analgesic administration.

"Why haven't you taken any pain killers?" A patient focused study of the walking wounded in an urban emergency department

OBJECTIVES

(1) To assess the proportion of patients of triage category 3-5 presenting to the minor side of an urban emergency department who present without taking prior pain relief, and (2) to describe the reasons why they do not take pain relief for their presenting complaint

METHOD

By patient interview of a convenience sample of 60 adult patients in the setting of an urban emergency department.

RESULTS

Fifteen of 60 patients had taken analgesia and 45 of 60 (75%) had not. Sixteen reasons were volunteered to the interviewer. Most patients offered one reason only 39 of 45 (87%). The three commonest single reasons cited for not taking pain relief were "don't like taking tablets" 10 (22%), "run out of tablets" 10 (22%), five (11%) said their "pain not bad enough". Six (13%) patients cited two reasons for not taking pain relief. Only three (6%) patients indicated that they "did not think about pain relief". Six (13%) of patients had inappropriate perceptions of how pain killers may interfere with their care.

CONCLUSION

Most patients presenting with painful conditions to the minor side of an urban emergency department had not taken pain relief. The study highlights there are many different reasons for this and staff should not presume that it was because the patient "did not think about it". Ongoing education of staff and patients is needed.

Underuse of analgesia in very young pediatric patients with isolated painful injuries

STUDY OBJECTIVE

We sought to compare the use of analgesic agents in very young children with that in older children with isolated painful injuries.

METHODS

We performed a retrospective chart review of patients seen between 1999 and 2000 in a pediatric emergency department. Patients aged 6 months to 10 years who sustained isolated long bone fractures or second- and third-degree burns were included. Exclusion criteria included head injury, chest or abdominal trauma, and developmental delay or neurologic disorder. Research subjects were separated into 2 study groups: very young (ages 6 to 24 months) and school age (ages 6 to 10 years).

RESULTS

One hundred eighty research subjects met the inclusion and exclusion criteria: 96 in the very young group and 84 in the school age group. Research subjects in the very young group received no analgesic agents more often than school age research subjects for all injuries (64.6% versus 47.6%, respectively), all fractures (70.6% versus 48.8%, respectively), displaced fractures (55.0% versus 22.0%, respectively), and all burns (50.0% versus 25.0%, respectively). When analgesic agents were administered, very young patients were less likely to receive narcotics compared with school age patients. Analgesic dosing for both the very young and school age groups was similar and within established guidelines.

CONCLUSION

Children younger than 2 years of age receive disproportionately less analgesia than school age children, despite having obviously painful conditions. Emergency physicians should consider special issues involved in assessing and managing pain in very young children.

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.

Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures

OBJECTIVES

To assess the analgesia practices of ambulance personnel and emergency department staff treating patients with fractured neck of femur.

METHODS

This is a retrospective analysis of 176 patients with an admission diagnosis of fractured neck of femur, who presented to a major western Sydney teaching hospital, between January and November 1999.

RESULTS

One hundred and twenty-eight patients met the inclusion criteria. The median age was 82, there were more female than male subjects. Ambulance officers made a clinical diagnosis of fractured neck of femur in 68% of cases. In 49% of cases no analgesia was given. Patients were given a higher triage category and pain relief faster if they had been given analgesia by ambulance officers, P = 0.0018 and P = 0.002, respectively. The median time to analgesia was 2 h 48 min.

CONCLUSIONS

Only a modest proportion of patients with fractured neck of femur received prehospital analgesia and delays to analgesia in the emergency department are considerable. Strategies to address the delivery of appropriate analgesia to this group of patients should be developed.

Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia

OBJECTIVES

The objectives of this study were: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia.

METHODS

A prospective convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses. Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min. Demographic, diagnostic and waiting time data were also recorded.

