Assessment of pain management skills in emergency medicine residents: the role of a pain education program

Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription

Background

Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon.

Objective

This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED.

Methods

A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression.

Results

A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not.

Conclusion

This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

Pain Medicine Education in Emergency Medicine Residency Programs

Background Pain is a common complaint in the emergency department (ED), yet there is a lack of robust pain curricula in emergency medicine (EM) residency programs. In this study, we investigated pain education in EM residencies and various factors related to educational development. Methodology This was a prospective study collecting online survey results sent to Program Directors, Associate Program Directors, and Assistant Program Directors of EM residencies in the United States. Descriptive analyses with nonparametric tests were performed to investigate relationships between these factors, including educational hours, level of educational collaboration with pain medicine specialists, and multimodal therapy utilization. Results The overall individual response rate was 39.8% (252 out of 634 potential respondents), representing 164 out of 220 identified EM residencies with 110 (50%) Program Directors responding. Traditional classroom lectures were the most common modality for the delivery of pain medicine content. EM textbooks were the most common resource utilized for curriculum development. An average of 5.7 hours per year was devoted to pain education. Up to 46.8% of respondents reported poor or absent educational collaboration with pain medicine specialists. Greater collaboration levels were associated with greater hours devoted to pain education (p = 0.01), perceived resident interest in acute and chronic pain management education (p < 0.001), and resident utilization of regional anesthesia (p = <0.01). Faculty and resident interest in acute and chronic pain management education were similar to each other and high on the Likert scale, with higher scores correlating to greater hours devoted to pain education (p = 0.02 and 0.01, respectively). Faculty expertise in pain medicine was rated the most important factor in improving pain education in their programs. Conclusions Pain education is a necessity for residents to adequately treat pain in the ED, but remains challenging and undervalued. Faculty expertise was identified as a factor limiting pain education among EM residents. Collaboration with pain medicine specialists and recruitment of EM faculty with expertise in pain medicine are ways to improve pain education of EM residents.

A Systematic Review of Pain Management Education in Graduate Medical Education

BACKGROUND

Despite the importance of pain management across specialties and the effect of poor management on patients, many physicians are uncomfortable managing pain. This may be related, in part, to deficits in graduate medical education (GME).

OBJECTIVE

We sought to evaluate the methodological rigor of and summarize findings from literature on GME interventions targeting acute and chronic non-cancer pain management.

METHODS

We conducted a systematic review by searching PubMed, MedEdPORTAL, and ERIC (Education Resources Information Center) to identify studies published before March 2019 that had a focus on non-cancer pain management, majority of GME learners, defined educational intervention, and reported outcome. Quality of design was assessed with the Medical Education Research Study Quality Instrument (MERSQI) and Newcastle-Ottawa Scale-Education (NOS-E). One author summarized educational foci and methods.

RESULTS

The original search yielded 6149 studies; 26 met inclusion criteria. Mean MERSQI score was 11.6 (SD 2.29) of a maximum 18; mean NOS-E score was 2.60 (SD 1.22) out of 6. Most studies employed a single group, pretest-posttest design (n=16, 64%). Outcomes varied: 6 (24%) evaluated reactions (Kirkpatrick level 1), 12 (48%) evaluated learner knowledge (level 2), 5 (20%) evaluated behavior (level 3), and 2 (8%) evaluated patient outcomes (level 4). Interventions commonly focused on chronic pain (n=18, 69%) and employed traditional lectures (n=16, 62%) and case-based learning (n=14, 54%).

CONCLUSIONS

Pain management education research in GME largely evaluated chronic pain management interventions by assessing learner reactions or knowledge at single sites.

A prospective study to compare serial changes in pain scores for patients with and without a history of frequent ED utilization

Background

In the face of the opiate addiction epidemic, there is a paucity of research that evaluates limitations for our current pain rating methodologies for patient populations at risk for drug seeking behavior.

Objective

We hypothesized that VAS scores would be higher and show less serial improvement for patients with a history of frequent ED use.

Methods

This was a prospective, observational cohort study of a convenience sample of adult ED patients with chief complaint of pain. Initial VAS scores were recorded. Pain scores were subsequently updated 30–45 min after pain medication administration. ED frequenter defined as having >4 ED visits over a 1-year time period. Categorical data analyzed by chi-square; continuous data analyzed by t-tests. A multiple linear regression performed to control for confounding.

