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Burgess L, Theobald K, Kynoch K, Keogh S. Implementing Evidence-Based Pain Management Interventions Into an Emergency Department: Outcomes Guided by Use of the Ottawa Model of Research Use. J Adv Nurs 2024. [PMID: 39379283 DOI: 10.1111/jan.16457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 08/14/2024] [Accepted: 09/01/2024] [Indexed: 10/10/2024]
Abstract
AIM To implement strategies to improve the care of patients with acute pain in the emergency department (ED). DESIGN Pre-post implementation study using a Type 2 hybrid effectiveness-implementation design. METHODS Implementation strategies were introduced and monitored through the Ottawa Model of Research Uses' assessment, monitoring and evaluation cycles, supported by focused and sustained facilitation. RESULTS Improvements in time-to-analgesia within 30 min (21%-27%), administration of nurse-initiated analgesia (NIA) (17%-27%) and measurement of pain (65%-75%) were achieved post-implementation. NIA was the strongest predictor of receiving analgesia within 30 min. Adoption of pain interventions into practice was not immediate yet responded to sustained facilitation of implementation strategies. CONCLUSION Collaboration with local clinicians to introduce simple interventions that did not disrupt workflow or substantially add to workload were effective in improving analgesia administration rates, and the proportion of patients receiving analgesia within 30 min. The assessment, monitoring and evaluation cycles enabled agile and responsive facilitation of implementation activities within the dynamic ED environment. Improvements took time to embed into practice, trending upward over the course of the implementation period, supporting the sustained facilitation approach throughout the study. IMPLICATIONS Sustained adoption of evidence-based pain interventions into the care of people presenting to the ED with acute pain can be achieved through sustained facilitation of implementation. NIA should be at the centre of acute pain management in the ED. IMPACT This study addressed the lingering gap between evidence and practice for patients with acute pain in the ED. Implementation of locally relevant/informed implementation strategies supported by focused and sustained facilitation improved the care of patients with acute pain in the ED. This research will have an impact on people presenting to EDs with acute pain, and on clinicians treating people with acute pain in the ED. Relevant equator guidelines were followed and the StaRI reporting method used. PATIENT OR PUBLIC CONTRIBUTION No Patient or Public Contribution in this study.
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Affiliation(s)
- Luke Burgess
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
- Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Karen Theobald
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
| | - Kathryn Kynoch
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
- Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Samantha Keogh
- QUT School of Nursing and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
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Crisman E, Appenzeller-Herzog C, Tabakovic S, Nickel CH, Minotti B. Multidimensional versus unidimensional pain scales for the assessment of analgesic requirement in the emergency department: a systematic review. Intern Emerg Med 2024; 19:1463-1471. [PMID: 38664325 PMCID: PMC11364591 DOI: 10.1007/s11739-024-03608-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/07/2024] [Indexed: 08/31/2024]
Abstract
Pain is a multidimensional experience, potentially rendering unidimensional pain scales inappropriate for assessment. Prior research highlighted their inadequacy as reliable indicators of analgesic requirement. This systematic review aimed to compare multidimensional with unidimensional pain scales in assessing analgesic requirements in the emergency department (ED). Embase, Medline, CINAHL, and PubMed Central were searched to identify ED studies utilizing both unidimensional and multidimensional pain scales. Primary outcome was desire for analgesia. Secondary outcomes were amount of administered analgesia and patient satisfaction. Two independent reviewers screened, assessed quality, and extracted data of eligible studies. We assessed risk of bias with the ROBINS-I tool and provide a descriptive summary. Out of 845 publications, none met primary outcome criteria. Three studies analyzed secondary outcomes. One study compared the multidimensional Defense and Veterans Pain Rating Scale (DVPRS) to the unidimensional Numerical Rating Scale (NRS) for opioid administration. DVPRS identified more patients with moderate instead of severe pain compared to the NRS. Therefore, the DVPRS might lead to a potential reduction in opioid administration for individuals who do not require it. Two studies assessing patient satisfaction favored the short forms (SF) of the Brief Pain Inventory (BPI) and McGill Pain Questionnaire (MPQ) over the Visual Analogue Scale (VAS) and the NRS. Limited heterogenous literature suggests that in the ED, a multidimensional pain scale (DVPRS), may better discriminate moderate and severe pain compared to a unidimensional pain scale (NRS). This potentially impacts analgesia, particularly when analgesic interventions rely on pain scores. Patients might prefer multidimensional pain scales (BPI-SF, MPQ-SF) over NRS or VAS for assessing their pain experience.
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Affiliation(s)
- Elena Crisman
- Department of Internal Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | | | | | - Christian Hans Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bruno Minotti
- Emergency Department, University Hospital Basel, Basel, Switzerland.