RESULTS

Three hundred and forty nine patients were enrolled over a 12-month period. The median initial pain score was 8.5 cm, with a reduction to 4.0 cm at 1 h. Respiratory rate, oxygen saturation, heart rate and blood pressure all showed small but statistically significant reductions over 60 min. There were 15 predefined adverse events, 10 episodes of hypotension and five episodes of oxygen desaturation. No intervention other than supplemental oxygen was required. There were no episodes of bradycardia, bradypnoea or reduced level of consciousness. The median time to narcotic was 18 min and the median time to be seen by a doctor was 52 min.

CONCLUSION

Experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment, with minimal change in physiological parameters. This process can improve the time to analgesia for patients in acute pain.

The pain experience of adolescents after acute blunt traumatic injury

Because little is known about adolescent pain, in particular pain after blunt traumatic injury, a descriptive exploratory approach was used to examine the pain experience of adolescents after acute blunt traumatic injury in three contexts: at the scene of the accident, in the emergency department, and in the hospital setting. For the 13 adolescents (11-17 years) who experienced multiple sites of blunt unintentional injury, the majority recalled their worst pain at the scene and in the emergency department, with high, intense pain persisting into the hospital setting. Regardless of the context, adolescents recalled multiple aspects of their pain experience. Study findings have implications for the understanding and management of adolescent pain resulting from blunt traumatic injury.

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.

Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997

This article describes parenteral analgesic and sedative (PAS) use among patients treated in US emergency departments (EDs). Data representing 6 consecutive years (1992-1997) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined and analyzed. Patients were identified as having received PAS if they received fentanyl, ketamine, meperidine, methohexital, midazolam, morphine, nitrous oxide, or propofol. Patients were stratified according to age (pediatric <18 yrs), race, sex, insurance, type of hospital, urgency of visit, and ICD-9 (International Classification of Diseases, 9th revision) diagnostic codes. Logistic regression was performed to determine independent associations and calculate odds ratios (OR) for receiving analgesia or sedation. A total of 43,725 pediatric and 114,207 adult ED encounters were analyzed and represented a weighted sample of 555.3 million ED visits. For patients with orthopedic fractures, African-American children covered by Medicaid insurance were the least likely to receive PAS (OR 0.2, 95% confidence interval [CI] 0.1-0.6). These results suggest that variations may be occurring among ED patients receiving PAS.

Gender differences in narcotic-induced emesis in the ED

Narcotic analgesia is commonly given in the emergency department. Narcotic-induced nausea and vomiting is thought to be a common occurrence, but the gender incidence and associations are not well defined. The aim of this study was to document the sex-related complication of nausea and vomiting after opiate administration for pain relief in the ED. The study hypothesis was that men and women have the same rate of narcotic-induced emesis in the ED. A prospective, convenience study of the use of narcotic analgesic on patients in an innercity Level I Trauma Center was undertaken. Information concerning the reason for narcotics, complications, number of doses, and route of administration were studied. The emergency physicians were allowed clinical judgment to treat the patients with any narcotic agent in any dose increment. The data were entered into an SPSS program (Chicago, IL). Analysis between groups (men v women) was then conducted by an independent t test. We compared the 2 groups across 6 categories: cause of injury, presenting pain scale, first drug given, first dose given, first route of drug, and requires an anti-emetic. A Bonferroni procedure was used to correct for the higher probability of significant findings when multiple tests were performed. All findings that are significant are after Bonferroni. The study was Institutional Review Board (IRB) approved. A total of 325 consenting patients were studied from October 1996 to April 1998. The patients consisted of 174 men and 151 women, with an average of 35.8 years of age. The race of the patients was 70% African American and 20% Hispanic. Of the total of 325 patients, 20.3% (74) required an anti-emetic because of nausea and/or vomiting. A significant difference occurred in causes of pain for women (t = 2.79, P <.007). The causes of pain for women were general pain, fracture, abdominal, back pain, and other as compared with men with gun shot wounds, general, fracture, low back, and flank. Women showed no significant difference with regard to presenting pain scale (t =.122, P <.903), first drug given (t = 1.643, P <.101), and first dose given (t =.708, P <.408). The majority of patients received morphine (55.4%), followed by meperidine (24.3%), and hydrocodone (13.5%). The most frequent route of administration was intravenous (IV, 45.2%), intramuscular (IM, 35.7%), with oral being the least frequent route (19.1%). There was a difference for women with first route given (t = 2.543, P <.01) and requires anti-emetic (t = 3.06, P <.002). The majority of women received IM (58.6%) versus IV (37.7%), whereas the majority of men (62.3%) received IV versus IM (41.4%). A significant number of patients became nauseated and/or vomited from Emergency Department-administered narcotics. The nausea and vomiting was associated with female sex and the cause of pain. A comparative study of other pain medications versus narcotics for incidence of induced nausea and emesis would be useful.