Results

125 patients were enrolled; 51% ED frequenters. ED frequenters were similar to non-ED frequenters with respect to gender, mean age, Hispanic race, educational level, chief complaint type, and initial pain medication narcotic. ED frequenters more likely to have higher initial VAS score (9.17+/-1.25 vs. 8.51+/-1.68; p = 0.01) and higher second VAS scores (7.48+/-2.56 vs. 5.00+/-3.28; p <0.001) and significantly lower mean change in first to second VAS scores (1.69+/-2.17 vs. 3.51+/-3.25; p <0.001). Within our multiple linear regression model, only ED frequenter group (p < 0.001) and private insurance status (0.04) were associated with differences in mean reduction in pain scores.

Conclusion

We found that ED frequenters had significantly less improvement between first and second VAS measurements.

Emergency Providers' Pain Management in Patients Transferred to Intensive Care Unit for Urgent Surgical Interventions

Introduction

Pain is the most common complaint for an emergency department (ED) visit, but ED pain management is poor. Reasons for poor pain management include providers’ concerns for drug-seeking behaviors and perceptions of patients’ complaints. Patients who had objective findings of long bone fractures were more likely to receive pain medication than those who did not, despite pain complaints. We hypothesized that patients who were interhospital-transferred from an ED to an intensive care unit (ICU) for urgent surgical interventions would display objective pathology for pain and thus receive adequate pain management at ED departure.

Methods

This was a retrospective study at a single, quaternary referral, academic medical center. We included non-trauma adult ED patients who were interhospital-transferred and underwent operative interventions within 12 hours of ICU arrival between July 2013 and June 2014. Patients who had incomplete ED records, required invasive mechanical ventilation, or had no pain throughout their ED stay were excluded. Primary outcome was the percentage of patients at ED departure achieving adequate pain control of ≤ 50% of triage level. We performed multivariable logistic regression to assess association between demographic and clinical variables with inadequate pain control.

Results

We included 112 patients from 39 different EDs who met inclusion criteria. Mean pain score at triage and ED departure was 8 (standard deviation 8 and 5 [3]), respectively. Median of total morphine equivalent unit (MEU) was 7.5 [5–13] and MEU/kg total body weight (TBW) was 0.09 [0.05–0.16] MEU/kg, with median number of pain medication administration of 2 [1–3] doses. Time interval from triage to first narcotic dose was 61 (35–177) minutes. Overall, only 38% of patients achieved adequate pain control. Among different variables, only total MEU/kg was associated with significant lower risk of inadequate pain control at ED departure (adjusted odds ratio = 0.22; 95% confidence interval = 0.05–0.92, p = 0.037).

Conclusion

Pain control among a group of interhospital-transferred patients requiring urgent operative interventions, was inadequate. Neither demographic nor clinical factors, except MEU/kg TBW, were shown to associate with poor pain management at ED departure. Emergency providers should consider more effective strategies, such as multimodal analgesia, to improve pain management in this group of patients.

Postoperative surgical trainee opioid prescribing practices (POST OPP): an institutional study

BACKGROUND

Increasing mortality from opioid overdoses has prompted increased focus on prescribing practices of physicians. Unfortunately, resident physicians rarely receive formal education in effective opioid prescribing practices or postoperative pain management. Data to inform surgical training programs regarding the utility and feasibility of formal training are lacking.

METHODS

Following Institutional Review Board approval, a single institution's resident physicians who had completed at least one surgical rotation were surveyed to assess knowledge of pain management and evaluate opioid prescribing practices.

RESULTS

Fifty-three respondents (68% males and 32% females) completed the survey. Most respondents denied receiving formal instruction in opioid pain medication prescribing practices during either medical school (62.3%) or residency (56.6%); however, nearly all respondents stated they were aware of the side effects of opioid pain medications, and a majority felt confident in their knowledge of opioid pharmacokinetics and pharmacodynamics. Of the respondents, 47% either "agreed" or "strongly agreed" that they prescribed more opioid medications than necessary to patients being discharged following a surgical procedure. Individual case scenario responses demonstrated variability in the number of morphine milligram equivalents prescribed across scenarios (P < 0.001). Male and nonsurgical specialty respondents reported prescribing significantly fewer overall morphine milligram equivalents in these scenarios.

