Differences in acute pain perception between patients and physicians in the emergency department

Background

Pain is a subjective complaint that comprises a vast majority of emergency department (ED)1 visits. Owing to its subjectivity, pain reporting is prone to variations that could impact patient care. We aimed to determine the extent of differences in pain rating-scores between patients and their physicians in the ED and impact on patient satisfaction.

Methods

A prospective cross-sectional sample of eligible patients was recruited from two centers in Saudi Arabia. Pain scorings were performed using validated online questionnaires during patients' ED stay.

Results

Pain rating scores by physicians was lower than that by patients (6.3 ± 2.0 versus 7.0 ± 3.1, p = 0.004). Additionally, severe pain rating (8–10 rating) was given less frequently by physicians compared with that by patients (26.0% versus 48.1%, p = 0.004). Comparing the ratings by physicians with those by patients, underestimation was observed in 70.1%, overestimation in 16.9%, and matching rating in 13.0% cases. The most frequent analgesic medication administered was paracetamol (79.2%), followed by diclofenac (26.0%), morphine (10.4%), and ketorolac (9.1%). The medications were administered mainly intravenously (87.0%) and, to a lesser extent, intramuscularly (31.2%). Majority of patients (62.5%) reported not to have sufficient pain relief after treatment.

Conclusion

Most physicians tend to underestimate the level of pain perceived by their patients, which often leads to under-treatment and lower patient satisfaction. The present study revealed a significant difference in pain ratings between patients and physicians.

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There was a significant difference between patient and physician pain ratings

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Pain ratings by physicians were lower than those of patients

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Comparing the physicians' with patients' ratings, underestimation was 70.1%

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Comparing the physicians' with patients' ratings, overestimation was 16.9%,

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Comparing the physicians' with patients' ratings, matching rating was 13.0%.

Assessment of Acute Pain Management and Associated Factors among Emergency Surgical Patients in Gondar University Specialized Hospital Emergency Department, Northwest Ethiopia, 2018: Institutional Based Cross-Sectional Study

Background

Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients.

Patients and Methods

After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department.

Results

A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery.

Conclusion

The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice.

Pain and Pain Management in a Hong Kong Emergency Department

Background

The prevalence of pain is high in emergency departments (ED), according to previous studies. There is little information on the epidemiology of pain in Hong Kong EDs. This study aimed to explore the epidemiology of pain in a single academic ED in Hong Kong, and to evaluate the pain management policy in the ED.

Methods

Retrospective case review study with explicit record review of ED clinical records; records obtained by means of systematic sampling of a seven-consecutive-day period attendance. Data on the prevalence and location of pain, waiting time for drugs for pain relief, and pain drug prescription rates were obtained. Descriptive data analysis was performed.

Results

A total of 494 ED clinical records were reviewed. The prevalence of pain was 60.7% (300/494) during the study period. 72.3% (217/300) of patient attendances with pain had duration of pain not exceeding three days; 79.0% (237/300) of them were classified as ‘semi-urgent’ or ‘non-urgent’. 41.7% (125/300) of patients suffering from pain were given drugs for pain relief. The median time for patients to receive analgesic drugs was 56.0 (IQR 25.0-104.5) minutes after registration. Pain assessment using a numerical rating scale was positively associated with drug prescriptions for pain relief.

Conclusion

The prevalence of pain in ED patients was high, and comparable with the figures from studies in other EDs. Patients attending with pain had to wait more than 60 minutes for drugs for pain relief on average. (Hong Kong j.emerg.med. 2011;18:406-411)

Emergency Department Triage Nurse Initiated Pain Management

Objectives

1) To determine the time difference to analgesia administration for patients with painful limb conditions using an emergency triage nurse initiated pain management protocol versus analgesia administration by emergency doctors after consultation. 2) To determine the frequency of adverse events following such a protocol implementation.

Methods

For emergency department patients with isolated limb injury or inflammation, a triage nurse initiated pain management policy was implemented in 2004. The protocol did not require the triage nurse to consult a physician. The triage nurse would record the chief complaint, past medical history, allergy, medication, vital signs, and pain severity using a combination of 0 to 10 numerical and face pain scales. Unless contraindicated, the triage nurse would offer intramuscular ketorolac to patients with pain score ≥5. Medical charts of patients fulfilling the inclusion criteria were reviewed from 1 to 30 September 2004.

Results

Two hundred seventy-three patients were reviewed, of whom 73.3% were men and the overall mean age was 40.1 years (standard deviation SD 19.5). Two hundred and nine patients (76.6%) had pain score recorded at triage, and the median was 6. One hundred and five patients (38.5%) received analgesia, of which 69 were given by triage nurses and 36 by physicians. The mean time interval for analgesia given by triage nurse was 2.5 minutes (SD 8.9) and that for physician was significantly longer (p<0.0001) at 68.2 minutes (SD 59.5). There was no adverse drug reaction observed in patients who received intramuscular ketorolac given by triage nurses.

Conclusion

The time interval for pain relief of emergency department patients with painful limb conditions was reduced when the triage nurse initiated pain management.

Time to analgesia in an emergency department in Eastern Nepal

OBJECTIVES

Nepal is a least developed country, with limited healthcare resources. An 18 month Fellowship in Emergency Medicine has contributed some improvements to care. This study assessed time to first analgesia in higher and lower acuity patients.

METHODS

A prospective observational study of 101 patients in each of the Australasian Triage Scale (ATS) 2, 3 and 100 in ATS 4 was undertaken at B.P. Koirala Institute of Health Sciences. Convenience sampling was used coinciding with researcher's duty hours. Pain scores and time to analgesia were recorded.

RESULTS

A total of 302 patients were included. The doctors identified pain in 274 (90%, 95% confidence interval [CI] 86.74-93.65), severity recorded in 92 (30.5%, 95% CI 25-36). Median time from triage to analgesia was 30 min (interquartile range [IQR] 15-60) for ATS 2 patients, 60 min (IQR 40-70) for ATS 3 and 69 min (IQR 45-116) for ATS 4. Tramadol was the analgesic used most commonly (33%), followed by diclofenac (25%), morphine (16%), paracetamol (14%) and ketamine (2%). Analgesia was provided to 212 (70%, 95% CI 64.6-75.2), 65 (30.66%, 95% CI 24.5-37.3) with ATS 2, 85 (40%, 95% CI 33.4-47) with ATS 3 and 62 (29.2%, 95% CI 23.2-35.8) with ATS 4. A total of 44 patients (20.7%, 95% CI 15.5-26.8) with mild, 101 (47.6%, 95% CI 40.7-54.6) with moderate and 60 (28.3%, 95% CI 22.3-34.8) with severe pain received analgesics.

CONCLUSION

Time to analgesia for triage score 2 is lower compared to higher triage score. However, a large proportion of patients still do not receive analgesia. This is likely addressed by using a combination of strategies.