Patient anxiety may influence the efficacy of ED pain management

Effects of virtual reality on anxiety and pain in adult patients undergoing wound-closure procedures: A pilot randomized controlled trial

Background

In emergency departments, suturing is a typical procedure for closing lacerated wounds but is invasive and often causes anxiety and pain. Virtual reality (VR) intervention has been reported as a relaxing measure.

Objective

The study aims to examine the effects of VR intervention on anxiety, pain, physiological parameters, local anesthesia requirements and satisfaction in Chinese adult patients undergoing wound closure in emergency departments in Hong Kong.

Methods

Adult patients who had lacerated wounds and were undergoing wound closure by suturing can communicate in Chinese and were hemodynamically stable were invited for this trial. Eighty patients were randomly assigned to the VR group, which received VR intervention and standard care, or to the control group, which received standard care only. The primary outcome was anxiety, and the secondary outcomes included pain, blood pressure, pulse rate, satisfactory with pain management, service satisfactory, and extra local analgesia requirement. Outcomes were conducted at baseline, during the procedure and 5 min after the procedure.

Results

The VR group had a significantly greater reduction in anxiety (p < 0.001), pain (p < 0.001), systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), pulse rate (p = 0.003) and requested less amount of additional local anesthesia (p = 0.025). The satisfactory level with pain management (p = 0.019) and service (p = 0.002) were significantly higher in participants who received VR intervention. In addition, most participants preferred to have VR in the future, and no major adverse events associated with the use of VR were reported.

Conclusion

This pilot study provides insight into the use of VR and the direction of future studies. It may effectively improve psychological and physiological outcomes in adult patients during wound-closure procedures in emergency departments.

Analgesic and Anxiolytic Effects of Virtual Reality During Minor Procedures in an Emergency Department: A Randomized Controlled Study

STUDY OBJECTIVE

We aimed to assess the analgesic and anxiolytic efficacy of distraction, a nonpharmacologic intervention provided by 3-dimensional (3D) virtual reality (VR) compared with that provided by 2-dimensional (2D) VR during minor emergency department (ED) procedures.

METHODS

This randomized controlled study conducted in the ED of a teaching hospital included patients aged more than or equal to 18 years undergoing minor procedures. The patients watched the same computer-generated VR world either in 3D in a head-mounted display (intervention) or in 2D on a laptop screen (control). Our main outcomes were pain and anxiety during the procedure, assessed on a 100-mm visual analog scale. Secondary outcomes included the impression of telepresence in the computer-generated world assessed using the Igroup Presence Questionnaire, and the prevalence and intensity of cybersickness measured on a 100-mm visual analog scale.

RESULTS

The final analysis included 117 patients. The differences in median procedural pain and anxiety levels between the 2D and 3D VR groups were not significant: -3 mm (95% confidence interval [CI] -14 to 8) and -4 mm (95% CI -15 to 3), respectively; the difference in telepresence was 2.0 point (95% CI 0 to 2.0), and the proportion difference of cybersickness was -4% (95% CI -22 to 14), with an intensity difference of -5 mm (95% CI -9 to 3).

CONCLUSION

During minor procedures in adult patients in the ED, distraction by viewing a 3D virtual world in a head-mounted VR display did not result in lower average levels of procedural pain and anxiety than that by 2D viewing on a screen despite a higher sense of telepresence. There were no significant differences in the prevalence and intensity of cybersickness between the 2 groups.

Adult pain and anticipatory anxiety assessment in the emergency department: An integrative literature review

INTRODUCTION

Patients presenting to the emergency departments in pain often experience co-occurring symptoms. Anticipatory anxiety in the emergency department may be currently under-recognised. Clinical tools to facilitate the assessment of co-occurring symptoms aligns with providing more patient centred care and improved outcomes and experience.

AIMS

This integrative review aimed to identify and examine the psychometric properties of tools currently used for pain and anticipatory anxiety assessment in adult patients presenting to the emergency department. This study also aimed to identify the current clinical practice used to assess adult pain and anticipatory anxiety.