CONCLUSIONS

This pilot study shows wide variability in opioid prescribing practices and attitudes toward pain management among surgical trainees, illustrating the potential utility of formal education in pain management and effective prescribing of these medications. A broader assessment of surgical trainees' knowledge and perception of opioid prescribing practices is warranted to facilitate the development of such a program.

Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents

OBJECTIVE

Opioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience.

DESIGN

Anonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription.

SETTING

Accreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital.

PARTICIPANTS

Categorical and preliminary general surgery residents of all postgraduate years.

RESULTS

The percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription.

CONCLUSION AND RELEVANCE

Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.

The lack of analgesic use (oligoanalgesia) in small animal practice

Oligoanalgesia is defined as failure to provide analgesia in patients with acute pain. Treatment of pain in emergencies, critical care and perioperatively may influence patient outcomes: the harmful practice of withholding analgesics occurs in teaching hospitals and private practices and results in severe physiological consequences. This article discusses the prevalence, primary causes, species and regional differences and ways to avoid oligoanalgesia in small animal practice. Oligoanalgesia may be addressed by improving education on pain management in the veterinary curriculum, providing continuing education to veterinarians and implementing pain scales.

Acute pain in the emergency department: Effect of an educational intervention

BACKGROUND AND AIMS

Pain management is often inadequate in emergency departments (ED) despite the availability of effective analgesics. Interventions to change professional behavior may therefore help to improve the management of pain within the ED. We hypothesized that a 2-h educational intervention combining e-learning and simulation would result in improved pain treatment of ED patients with pain.

METHODS

Data were collected at the ED of Horsens Regional Hospital during a 3-week study period in March 2015. Pain intensity (NRS, 0-10) and analgesic administration were recorded 24h a day for all patients who were admitted to the ED during the first and third study weeks. Fifty-three ED nurses and 14 ED residents participated in the educational intervention, which took place in the second study week.

RESULTS

In total, 247 of 796 patients had pain >3 on the NRS at the admission to the ED and were included in the data analysis. The theoretical knowledge of pain management among nurses and residents increased as assessed by a multiple choice test performed before and after the educational intervention (P=0.001), but no change in clinical practice could be observed: The administration for analgesics [OR: 1.79 (0.97-3.33)] and for opioids [2.02 (0.79-5.18)] were similar before and after the educational intervention, as was the rate of clinically meaningful pain reduction (NRS >2) during the ED stay [OR: 0.81 (CI 0.45-1.44)].

CONCLUSIONS

Conduction of a 2-h educational intervention combining interactive case-based e-learning with simulation-based training in an ED setting was feasible with a high participation rate of nurses and residents. Their knowledge of pain management increased after completion of the program, but transfer of the new knowledge into clinical practice could not be found. Future research should explore the effects of repeated education of healthcare providers on pain management.

IMPLICATIONS

It is essential for nurses and residents in emergency departments to have the basic theoretical and practical skills to treat acute pain properly. A modern approach including e-learning and simulation lead to increased knowledge of acute pain management. Further studies are needed to show how this increased knowledge is transferred into clinical practice.

Assessment of Patient Pain in the Postoperative Context

Because of its subjective nature, the assessment of pain requires the use of comprehensive practices that accurately reflect a patient’s experiences of pain. The purpose of this study was to determine how nurses make decisions in their assessment of patients’ pain in the postoperative clinical setting. An observational design was chosen as the means of examining pain activities in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were selected. Each 2-hour observation period was examined 12 times thus resulting in 74 observations. In total, 316 pain activities were determined. Five themes relating to assessment were identified from the data analysis: simple questioning, use of a pain scale, complex assessment, the lack of pain assessment, and physical examination for pain. The study identified how nurses’ prioritization of work demands created barriers in conducting timely and comprehensive pain assessment decisions.

Consensus-Based Recommendations for an Emergency Medicine Pain Management Curriculum

BACKGROUND

Increased prescribing of opioid pain medications has paralleled the subsequent rise of prescription medication-related overdoses and deaths. We sought to define key aspects of a pain management curriculum for emergency medicine (EM) residents that achieve the balance between adequate pain control, limiting side effects, and not contributing to the current public health opioid crisis.