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Lvovschi VE, Carrouel F, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription. Front Public Health 2024; 12:1352833. [PMID: 38454991 PMCID: PMC10918692 DOI: 10.3389/fpubh.2024.1352833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
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.
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Affiliation(s)
- Virginie E. Lvovschi
- Emergency Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- Laboratory “Research on Healthcare Performance” (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Florence Carrouel
- Laboratory “Health, Systemic, Process” (P2S), UR4129, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Karl Hermann
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
| | - Frédéric Lapostolle
- SAMU 93, UF Research and Teaching quality, Avicenne Hospital-APHP, Bobigny, France
- INSERM U942, Sorbonne Paris Cité, Paris 13 University, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, Rouen, France
| | - Marie-Pierre Tavolacci
- Rouen University Hospital, CIC-CRB 1404, Rouen, France
- Univ Rouen Normandie, UMR1073 ADEN, Rouen, France
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Ku NW, Cheng MT, Liew CQ, Chen YC, Sung CW, Ko CH, Lu TC, Huang CH, Tsai CL. Prospective study of pain and patient outcomes in the emergency department: a tale of two pain assessment methods. Scand J Trauma Resusc Emerg Med 2023; 31:56. [PMID: 37872561 PMCID: PMC10594810 DOI: 10.1186/s13049-023-01130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/12/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Accurate pain assessment is essential in the emergency department (ED) triage process. Overestimation of pain intensity, however, can lead to unnecessary overtriage. The study aimed to investigate the influence of pain on patient outcomes and how pain intensity modulates the triage's predictive capabilities on these outcomes. METHODS A prospective observational cohort study was conducted at a tertiary care hospital, enrolling adult patients in the triage station. The entire triage process was captured on video. Two pain assessment methods were employed: (1) Self-reported pain score in the Taiwan Triage and Acuity Scale, referred to as the system-based method; (2) Five physicians independently assigned triage levels and assessed pain scores from video footage, termed the physician-based method. The primary outcome was hospitalization, and secondary outcomes included ED length of stay (EDLOS) and ED charges. RESULTS Of the 656 patients evaluated, the median self-reported pain score was 4 (interquartile range, 0-7), while the median physician-rated pain score was 1.5 (interquartile range, 0-3). Increased self-reported pain severity was not associated with prolonged EDLOS and increased ED charges, but a positive association was identified with physician-rated pain scores. Using the system-based method, the predictive efficacy of triage scales was lower in the pain groups than in the pain-free group (area under the receiver operating curve, [AUROC]: 0.615 vs. 0.637). However, with the physician-based method, triage scales were more effective in predicting hospitalization among patients with pain than those without (AUROC: 0.650 vs. 0.636). CONCLUSIONS Self-reported pain seemed to diminish the predictive accuracy of triage for hospitalization. In contrast, physician-rated pain scores were positively associated with longer EDLOS, increased ED charges, and enhanced triage predictive capability for hospitalization. Pain, therefore, appears to modulate the relationship between triage and patient outcomes, highlighting the need for careful pain evaluation in the ED.
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Affiliation(s)
- Nai-Wen Ku
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Ming-Tai Cheng
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd., Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Hsinchu, Taiwan
| | - Chiat Qiao Liew
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd., Taipei, 100, Taiwan
| | - Yun Chang Chen
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Hsinchu, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chia-Hsin Ko
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd., Taipei, 100, Taiwan
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd., Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd., Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd., Taipei, 100, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Whitley GA, Wijegoonewardene N, Nelson D, Curtis F, Ortega M, Siriwardena AN. Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis. J Am Coll Emerg Physicians Open 2023; 4:e12940. [PMID: 37056718 PMCID: PMC10086522 DOI: 10.1002/emp2.12940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Background We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care. Methods A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated. Results Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey. Conclusion Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.