METHODS

Whittemore and Knafl's methodology guided the review process, and it is reported according to relevant items from PRISMA checklist. Studies were included if they focused on tools for pain or anxiety assessment of adults in emergency departments in English language publications since 2010. Quality of studies was evaluated using the Mixed Methods Appraisal Tool (MMAT). The results were summarised through narrative synthesis.

RESULTS

A total of 15 studies were identified for narrative synthesis. Six tools for pain, and four tools for anticipative anxiety were found. All currently used clinical tools assess symptoms in isolation. There was limited discussion of the clinical context of identified tools within the included studies.

CONCLUSION

Pain and anxiety assessment are currently performed in symptom isolation with a variety of tools with varying degrees of reliability. There exists a lack of clinical tools able to assess co-occurring symptoms of pain and anticipatory anxiety in the clinical setting of the emergency department. No studies discussed clinical tool use in current practice.

RELEVANCE TO CLINICAL PRACTICE

The reconstruction of available pain and anxiety assessment tools into one validated and holistic tool for assessment in the ED clinical setting, would provide a contextually appropriate guide to clinical assessment and treatment. Acknowledging and measuring these symptoms may facilitate future rigorous testing of experimental studies of novel methods to reduce pain and anxiety in the ED.

NO PATIENT OR PUBLIC CONTRIBUTION

Patient or public contribution does not apply to this Integrative Review.

CLINICAL TRIAL REGISTRATION NUMBER

Not applicable.

Higher Risk of Anxiety and Depression in Women with Adenomyosis as Compared with Those with Uterine Leiomyoma

The main symptoms of adenomyosis may adversely affect physical and mental health and quality of life (QOL). However, studies are few on this topic. This study evaluated the effect of adenomyosis on anxiety, depression, and QOL. Participants with adenomyosis (n = 90) or leiomyoma (n = 59) completed questionnaires, including the visual analog scale (VAS) for pain, Hospital Anxiety and Depression Scale (HADS), and Short Form (SF)-36. HADS anxiety and depression positive rates, physical (PCS) and mental (MCS) component summary scores, and eight subscale scores of SF-36 were compared between the two groups. Among patients with adenomyosis, the incidence of anxiety symptoms was 28.9% (control group, 10.2%; OR = 3.589, 95%CI: 1.375–9.367), with 10% of patients showing moderate-to-severe symptoms. The incidence of depressive symptoms was 14.4% (control group, 3.4%; OR = 4.812, 95%CI: 1.044–22.168). The case group had significantly lower PCS and MCS scores than the control group. In patients with adenomyosis, being employed (OR = 6.393, 95%CI: 1.153–35.440) and perianal pain (OR = 25.419, 95%CI: 2.504–258.024) were risk factors for anxiety, and perianal pain (OR = 15.208, 95%CI: 3.050–75.836) was a risk factor for depression. Compared with leiomyoma, adenomyosis is associated with a higher risk of anxiety and depression, with a poorer QOL.

Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline

BACKGROUND

Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety.

METHODS

We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach.

RESULTS

A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty).

CONCLUSIONS

We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.

Hydroxyzine for lowering patient's anxiety during prehospital morphine analgesia: A prospective randomized double blind study

STUDY OBJECTIVE

Hydroxyzine is an antihistamine drug used for symptomatic relief of anxiety and tension. We hypothesized that managing the anxiety of patients with severe pain by adding hydroxyzine to a conventional intravenous morphine titration would relieve their pain more effectively.

METHODS

This was a randomized, double-blind, controlled group study of prehospital patients with acute pain scored greater than or equal to 6 on a 0-10 verbal numeric rating scale (NRS). Patients'anxiety was measured with the self-reported Face Anxiety Scale (FAS) ranking from 0 to 4. The percentage of patients with pain relief (NRS score ≤ 3) 15 min after the first injection was the primary outcome.