METHODS

We convened a symposium to discuss pain management education in EM and define the needs and objectives of an EM-specific pain management curriculum. Multiple pertinent topics were identified a priori and presented before consensus work. Subgroups then sought to define perceived gaps and needs, to set a future direction for development of a focused curriculum, and to prioritize the research needed to evaluate and measure the impact of a new curriculum.

RESULTS

The group determined that an EM pain management curriculum should include education on both opioid and nonopioid analgesics as well as nonpharmacologic pain strategies. A broad survey is needed to better define current knowledge gaps and needs. To optimize the impact of any curriculum, a modular, multimodal, and primarily case-based approach linked to achieving milestones is best. Subsequent research should focus on the impact of curricular reform on learner knowledge and patient outcomes, not just prescribing changes.

CONCLUSIONS

This consensus group offers a path forward to enhance the evidence, knowledge, and practice transformation needed to improve emergency analgesia.

An interventional study to improve the quality of analgesia in the emergency department

Objective:

We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention.

Methods:

We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol.

Results:

Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%–68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively).

Conclusion:

Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.

Model determination of delayed causes of analgesics prescription in the emergency ward in arak, iran

Background

According to the reports of the World Health Organization 20% of world population suffer from pain and 33% of them suffer to some extent that they cannot live independently.

Methods

This is a cross-sectional study which was conducted in the emergency department (ED) of Valiasr Hospital of Arak, Iran, in order to determine the causes of delay in prescription of analgesics and to construct a model for prediction of circumstances that aggravate oligoanalgesia. Data were collected during a period of 7 days.

Results

Totally, 952 patients participated in this study. In order to reduce their pain intensity, 392 patients (42%) were treated. Physicians and nurses recorded the intensity of pain for 66.3% and 41.37% of patients, respectively. The mean (SD) of pain intensity according to visual analogue scale (VAS) was 8.7 (1.5) which reached to 4.4 (2.3) thirty minutes after analgesics prescription. Median and mean (SD) of delay time in injection of analgesics after the physician's order were 60.0 and 45.6 (63.35) minutes, respectively. The linear regression model suggested that when the attending physician was male or intern and patient was from rural areas the delay was longer.

Conclusions

We propose further studies about analgesics administration based on medical guidelines in the shortest possible time and also to train physicians and nurses about pain assessment methods and analgesic prescription.

Pain after earthquake

INTRODUCTION

On 6 April 2009, at 03:32 local time, an Mw 6.3 earthquake hit the Abruzzi region of central Italy causing widespread damage in the City of L Aquila and its nearby villages. The earthquake caused 308 casualties and over 1,500 injuries, displaced more than 25,000 people and induced significant damage to more than 10,000 buildings in the L'Aquila region.

OBJECTIVES

This observational retrospective study evaluated the prevalence and drug treatment of pain in the five weeks following the L'Aquila earthquake (April 6, 2009).

METHODS

958 triage documents were analysed for patients pain severity, pain type, and treatment efficacy.

RESULTS

A third of pain patients reported pain with a prevalence of 34.6%. More than half of pain patients reported severe pain (58.8%). Analgesic agents were limited to available drugs: anti-inflammatory agents, paracetamol, and weak opioids. Reduction in verbal numerical pain scores within the first 24 hours after treatment was achieved with the medications at hand. Pain prevalence and characterization exhibited a biphasic pattern with acute pain syndromes owing to trauma occurring in the first 15 days after the earthquake; traumatic pain then decreased and re-surged at around week five, owing to rebuilding efforts. In the second through fourth week, reports of pain occurred mainly owing to relapses of chronic conditions.

CONCLUSIONS

This study indicates that pain is prevalent during natural disasters, may exhibit a discernible pattern over the weeks following the event, and current drug treatments in this region may be adequate for emergency situations.

Acute pain management curriculum for emergency medicine residency programs

Pain is the most common reason people visit emergency departments (EDs); this implies that emergency physicians (EPs) should be experts in managing acute painful conditions. The current trend in the literature, however, demonstrates that EPs possess inadequate knowledge and lack formal training in acute pain management. The purpose of this article is to create a formal educational curriculum that would assist emergency medicine (EM) residents in proper assessment and treatment of acute pain, as well as in providing a solid theoretical and practical knowledge base for managing acute pain in the ED. The authors propose a series of lectures, case-oriented study groups, practical small group sessions, and class-specific didactics with the goal of enhancing the theoretical and practical knowledge of acute pain management in the ED.