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.

The problem of pain in emergency care

Pain is one of the most common complaints that cause patients to seek care in the emergency department. Research and patient complaints however, continue to demonstrate that pain management needs improvement. This article addresses pain management in emergency care. It presents both pharmacologic and nonpharmacologic methods of pain management.

Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997

The objective of the study was to describe parenteral analgesic and sedative (PAS) use among patients treated in US emergency departments (EDs). Data representing 6 consecutive years (1992-1997) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined and analyzed. Patients were identified as having received PAS if they received fentanyl, ketamine, meperidine, methohexital, midazolam, morphine, nitrous oxide, or propofol. Patients were stratified according to age (pediatric <18 years), race, gender, insurance, type of hospital, urgency of visit, and ICD-9 diagnostic codes. Logistic regression was performed to determine independent associations and calculate odds ratios (OR) for receiving analgesia or sedation. A total of 43,725 pediatric and 114,207 adult ED encounters were analyzed and represented a weighted sample of 555.3 million ED visits. For patients with orthopedic fractures, African American children covered by Medicaid insurance were the least likely to receive PAS (OR 0.2, 95% confidence interval 0.1-0.6). These results suggest that variations may be occurring among ED patients receiving PAS.

Use of analgesia in a paediatric accident and emergency department following limb trauma

The objective of this study was to assess analgesic use and the use of a pain scoring system on those children presenting to a paediatric accident and emergency (A&E) department with a history of injury due to trauma. A random sample of patients who presented to a paediatric A&E department over a 6-week period with a history of limb trauma were prospectively studied. Pain severity scores were assessed on arrival and at 10, 30 and 60 minutes using the Douhit Faces Scale and any analgesia given or plaster application was noted. One hundred and seventy-two patients were studied. The median age was 10 years (range 3-13 years) and the majority, 56%, were male. The mean initial pain scores were 2.7 (range 1-4) for boys and 3.0 (range 1-4) for girls. The presenting injuries were 103 upper or lower limb fractures and 69 'soft tissue' injuries. Only 84 (49%) patients received analgesic medication in the department (30% morphine; 70% paracetamol); analgesia was not given to the remaining 88 (51%). Of these, 7 declined analgesia, and 5 had already taken analgesia on arrival to A&E. Despite prompt triage (median time 2 minutes, range 0-10 minutes), the median time from arrival to paracetamol administration was 20 minutes (range 4-105 minutes) and for morphine was 14 minutes (range 2-57 minutes). Pain is a common symptom in patients presenting to A&E. Because children's pain can be particularly difficult to assess, a pain scoring system such as the Douhit Faces Scale can be a useful means of pain assessment in the A&E setting. Despite increased awareness, pain is still under treated in the A&E department.

Emergency analgesia in the paediatric population. Part I: current practice and perspectives

Children frequently present to the accident and emergency (A&E) department in pain. Most presentations are acute, but children with pain of longer duration also present. Children also often undergo painful procedures in A&E in the process of diagnosis or treatment. These papers review recent literature to examine factors involved in the provision of emergency analgesia in the paediatric population. This will include a discussion of current practice and make recommendations for future management of children's pain and anxiety in the A&E department. Part I: Current practice and perspectives. Part II: Pharmacological methods of paediatric analgesia. Part III: Non-pharmacological methods of pain control and anxiolysis. Part IV: Paediatric sedation in accident and emergency.