RESULTS

One hundred forty patients were enrolled. Fifty-one percent (95% CI 39% to 63%) of hydroxyzine patients versus 52% (95% CI 40% to 64%) of placebo patients reported a pain numeric rating scale score of 3 or lower at 15 min. Ninety-one percent (95% CI 83% to 98%) of patients receiving hydroxyzine reported no more severe anxiety versus 78% (95% CI 68% to 88%) of patients with placebo (p > 0.05). Adverse events were minor, with no difference between groups (6% in hydroxyzine patients and 14% in placebo patients).

CONCLUSION

Addition of hydroxyzine to morphine in the prehospital setting did not reduce pain or anxiety in patients with acute severe pain and therefore is not indicated based on our results.

Pet therapy in the emergency department and ambulatory care: A systematic review and meta-analysis

BACKGROUND

Pet therapy, or animal-assisted interventions (AAIs), has demonstrated positive effects for patients, families, and health care providers (HCPs) in inpatient settings. However, the evidence supporting AAIs in emergency or ambulatory care settings is unclear. We conducted a systematic review to evaluate the effectiveness of AAIs on patient, family, and HCP experience in these settings.

METHODS

We searched (from inception to May 2020) Medline, Embase, Cochrane CENTRAL, PsycINFO, and CINAHL, plus gray literature, for studies assessing AAIs in emergency and ambulatory care settings on: (1) patient and family anxiety/distress or pain and (2) HCP stress. Screening, data extraction, and quality assessment were done in duplicate with conflicts adjudicated by a third party. Random-effects meta-analyses are reported as mean differences (MDs) or standardized mean differences (SMDs) and 95% confidence intervals (CIs), as appropriate.

RESULTS

We included nine randomized controlled trials (RCTs; 341 patients, 146 HCPs, 122 child caregivers), four before-after (83 patients), and one mixed-method study (124 patients). There was no effect across three RCTs measuring patient-reported anxiety/distress (n = 380; SMD = -0.36, 95% CI = -0.95 to 0.23, I²  = 81%), while two before-after studies suggested a benefit (n = 80; SMD = -1.95, 95% CI = -2.99 to -0.91, I²  = 72%). Four RCTs found no difference in measures of observed anxiety/distress (n = 166; SMD = -0.44, 95% CI = -1.01 to 0.13, I²  = 73%) while one before-after study reported a significant benefit (n = 60; SMD = -1.64, 95% CI = -2.23 to -1.05). Three RCTs found no difference in patient-reported pain (n = 202; MD = -0.90, 95% CI = -2.01 to 0.22, I²  = 68%). Two RCTs reported positive but nonsignificant effects on HCP stress.

CONCLUSIONS

Limited evidence is available on the effectiveness of AAIs in emergency and ambulatory care settings. Rigorous studies using global experience-oriented (or patient-identified) outcome measures are required.

The Effect of a Nurse Initiated Therapeutic Conversation Compared to Standard Care for Patients With Acute Pain in the ED: A Randomized Controlled Trial

Acute pain is a common presenting complaint in the emergency department (ED) and is most often treated with opioid or nonopioid analgesia. However, studies have shown that receiving analgesia alone does not always influence patient satisfaction with pain management in the ED. Pain anxiety and catastrophizing have been shown to affect pain intensity and patients' response to analgesia. The objective of this study was to determine whether a brief therapeutic conversation would improve patient satisfaction with pain management compared with standard care for adult patients presenting to the ED with moderate to severe acute pain. Adult (18 years or older) patients presenting to the ED with moderate to severe acute pain were randomized to either the standard care group or the intervention group. Patients in the intervention group participated in a brief therapeutic conversation with an ED nurse to discuss their perceived cause of pain, level of anxiety, and expectations of their pain management. Prior to discharge, all patients were asked to complete a self-reported, 9-item questionnaire to assess their level of satisfaction with their overall ED experience. A total of 166 patients (83 in each group) were enrolled. Patient satisfaction with ED pain management and the proportion of patients who received analgesia in the ED were similar in both the control (n = 57; 68.7%) and intervention (n = 58; 69.9%) groups (Δ 1.2%; 95% CI [12.6, 15]). Qualitative findings demonstrate that patients place high importance on acknowledgment from ED staff and worry about the unknown cause of pain. This study suggests that patient satisfaction with pain management in the ED is multifactorial and complex. Further research should investigate additional methods of integrating nurse-led interventions into the care of patients in acute pain.