Mandatory pain scoring at triage reduces time to analgesia

STUDY OBJECTIVE

We study whether mandatory triage pain scoring and an educational program reduces the time to initial analgesic treatment.

METHODS

We performed a prospective interventional study in the emergency department (ED) of an adult tertiary referral hospital and major trauma center. After an observational assessment of baseline time to analgesic administration, we mandated the recording of triage pain scores through our computerized information system. In a second separate phase, we administered a staff educational package on the importance of timely analgesia. We measured time to initial analgesia after each phase and at 12-month follow-up.

RESULTS

We studied 35,628 patients (8,743 baseline, 8,462 after mandating pain scoring, 9,043 after the educational program, and 9,380 at follow-up), with 12,925 patients (36.3%) overall receiving analgesics. At baseline, the median time to analgesia was 123 minutes (interquartile range [IQR] 58 to 231 minutes), which reduced with pain scoring (95 minutes; IQR 45 to 194 minutes) but no further with the educational package (98 minutes; IQR 45 to 191 minutes). At 12-month follow-up, the median time to analgesia was 78 minutes (IQR 45 to 143 minutes), 45 minutes (36.4%) faster than at baseline.

CONCLUSION

The simple act of altering our ED computerized information system to require pain scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at 12 months.

Assessment and management of acute pain in adult medical inpatients: a systematic review

OBJECTIVE

To review the literature addressing effective care for acute pain in inpatients on medical wards.

METHODS

We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions.

RESULTS

We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion.

CONCLUSIONS

Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.

No relief in sight: postgraduate training in pain management

This study investigated training in pain management in postgraduate medical education programs. A mail survey of program directors was conducted, evaluating the format of training in pain management and the self-assessed adequacy of the training. The response rate was 70%, with 188 total respondents. It included all programs in a large Midwestern state, representing most specialties. Just over half of all programs offered any formal training in pain management, and even fewer required it. Less than one quarter required a clinical component to such training. Nonetheless, an overwhelming majority of program directors (85%) rated their training as adequate or excellent. Improvements are clearly needed in postgraduate training in pain management, and external incentives, such as requirements in the accreditation process, will be needed.

Emergency management of chronic pain and drug-seeking behavior: an alternate perspective

Pain is one of the most prevalent conditions treated by Emergency Physicians, although it remains contested how to interpret, measure, and treat this condition. In particular, there is controversy over how to identify and treat patients with chronic under-treated pain and those who are potentially malingering (drug-seeking). This article discusses currently accepted paradigms for treating potentially malingering patients, difficulties some communities may have when these paradigms are applied, and the results of implementing pain treatment guidelines that limit opioid use. Systematically limiting opioids via these guidelines was not associated with a decrease in overall patient satisfaction, patient satisfaction with pain management, overall volume, or volume of patients with potential drug-seeking diagnoses. Emergency Physicians' perception of quality of care delivered, as well as job satisfaction, increased after implementation of the guidelines.

Oligoanalgesia in the emergency department: short-term beneficial effects of an education program on acute pain

STUDY OBJECTIVE

Acute pain is the most frequent complaint in emergency department (ED) admissions, but its management is often neglected, placing patients at risk of oligoanalgesia. We evaluate the effect of the implementation of guidelines for pain management in ED patients with pain at admission or anytime during their stay in our ED.

METHODS

This prospective pre-post intervention cohort study included data collection both before and after guideline implementation. Consecutive adult patients admitted with acute pain from any cause or with pain at any time after admission were enrolled. The quality of pain management was evaluated according to information in the ED medical records by using a standardized collection form, and its impact on patients was recorded with a questionnaire at discharge.

RESULTS

Two hundred forty-nine and 192 patients were included during pre- and postintervention periods. Pain was documented in 61% and 76% of nurse and physician notes, respectively, versus 78% and 85% after the intervention (difference 17%/9%; 95% confidence interval [CI] 8% to 26%/2% to 17%, respectively). Administration of analgesia increased from 40% to 63% (difference 23%; 95% CI 13% to 32%) and of morphine from 10% to 27% (difference 17%; 95% CI 10% to 24%). Mean doses of intravenous morphine increased from 2.4 mg (95% CI 1.9 to 2.9 mg) to 4.6 mg (95% CI 3.9 to 5.3 mg); administration of nonsteroidal antiinflammatory drugs and acetaminophen increased as well. There was a greater reduction of visual analogue scale score after intervention: 2.1 cm (95% CI 1.7 to 2.4 cm) versus 2.9 cm (95% CI 2.5 to 3.3 cm), which was associated with improved patient satisfaction.