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Affiliation(s)
- Gregory Adam Whitley
- Community and Health Research UnitUniversity of LincolnLincolnUK
- Clinical Audit and Research UnitEast Midlands Ambulance Service NHS TrustLincolnUK
| | - Nimali Wijegoonewardene
- Community and Health Research UnitUniversity of LincolnLincolnUK
- Healthcare Quality and SafetyMinistry of HealthColomboSri Lanka
| | - David Nelson
- Lincoln International Institute for Rural HealthUniversity of LincolnLincolnUK
| | - Ffion Curtis
- Centre for Ethnic Health ResearchEast Midlands Applied Research CollaborationUniversity of LeicesterLeicesterUK
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Ginsberg Z, Lindor RA, Campbell RL, Ghaith S, Buckner-Petty S, McElhinny ML. Return Rates for Opioid versus Nonopioid Management of Patients with Abdominal Pain in the Emergency Department. J Emerg Med 2023; 64:471-475. [PMID: 36997433 DOI: 10.1016/j.jemermed.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/27/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Research suggests that opioid treatment for abdominal pain, which comprises a large proportion of patients presenting to the emergency department (ED), may contribute to long-term opioid use without significant benefits with regard to symptom management. OBJECTIVES This study seeks to assess the association between opioid use for management of abdominal pain in the ED and return ED visits for abdominal pain within 30 days for patients discharged from the ED at initial presentation. METHODS We conducted a retrospective, multicenter observational study of adult patients presenting to and discharged from 21 EDs with a chief concern of abdominal pain between November 2018 and April 2020. The proportion of 30-day return visits to the ED for patients who received opioid analgesics was compared with a reference group of patients who only received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or both. RESULTS Of the 4745 patients, 1304 (27.5%) received opioids and 1101 (23.2%) only received either acetaminophen, NSAIDs, or both. Among those given opioids, 287 (22.0%) returned to the ED for abdominal pain within 30 days, compared with 162 (14.7%) of those in the reference group (odds ratio 1.57, 95% confidence interval 1.27-1.95, p-value < 0.001). CONCLUSION Patients given opioids for abdominal pain in the ED had 57% increased odds of a return ED visit within 30 days compared with those given only acetaminophen or NSAIDs. This warrants further research on the use of nonopioid analgesics in the ED, especially in patients with anticipated discharge.
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Affiliation(s)
| | - Rachel A Lindor
- Department of Emergency Medicine, Mayo Clinic, Phoenix, Arizona
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Summer Ghaith
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Skye Buckner-Petty
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | - Megan L McElhinny
- Department of Emergency Medicine, Mayo Clinic, Phoenix, Arizona; Creighton University School of Medicine, Valleywise Medical Center, Phoenix, Arizona
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Mccahill R, Keogh S, Hughes JA. Adult pain and anticipatory anxiety assessment in the emergency department: An integrative literature review. J Clin Nurs 2022. [PMID: 36221311 DOI: 10.1111/jocn.16520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/19/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Robyn Mccahill
- Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Queensland, Australia.,Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Mackay Hospital and Health Service (MHHS), Queensland Health, Mackay, Queensland, Australia
| | - Samantha Keogh
- Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Queensland, Australia.,Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Alliance for Vascular Access Teaching and Research Group (AVATAR), Griffith University, Brisbane, Queensland, Australia
| | - James A Hughes
- Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Queensland, Australia.,Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
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Hsu HP, Cheng MT, Lu TC, Chen YC, Liao ECW, Sung CW, Liew CQ, Ling DA, Ko CH, Ku NW, Fu LC, Huang CH, Tsai CL. Pain Assessment in the Emergency Department: A Prospective Videotaped Study. West J Emerg Med 2022; 23:716-723. [PMID: 36205678 PMCID: PMC9541978 DOI: 10.5811/westjem.2022.6.55553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 06/27/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician’s perception of a patient’s pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment.
Methods: We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos.
Results: A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0-6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain (correlation coefficient, 0.46; P <0.001), with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001).
Conclusion: Patients’ self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors.
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Affiliation(s)
- Hao-Ping Hsu
- National Taiwan University, College of Medicine, Department of Medicine, Taipei, Taiwan
| | - Ming-Tai Cheng
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Tsung-Chien Lu
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Yun Chang Chen
- National Taiwan University Hospital Yun-Lin Branch, Department of Emergency Medicine, Hsinchu, Taiwan
| | - Edward Che-Wei Liao
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Chih-Wei Sung
- National Taiwan University Hospital Hsin-Chu Branch, Department of Emergency Medicine, Hsinchu, Taiwan
| | - Chiat Qiao Liew
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Dean-An Ling
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Chia-Hsin Ko
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Nai-Wen Ku
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Li-Chen Fu
- National Taiwan University, Department of Computer Science and Information Engineering, Taipei, Taiwan
| | - Chien-Hua Huang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Chu-Lin Tsai
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; National Taiwan University, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
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Enhancing the use of pain assessment at emergency department: a best practice implementation project. JBI Evid Implement 2022; 20:S15-S22. [PMID: 36372789 DOI: 10.1097/xeb.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The main aim of the best practice implementation project was to enhance the use of pain assessment and the compliance with evidence-based criteria regarding pain assessment among incoming patients to emergency department. INTRODUCTION Adequate approaches to pain assessment and documentation have been demonstrated beneficial for emergency department patients. Evidence-based recommendations establish a focus on education about the implications for evaluating and recording pain in order to improve outcome strategies and quality of care. METHODS The implementation project was undertaken in the emergency department following JBI Implementation framework in order to seek whether pain assessment was taken and registered as per protocols. Random selection for 100 anonymized emergency department admission episodes, which had to meet the specified inclusion criteria, was carried out. RESULTS The baseline audit showed low compliance in criterion 3 (C3) 'Pain was documented in each assessment' (6%), C4 'Pain was assessed after treatment' (9%) and C5 'Pain was assessed prior to discharge' (10%). In the follow-up audit, noticeable improvement was shown for four of the criteria; C3 (14%), C4 (22%) and for C5 (41%). C1 'Pain was assessed in a timely manner' improved from 81% up to 95%. C2 'Use of a validated scoring tool' had a compliance of 100% as the hospital's assessing system default has NRS-11 scale set up. CONCLUSION We performed an audit of pain assessment documentation. Enhancing the use of pain assessment among emergency department nurses by means of specific training emphasizing the importance of documentation showed a positive impact on practice. Follow-up audit results justify the continuity of the implemented strategies.