Impact of emergency department length of stay on anxiety and comfort in older people

INTRODUCTION

Older people are frequent emergency department (ED) users, a vulnerable population and often have long stays in the ED. The aim of this study was to determine whether ED length of stay (LOS) had an impact on older people's (aged ≥65 years) anxiety, comfort and adverse events.

METHODS

This prospective observational study was conducted in Melbourne, Australia. Patients (n = 301) from three EDs were classified by ED LOS: ≤4-hours (n = 89), 4-8 h (n = 136) and >8-hours (n = 76). Current state and trait anxiety and comfort were measured in ED. Adverse event data were collected from medical records. LOS groups were compared using Chi-Square and Kruskal-Wallis test.

RESULTS

There was no significant difference in Trait Anxiety Scores. Patients with ED LOS ≤ 4-hours had lower median State Anxiety Scores (p = 0.003), were less likely to require ward admission (p < 0.001), and more likely to require short stay unit admission (p < 0.001). There were no significant differences between groups in comfort or adverse events during ED care or hospitalisation (for admitted patients).

CONCLUSION

The impact of ED LOS on the anxiety of older ED users appears limited. There was no association identified between ED LOS and comfort during ED care or adverse events during ED care or hospitalisation.

Usefulness of a Visual Analog Scale for Measuring Anxiety in Hospitalized Patients Experiencing Pain: A Multicenter Cross-Sectional Study

BACKGROUND

Anxiety is common in hospitalized patients and can worsen pain or lead to unsuccessful pain relief.

AIMS

The purpose of this study was to evaluate the usefulness of measuring anxiety with a visual analog scale (VAS) in the hospitalized patient experiencing pain.

DESIGN

We conducted a multiple-center cross-sectional study.

PARTICIPANTS/SUBJECTS

Adult inpatients experiencing moderate to severe pain defined by a pain VAS score ≥40 of 100 were included.

METHODS

Pain and anxiety data were collected using the following instruments: pain VAS, anxiety VAS, State Anxiety Scale of the Spielberger State-Trait Anxiety Inventory (STAI-YA) and Anxiety Subscale of the Hospital Anxiety and Depression Scale (HAD-A).

RESULTS

Data were collected from 394 patients. Of those patients, 43.6% (171 of 392) and 36.6% (143 of 391) had significant anxiety according to STAI-Ya and HAD-A, respectively. Correlation was good between anxiety-VAS and STAI-YA (ρ = 0.67 [95% confidence interval 0.61-0.72]) and moderate between anxiety VAS and HAD-D (ρ = 0.48 [0.39-0.56]). The main factor predictive of situational anxiety was history of anxiety-depression symptoms (odds ratio = 2.95 [1.93-4.56]). For anxiety VAS score ≥ 40 of 100, the sensitivity for detecting anxiety was 81% with 70% specificity.

CONCLUSION

This study confirmed the high prevalence of anxiety among inpatients experiencing pain, demonstrated the capacity of a VAS to assess this anxiety, determined an anxiety VAS cutoff level to screen for significant anxiety, and identified risk factors of anxiety in this population. Anxiety VAS has been found to be an easy-to-use method familiar to caregivers, with all the advantages needed for an effective screening instrument. An anxiety VAS score ≥40 of 100 would thus warrant particular attention to adapt care to the patient's anxiety-related pain and initiate specific therapeutic interventions.

Effects of Aromatherapy on Pain and Anxiety Scores in Adult Patients Admitted to a Community Hospital on the Medical Unit or Telemetry Unit: A Pilot Study

The purpose of the study was to determine the impact of aromatherapy intervention on pain and anxiety. The hypothesis was that the use of aromatherapy will improve pain and anxiety scores when assessed within 30 to 60 minutes of administration. The study design was a prospective comparison of aromatherapy using a pre-/postdesign study. A convenience sample of patients was recruited from both a medical unit and a telemetry unit with patients aged 18+ years from a 182-bed acute care Magnet community hospital. Pain and anxiety levels were assessed prior to administration of a medication, within 60 minutes of receiving pain medication, and within 60 minutes of receiving aromatherapy. Ninety-six percent of the participants would use aromatherapy if offered again, would use it in the future, and would recommend its use to family and friends. Both pain and anxiety improved after the aromatherapy with a P value of <.0001. This pilot study demonstrated that aromatherapy is safe and effective at reducing pain and anxiety and should be considered as a valuable adjunct to symptom management.