CONCLUSION

Education program and guidelines implementation for pain management lead to improved pain management, analgesia, and patient satisfaction in the ED.

Pain in an emergency department: an audit

OBJECTIVE

To evaluate the quality of care in patients with pain who visit the emergency department of a university hospital and the evolution of their pain during their emergency department stay.

METHODS

A cross-sectional survey was performed using two valid scales (a numerical descriptor scale or a verbal pain intensity scale), and a structured questionnaire to patients and use of patient charts to collect information on pain intensity on arrival and before discharge, characteristics of pain and of its management.

RESULTS

In the 726 participating patients, median age was 37 years (range: 18-97), and 54% of the patients were men. Upon arrival, 563 patients presented with pain (78%), rated > or =7 in 35% of the 390 patients evaluated using numerical descriptor scale. Forty-four percent had taken analgesics before arrival. Their median waiting time before initial medical examination was 30 min. Pain was identified by triage nurses (70%) or by physicians (77%) and was rated by nurses (23%) and physicians (11%). Forty-seven percent also experienced pain during care and 27% received analgesics during their stay. Pain intensity remained unchanged in 70% of patients, increased in 7% and decreased in 23%. Of the 480 patients with pain on arrival evaluated before discharge, 395 (82%) patients were unrelieved before going home, rated > or =7 in 32% of the 390 patients evaluated using numerical descriptor scale. Analgesics were ordered before leaving the emergency department in 81%.

CONCLUSION

Even if pain has been identified, its assessment and management remains inadequate. The quality of care may be improved by educating the personnel in developing protocols and in evaluating pain management.

The impact of educational intervention programs on pain management in a pediatric emergency department

Management of pain and anxiety is an important part of patient care in the pediatric emergency department (ED). Even though it has improved significantly over the past few years, it is still suboptimal. The objective of this study was to evaluate the effect of informal and formal education on pain and anxiety management in the pediatric ED. Management of pain and anxiety was assessed by comparing the use of analgesics and sedatives during three phases: A) year 2000 (baseline), B) years 2001-2002 (informal teaching) and C) year 2004 (following a structured simulation-based training in pediatric sedation and analgesia). During period B there was a significant increase in the yearly use of eutectic mixture of local anesthetics (EMLA) (RR=2.63, CI 1.23-5.6), ibuprofen (RR=14.16, CI 8.73-22.98), midazolam (RR=1.68, CI 1.39-2.03) and nitrous oxide (N2O) in comparison with period A, with an additional increment of the first three medicines during period C. There was no change in the use of ketamine, morphine and meperidine during period B. Whereas, during period C, a significant increase in the use of ketamine and morphine was demonstrated (RR=24.56, CI 10.71-56.3 and RR=3.07, CI 2.12-4.44, respectively), while the use of meperidine (RR=0.68, CI 0.49-0.94) and N2O (RR=0.46, 95% CI 0.32-0.67) declined significantly. Educational interventions have a clear impact on pain and anxiety management demonstrated by the subsequent change in the use of sedatives and analgesics and should be provided to pediatric ED physicians. Informal teaching affected mainly the use of milder sedatives and analgesics, while formal structured training influenced the use of opioids and dissociative agents.

Characteristics of pain and response to analgesic treatment in dogs and cats examined at a veterinary teaching hospital emergency service

OBJECTIVE

To estimate the prevalence and characteristics of pain in dogs and cats examined by an emergency service at a veterinary teaching hospital and evaluate the response of dogs and cats with signs of pain to analgesic treatment.

DESIGN

Cross-sectional study.

ANIMALS

317 dogs and 112 cats.

PROCEDURE

A questionnaire was used to categorize the characteristics of pain. The location, cause, and signs of pain were determined by obtaining a thorough history and conducting a physical examination. Pain was categorized by type (superficial somatic, deep somatic, or visceral), mechanism (inflammatory, neuropathic, or both), severity (mild, moderate, or severe), and duration. Evidence for primary or secondary hypersensitivity and hyposensitivity to manipulation was determined. The response to single or multiple analgesic drug administration was assessed.