Comparison of oral and intravenous morphine following acute injury in children

The objective of this research was to examine the speed of onset and effectiveness of pain relief between oral and intravenous morphine in acutely injured children. An observational study of children aged 3 to 13 years with closed forearm fractures was performed in three accident and emergency departments. The study gathered information on age, gender, body weight, time of arrival, dose, route and time of morphine administration. Pain assessment using a Faces Scale was documented on arrival and repeated at 10, 30 and 60 minutes after morphine was given. Forty-seven children were studied. Of these, 25 were given intravenous morphine, 22 were given oral morphine. There was no statistically significant difference in age, body weight or time until morphine was administered. The change in median pain scores was analysed using the Mann-Whitney U test. This showed that there was a statistically significant reduction in pain score in the intravenous group compared with the oral group between arrival and 10 minutes after giving morphine and between arrival and 60 minutes after giving morphine. Intravenous morphine appears to give more rapid onset and more prolonged pain relief than oral morphine for children with acute injuries. We recommend that in accident and emergency departments where staff are experienced in paediatric cannulation, morphine should be given via the intravenous route in acutely injured children. However we do not advocate inexperienced staff attempting multiple venepunctures in a child resulting in increased anxiety.

Clinically significant changes in pain along the visual analog scale

STUDY OBJECTIVE

We sought to test the hypothesis that the change in visual analog scale (VAS) associated with a clinically significant change in pain is related to the initial VAS score.

METHODS

A convenience sample of adults with isolated extremity trauma was enrolled. A VAS score was obtained on entry into the study. Descriptions of change in pain ("lot less," "little less," "about the same," "little more," or "lot more") and VAS scores were then obtained every 30 minutes until the patient was free of pain or discharged or a total of 2 hours had passed. Patients were divided into 3 cohorts on the basis of the initial VAS score: VAS score of less than 34, VAS score of 34 to 66, and VAS score of 67 or greater. The absolute values of VAS changes associated with pain descriptions of a "little less" or "little more" (defined as clinically significant), "about the same" (defined as clinically insignificant), and "lot less" or "lot more" were calculated.

RESULTS

The change in VAS associated with clinically significant changes in pain in the cohort with VAS scores of less than 34 was 13+/-14 (mean+/-SD), which was significantly lower than that of the cohort with VAS scores of 67 or greater (28+/-21). There was no statistically significant difference in clinically significant changes in pain between the middle cohort and either the upper or lower cohorts (P =.07 and P =.29, respectively). There was no significant change in VAS for clinically insignificant changes in pain among the 3 cohorts (3+/-4, 6+/-6, and 8+/-16, respectively).

CONCLUSION

Patients with greater pain require a greater change in VAS score to achieve clinically significant pain relief.

Improving the delivery of analgesia to children in pain

OBJECTIVES

To improve the time taken for children arriving to the accident and emergency (A&E) department in pain to receive analgesia. Delivery within 30 minutes of triage was taken as an achievable goal.

METHODS

262 children who had received analgesia in the "minor injuries" area of West Middlesex University Hospital A&E department were studied over a four month period. Current practice was indicated over the first two months by retrospectively looking at data from 129 children's A&E cards. A Paediatric Pain Protocol was then introduced and another 133 children's cards studied to see if this had made an improvement. The protocol for those children aged over 4 years differed to that for children aged 4 years and under.

RESULTS

For children aged 4 years and over, the introduction of the protocol significantly increased the number that received analgesia within 30 minutes of triage: 55.3% (n=54) post-protocol versus 34.0% (n=33) pre-protocol (p=0.003). However, for children aged 4 years and under there was no change in the proportion that received analgesia within 30 minutes of triage: 56.7% (n=17) postprotocol versus 59.4% (n=19) pre-protocol (p=0.829).