Heightened anxiety state among parents of sick children attending emergency department using State-Trait Anxiety Inventory

Background:

The anxiety and stress level of both parent and child seeking treatment at the emergency department is assumed to be high. However, it is rarely quantified as to ascertain any need for intervention.

Objective:

The study seeks to quantify anxiety of parents accompanying sick children presenting acutely to the emergency department and to explore possible pre-visit factors that may contribute to anxiety.

Methods:

A 12-month cross-sectional study was conducted at the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre. All parents accompanying a child presenting to the study location, fitting the inclusion and exclusion criteria, were invited to participate. Parents required to fill a self-administered questionnaire on anxiety, State-Trait Anxiety Inventory and any related factors that can influence anxiety.

Results:

A total of 233 subjects were recruited. The mean state anxiety score was 53.48 ± 11.36, compared to the mean score for trait anxiety of 39.85 ± 7.66, suggesting a heightened state of anxiety. Majority of subjects (65.7%) had reported clinically detected anxiety as defined by state anxiety score above 49. There was no significant association between parental anxiety level with pre-visit factors: children’s age, duration of illness, the presence of co-morbidities, time of presentation, prior medical contact and primary care referral. The child’s state of illness was the dominant psychosocial factor associated with parental anxiety reported by the subjects.

Conclusion:

Parental anxiety upon arrival appeared to be significantly higher than expected, suggesting intervention may be needed.

Relation between illness representation and self-reported degree-of-worry in patients calling out-of-hours services: a mixed-methods study in Copenhagen, Denmark

OBJECTIVES

To examine the relation between patients' illness representations, presented in telephone consultation to out-of-hours (OOH) services, and self-reported degree-of-worry (DOW), as a measure of self-evaluated urgency. If a clear relation is found, incorporating DOW during telephone triage could aid the triage process, potentially increasing patient safety.

DESIGN

A convergent parallel mixed methods design with quantitative data; DOW and qualitative data from recorded telephone consultations. Thematic analysis of the qualitative data was used to explore the content of the quantitatively scaled DOW, using the Common-Sense Model of Self-Regulation (CSM).

SETTING

A convenience sampling of calls to the OOH services in Copenhagen, Denmark, during 3 days was included in the study.

PARTICIPANTS

Calls from adults (≥15 years of age) concerning somatic illness during the data collection period were eligible for inclusion. Calls made on behalf of another person, calls concerning perceived life-threatening illness or calls regarding logistical/practical problems were excluded, resulting in analysis of 180 calls.

RESULTS

All five components of the CSM framework, regardless of DOW, were present in the data. All callers referred to identity and timeline and were least likely to refer to consequence (37%). Through qualitative analysis, themes were defined. Callers with a strong identity, illness duration of less than 24 hours, clear cause and solution for cure/control seemed to present a lower DOW. Callers with a medium identity, illness duration of more than 24 hours and a high consequence seemed to present a higher DOW.

CONCLUSION

This study suggests a relation between a patient's illness representation and self-evaluation of urgency. Incorporating a patient's DOW during telephone triage could aid the triage process in determining urgency and type of healthcare needed, potentially increasing patient safety. Research on patient outcome after DOW-assisted triage is needed before implementation of the DOW scale is recommended.

Using music to reduce anxiety among older adults in the emergency department: a randomized pilot study

BACKGROUND

An emergency department (ED) visit may be distressing and anxiety-provoking for older adults (age > 65 years). No studies have specifically evaluated the effect of music listening on anxiety in older adults in the ED.