RESULTS

179 (56%) dogs and 60 (54%) cats had signs of pain. In most of these dogs and cats, pain was classified as acute (< 24 hours' duration) and of moderate severity and was associated with primary hypersensitivity. Most dogs had deep somatic pain; most cats had visceral pain. Inflammation was the most common mechanism. One hundred nineteen (66%) dogs and 41 (68%) cats were treated with analgesic drugs. Analgesic treatment was considered effective in 73 (61%) dogs and 31 (76%) cats.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that moderate to severe acute somatic pain caused by inflammation is common in dogs and cats examined by an emergency service and that a combination of multiple analgesic drugs is more effective than any single analgesic drug in the treatment of pain in these dogs and cats.

Douleur aiguë de l’enfant dans l’aide médicale d’urgence

OBJECTIVES

To assess the knowledge and skills of physicians staffing mobile intensive care units (emergency ambulances) in the management of severe acute pain in children.

METHODS

Questionnaire-based telephone interviews with emergency physicians of all urban emergency ambulance services (n=360). This questionnaire covered knowledge of procedures for assessment of pain, definition of severe acute pain and its, treatment, availability of morphine and similar drugs, local guidelines and the physicians' opinion of the national guidelines.

RESULTS

Physicians from all but one ambulance service responded. Forty-nine percent were unaware of the French Society of Anesthesiology and Intensive Care guidelines, and 63% had no local guidelines. Eight percent defined severe acute pain correctly and 10% defined the therapeutic objective correctly. Forty-seven percent used morphine (which was available for 93%), and 7% and 13% respectively followed guidelines about doses and waiting periods between administrations.

CONCLUSION

This survey showed inadequate knowledge about the management (assessment and treatment) of severe acute pain in children in prehospital emergency settings. Training in this area is essential.

Teaching Behavioral Pain Management to Healthcare Professionals: A Systematic Review of Research in Training Programs

Pain is a common and potentially debilitating condition. Whereas there is vast literature on developmentally appropriate behavioral techniques for pain management, results of curriculum evaluations and knowledge surveys reveal a dearth of awareness of these strategies in healthcare professionals. As a result, the development and evaluation of pain management training programs are important endeavors. Results of studies evaluating such programs are promising and suggest that training might be an effective means of impacting healthcare professionals' knowledge, attitudes, and even patient care. These results must be interpreted with caution, however, because the literature contains several conceptual and methodologic limitations. These limitations, in combination with the wide diversity in program components, format of delivery, and research methods, preclude definitive conclusions on the most practical and effective means to provide training. To address this question, further systematic work on the development and evaluation of pain management training programs is warranted.

PERSPECTIVE

To address the problems of dissemination of behavioral pain management techniques, the development and evaluation of pain management training programs are important endeavors. The current article presents a systematic review of studies evaluating such programs and provides recommendations for future systematic work in this area.

Changing attitudes about pain and pain control in emergency medicine

Oligoanalgesia continues to be a large problem in the ED. An attitude of suspicion, a culture of ignoring the problem, and an environment that is not conducive to change in practice combine to present formidable obstacles for effective pain management in the emergency setting. Overcoming these obstacles for effective analgesia in the ED is not beyond the capabilities of the individual ED, the emergency physician, or the specialty of emergency medicine. Changing the attitudes of emergency medical providers about pain assessment and management will require attention in several areas of research, education and training. Oligoanalgesia remains a global problem within emergency medicine; however, this awareness is often not felt to be present "in my ED." Individual ownership of the problem may contribute to improvements in pain control. The last 15 years have seen a substantial increase in ED research focused on pain and pain management. Continued research efforts and focused clinical application of these efforts are still required. A better understanding of patient needs and expectations for pain relief, as well as continued efforts at patient education regarding pain, will also improve our treatment of pain in the ED. Recognition by providers of the ethnic, cultural, and gender differences in the expression, reporting, and expectations for treatment of pain should also continue to be a priority in changing attitudes toward pain and pain control. These goals must be realistic within the chaotic and unpredictable environment that defines emergency medicine. Practical and time-sensitive approaches to pain and pain management will continue to bea challenge to enact and enforce in our EDs. The stigma of opioids, in combination with the transient nature of the emergency physician/patient relationship, may be the largest hurdles to overcome for effective pain management not only in the ED, but also following ED discharge. Improvement in provider education of the realities, myths, and misunderstandings of opioid management may provide insight into this problem. The consequences of oligoanalgesia in the ED are not insignificant. To improve our treatment of pain in the ED, a fundamental change in attitude toward pain and the control of pain is required. This is unlikely to occur until pain is adequately addressed and treated appropriately as a true emergency.