CONCLUSIONS

The introduction of a simple Paediatric Pain Protocol has improved the time taken to deliver analgesia to children arriving in this A&E department.

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.

Pharmacology of emergency department pain management and conscious sedation

The endpoints of sedation and analgesia have been more difficult than traditional physiologic parameters to measure adequately. Several clinical scoring systems have been developed in an attempt to provide more consistent and objective assessments of sedation, but the few that have been validated are cumbersome to use in the clinical setting and cannot accurately determine subtle changes in the level of sedation. Recent developments in EEG monitoring, particularly one using bispectral (BIS) analysis of the EEG signal obtained through a noninvasive forehead "lead," are promising. BIS monitoring has been used as a reliable measure of depth of midazolam-induced sedation during general anesthesia. Anesthesiologists have used this technology to prevent awareness during paralysis. One recently completed but as yet unpublished study in the ED demonstrated a high correlation with traditional sedation scales and found the device easy to use (UNC Hospitals Department of Emergency Medicine, personal communication, 1999). It is anticipated that with BIS monitoring, in combination with titratable, short-acting agents, appropriate levels of sedation can be more easily achieved while minimizing associated complications and duration of ED stay.

Transcribing in triage: the Wrexham experience

The Manchester triage methodology and the practice of analgesic transcribing were introduced to the Accident & Emergency Department of the Wrexham Maelor Hospital in April 1998. The concept of nurse led transcribing is relatively new and its introduction was not without an element of administrative caution. The project was successfully implemented owing to the strategic input from a multidisciplinary group and elaborate steps towards quality assurance through audit. This paper describes the steps of implementation of this transcribing project and its successful completion through a prospective audit. Although there is a paucity of published literature in this topic, the Wrexham Pain Triage Group wishes to extend this implementation methodology into other areas of innovative nursing practice.

Adverse outcomes and opioid analgesic administration in acute abdominal pain

To the authors' knowledge, no outcome-based, randomized clinical trial of the safety of opioid analgesics in acute abdominal pain exists.

OBJECTIVES

1) To assess the feasibility of a randomized clinical trial of opioid safety by estimating the adverse outcome rate among patients with abdominal pain severe enough to necessitate opioid analgesics. 2) To explore the association of opioid administration with adverse outcomes in acute abdominal pain.

METHODS

The authors conducted a prospective observational study of emergency department (ED) abdominal pain patients, and followed them by telephone at three weeks to determine whether an adverse outcome occurred (defined as obstruction, perforation, ischemia, hemorrhage, peritonitis, sepsis, or death). A logistic regression of factors predicting adverse outcome was performed.

RESULTS

Adverse outcomes occurred in 67 of 860 abdominal pain patients (7.8%, 95% CI = 6.1% to 9.8%), and 252 of 860 (29%) received opioids. The adverse outcome rate was 12.7% (95% CI = 9.0% to 17.0%) among patients who received opioids. Variables predictive of adverse outcome in logistic regression included: ED diagnosis of adverse outcome (OR 12.4), age (OR 1.6 per decade), fever (OR 4.6), received opioids (OR 2.1), pain duration (OR 1.5 per day), and leukocytosis (OR 2.0).

CONCLUSIONS

A clinical trial would need to randomize more than 1,500 patients to establish the equivalent adverse outcome rates of opioids and placebo: the sample size of all existing studies combined is insufficient to make such a conclusion. Although opioids were associated with a higher adverse outcome rate in this logistic regression, the authors believe this may be due to confounding by pain severity. They emphasize that the study's design precludes conclusion of a causal link. No change in clinical practice is warranted. A randomized clinical trial of sufficient size to definitively resolve this issue is needed.

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.

Emergency department evaluation and treatment of hip and thigh injuries

This article reviews the clinical and diagnostic evaluation of patients with injuries to the hip and thigh. The history and physical examination, appropriate imaging strategies, complications and associated injuries, analgesia, treatment, and appropriate patient disposition are emphasized.