OBJECTIVE

The objective of this pilot study was to evaluate the effect of music listening on anxiety levels in older ED patients.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This was a randomized pilot study in the geriatric ED of an urban academic tertiary medical center. This was a sample of English-speaking adults (age > 65 years) who were not deaf (n = 35). Subjects consented to participate and were randomized to receive up to 60 min of music listening with routine care, while the control group received routine care with no music. Subjects in the music treatment group received headphones and an electronic tablet with pre-downloaded music, and were allowed to choose from 5 selections.

MAIN OUTCOME MEASURES

The primary outcome was change in anxiety levels, measured by the state-trait anxiety inventory (STAI), at enrollment and 1 h later.

RESULTS

A total of 35 participants were enrolled: 74% were female, 40% were white, and 40% were black; of these, 32 subjects completed the study protocol. When comparing control (n = 18) against intervention subjects (n = 17), there were no significant differences in enrollment STAI scores (43.00 ± 15.00 vs. 40.30 ± 12.80, P = 0.57). STAI scores 1 hour after enrollment (after the music intervention) were significantly reduced in the intervention subjects compared to the control subjects (with reduction of 10.00 ± 12.29 vs. 1.88 ± 7.97, P = 0.03).

CONCLUSION

These pilot results suggest that music listening may be an effective tool for reducing anxiety among older adults in the ED.

Adult Hippocampal Neurogenesis along the Dorsoventral Axis Contributes Differentially to Environmental Enrichment Combined with Voluntary Exercise in Alleviating Chronic Inflammatory Pain in Mice

Cognitive behavioral therapy, such as environmental enrichment combined with voluntary exercise (EE-VEx), is under active investigation as an adjunct to pharmaceutical treatment for chronic pain. However, the effectiveness and underlying mechanisms of EE-VEx remain unclear. In mice with intraplantar injection of complete Freund's adjuvant, our results revealed that EE-VEx alleviated perceptual, affective, and cognitive dimensions of chronic inflammatory pain. These effects of EE-VEx on chronic pain were contingent on the occurrence of adult neurogenesis in the dentate gyrus in a functionally dissociated manner along the dorsoventral axis: neurogenesis in the ventral dentate gyrus participated in alleviating perceptual and affective components of chronic pain by EE-VEx, whereas neurogenesis in the dorsal dentate gyrus was involved in EE-VEx's cognitive-enhancing effects. Chronic inflammatory pain was accompanied by decreased levels of brain-derived neurotrophic factor (BDNF) in the dentate gyrus, which were reversed by EE-VEx. Overexpression of BDNF in the dentate gyrus mimicked the effects of EE-VEx. Our results demonstrate distinct contribution of adult hippocampal neurogenesis along the dorsoventral axis to EE-VEx's beneficial effects on different dimensions of chronic pain.SIGNIFICANCE STATEMENT Environmental enrichment combined with voluntary exercise (EE-VEx) is under active investigation as an adjunct to pharmaceutical treatment for chronic pain, but its effectiveness and underlying mechanisms remain unclear. In a mouse model of inflammatory pain, the present study demonstrates that the beneficial effects of EE-VEx on chronic pain depend on adult neurogenesis with a dorsoventral dissociation along the hippocampal axis. Adult neurogenesis in the ventral dentate gyrus participates in alleviating perceptual and affective components of chronic pain by EE-VEx, whereas that in the dorsal pole is involved in EE-VEx's cognitive-enhancing effects in chronic pain.

Pain Catastrophizing, rather than Vital Signs, Associated with Pain Intensity in Patients Presenting to the Emergency Department for Pain