Mandated pain scales improve frequency of ED analgesic administration

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

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.

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.

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).

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.

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

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

National analgesia prescribing patterns in emergency department patients with burns

Previous studies suggest that many patients with burns receive inadequate analgesia. A secondary analysis of the 1992 to 1999 National Hospital Ambulatory Medical Care Survey (a national, weighted sample of emergency department [ED] encounters) was performed to estimate national analgesia prescribing patterns in ED patients with burns. In 1999, there were 21,103 patient encounters sampled from 376 EDs, resulting in an estimated 102.8 million ED visits in 1999. One hundred thirty-eight patients in the sample (0.7%) had burns for an estimated 827,000 annual burns. Patient mean age was 28 years. Forty-three percent were female, 25% were children under 18 years of age, and 81% were white. Pain assessments were performed in about half of the patients, and only half of the patients received analgesics. Analgesia administration did not differ by year, sex, age, race, ethnicity, geographic location, or insurance payment type, yet it was more likely with increased pain. We conclude that many patients with burns do not have documentation of pain assessment or analgesia administration while in the ED.

Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication

OBJECTIVE

To evaluate the effect of a new protocol allowing paramedics to administer morphine without a physician order to patients with extremity trauma with respect to time of morphine administration, scene time, morphine amount and number of doses per patient, and proportion of patients receiving morphine.

METHODS

Data were abstracted from transport forms for a ten-month period prior to the implementation of the new protocol and for nine months after implementation. Data elements included patient age and sex, date, time of EMS arrival on scene, amount and number of morphine doses, and total number of patients transported.

RESULTS

Implementation of the new protocol was associated with a decrease in time between emergency medical services (EMS) arrival on scene and administration of the first dose of morphine from 18.8 to 16.7 minutes, a difference of 2.1 minutes [95% confidence interval (95%CI) 1.3, 2.9]. The proportion of patients receiving analgesia at the scene, rather than during transport, increased from 62.7% before the protocol change to 69.5% after, an increase of 6.8% (95% CI 2.7, 11.0). Transports before and after implementation of the new protocol did not differ with respect to patient sex, age, or chief complaint; number of morphine doses or total morphine administered per patient; or proportion of prehospital patients receiving morphine.

CONCLUSIONS

A change in protocol that permits trained paramedics to administer morphine without physician approval reduces time to analgesia administration without influencing the amount of morphine delivered per patient or the rate of prehospital morphine use. Further study should measure the effect on base hospital physician interruptions and patient outcome.

Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?

BACKGROUND

Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices.

DESIGN

Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars.

MEASUREMENTS

Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs).

MAIN RESULTS

The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline.

CONCLUSIONS

This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.

Pain relief in major trauma patients: an Israeli perspective

BACKGROUND

The pain of major trauma patients remains often unrelieved while in the emergency department. Our objective was to examine pain management in several trauma units, and to evaluate the impact of implementation of a trauma pain management protocol.

METHODS

Current status was evaluated from questionnaires filled by trauma unit personnel of nine medical centers. In one, a pain management protocol was introduced. Staff and patients evaluated pain management before and after the protocol was instituted.

RESULTS

About 80% of staff respondents from various centers were not aware of guidelines for pain management in trauma. The belief that pain assists diagnosis was the main reason (78.6%) for withholding analgesia. Large variability existed on what contraindicates analgesia, with the majority withholding analgesia in abdominal and multiple injuries. When administered, analgesia was delayed, and most commonly intramuscular meperidine was given. After the protocol's implementation, the personnel's awareness of analgesia increased, and consequently it was administered earlier and to more patients, mostly as intravenous morphine. Patients appreciated the timely analgesia (38% after vs. 14% before, p = 0.01), with fewer receiving none. Analgesia was considered beneficial by more patients (70% after vs. 23% before, p < 0.001), and enhanced cooperativity with personnel (p < 0.001). This was reflected in increased overall satisfaction with pain relief during the entire hospitalization.

CONCLUSION

The importance of pain management protocols in major trauma was demonstrated by the response of personnel and patients.

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.