This study examined the relationships of self-reported pain intensity with vital signs, pain catastrophizing, and state anxiety in patients presenting to the emergency department (ED) for acute pain, exacerbations of chronic pain, or acute pain with concurrent chronic (combined) pain, comparing the pattern of relationships among these three pain groups. One hundred fifty-eight patients presenting to the ED for pain were recruited. Vital signs and self-reported pain intensity were obtained at triage, then participants completed self-report measures of pain catastrophizing, state anxiety, and demographic information. No significant associations were found between vital signs and pain intensity at triage in any of the pain groups. Pain catastrophizing was significantly associated with self-reported pain intensity in the acute pain group (r = .34, p < .05) and combined pain group (r = .30, p < .05), and state anxiety was significantly associated with self-reported pain intensity in with the acute pain group (r = .27, p < .05). When pain catastrophizing and state anxiety were used in a stepwise multiple regression analysis to predict self-reported pain intensity in the acute pain group, only pain catastrophizing emerged as a unique predictor (β = .405, p < .01). Consistent with previous research, vital signs were not associated with self-reported pain intensity in patients presenting to the ED for pain, including those with chronic pain. Given the significant association of pain catastrophizing and pain intensity among patients presenting to the ED for acute pain, brief measurement of pain catastrophizing may inform pain treatment in the ED.

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients' satisfaction of pain management

BACKGROUND

Pain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients' own experience regarding pain management in ED.

OBJECTIVE

The aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED.

METHOD

An observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire.

RESULTS

A total of 160 patients answered the questionnaire. In the pre- (n=80) and post-intervention (n=80) groups, 91/95% experienced pain in the ED. A significant difference (p<0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p<0.03) in patients' own reported pain intensity at discharge was found between the groups. Patients' reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly.

CONCLUSION

Patients' satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain.

IMPLICATION

According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients' satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients' satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.

Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study

Objective

To evaluate acceptability and clinical outcomes of acupuncture on patient-reported pain and anxiety in an emergency department (ED).

Design

Observational, retrospective pilot study.

Setting

Abbott Northwestern Hospital ED, Minneapolis, MN.

Methods

Retrospective data was used to identify patients receiving acupuncture in addition to standard medical care in the ED between 11/1/13 and 12/31/14. Feasibility was measured by quantifying the utilization of acupuncture in a novel setting and performing limited tests of its efficacy. Patient-reported pain and anxiety scores were collected by the acupuncturist using an 11-point (0-10) numeric rating scale before (pre) and immediately after (post) acupuncture. Efficacy outcomes were change in pain and anxiety scores.

Results

During the study period, 436 patients were referred for acupuncture, 279 of whom were approached by the acupuncturist during their ED visit. Consent for acupuncture was obtained from 89% (248/279). A total of 182 patients, who had a pre-pain score >0 and non-missing anxiety scores, were included in analyses. Of the 52% (94/182) who did not have analgesics before or during the acupuncture session, the average decrease of 2.37 points (95% CI: 1.92, 2.83) was not different (p > 0.05) than the mean decrease of 2.68 points for those receiving analgesics (95% CI 2.21, 3.15). The average pre-anxiety score was 4.73 points (SD = 3.43) and the mean decrease was 2.27 points (95% CI: 1.89, 2.66).

Conclusions

Results from this observational trial indicate that acupuncture was acceptable and effective for pain and anxiety reduction, in conjunction with standard medical care. These results will inform future randomized trials.

Patients Presenting to the Emergency Department with Acute Pain: The Significant Role of Pain Catastrophizing and State Anxiety

OBJECTIVE

Pain is one of the most common reasons for emergency department (ED) visits. Given the significant association of psychological variables and pain experience, it is critical to examine the relation of such factors with ED pain reports. This study sought to analyze the association of reported pain intensity in ED with pain catastrophizing and state anxiety.

METHODS

One hundred participants presenting with a primary complaint of acute pain in an urban ED completed the study. The measures included a demographic survey with questions pertaining to pain intensity, type and duration of present pain, the Pain Catastrophizing Scale (PCS), and the State-Trait Anxiety Inventory-State Subscale (STAI-S).

RESULTS

Pain intensity was significantly and positively associated with pain catastrophizing and state anxiety. Follow-up PROCESS mediation analysis revealed a significant indirect effect of pain catastrophizing on the relationship between state anxiety and pain intensity.

CONCLUSIONS

The results suggest that it is important to assess the psychological distress due to anxiety and pain catastrophizing of patients presenting to EDs with acute pain. Setting-appropriate brief behavioral interventions in conjunction with pharmacological interventions could improve outcomes.