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Schweizer L, Sieber R, Nickel CH, Minotti B. Ability of pain scoring scales to differentiate between patients desiring analgesia and those who do not in the emergency department. Am J Emerg Med 2022; 57:107-113. [PMID: 35550928 DOI: 10.1016/j.ajem.2022.04.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Pain is one of the most reasons for a visit to an emergency department (ED). Pain scores as the verbal rating scale (VRS) or numerical rating scale (NRS) are used to determine pain management. While it is crucial to measure pain levels, it is equally important to identify patients who desire pain medication, so that adequate provision of analgesia can occur. OBJECTIVE To establish the association between pain scores on the NRS and VRS, and the desire for, and provision of, pain medication. DESIGN, SETTINGS AND PARTICIPANTS Retrospective monocentric observational cohort study of ED patients presenting with painful conditions. OUTCOMES MEASURE AND ANALYSIS The primary outcome was to establish for each pain score (NRS and/or VRS), those patients who desired, and were ultimately provided with, pain medication, and those who did not. Secondary outcomes included establishing the prediction of pain scores to determine desire of pain medication, and the correlation between NRS and VRS when both were reported. MAIN RESULTS 130,279 patients were included for analysis. For each patient who desired pain medication, pain medication was provided. Proportion of patients desiring pain medication were 4.1-17.8% in the pain score range 0.5-3.5, 31.9-63.4% in the range 4-6.5, and 65-84.6% in the range 7-10. The prediction probability of pain scores to determine desire for pain medication was represented with an AUROC of 0.829 (95% CI 0.826-0.831). The optimal threshold predicting the desire for pain medication would be a pain score of 4.25, with sensitivity 0.86, and specificity 0.68. For the 7835 patients with both NRS and VRS scores available, the Spearman-Rho coefficient assessing correlation was 0.946 (p < 0.001). CONCLUSIONS Despite guidelines currently recommending pain medication in patients with a NRS score > 4, we found a discrepancy between pain scores and desire for pain medication. Results of this large retrospective cohort support that the desire for pain medication in the ED might not be derived from a pain score alone.
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Affiliation(s)
- Lisa Schweizer
- Internal Medicine Department, Hospital of Herisau, Herisau, Switzerland
| | - Robert Sieber
- Emergency Department, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bruno Minotti
- Emergency Department, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
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Lvovschi VE. Quelle est la pertinence de l’auto-évaluation de l’intensité de la douleur dans le tri aux urgences des douleurs abdominales ? ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Hämäläinen J, Kvist T, Kankkunen P. Acute Pain Assessment Inadequacy in the Emergency Department: Patients' Perspective. J Patient Exp 2022; 9:23743735211049677. [PMID: 35005219 PMCID: PMC8733361 DOI: 10.1177/23743735211049677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
For many patients, acute pain is a common cause to seek treatment in an Emergency Department (ED). An inadequate assessment could cause inappropriate pain management. The aim of this study was to describe and explain patients’ perceptions of acute pain assessment in the Emergency Department. The data were collected from ED patients (n = 114). Patients reported that nurses were asking about intensity of pain at rest, but only 52% during movement. According to the patients, the most common tools to assess acute pain were the verbal rating scale (VRS; 54% of patients), numerical rating scale (NRS; 28% of patients), and visual analogue scale (VAS; 9.7% of patients). Over twenty per cent of patients stated that ED nurses did not ask about the intensity of pain after analgesic administration. Twenty-four per cent of the patients were not pleased with nursing pain assessment in the ED. The assessment of acute pain is still inadequate in the ED. Therefore, ED nurses need to be more attentive to systematic acute pain management of patients in the ED.
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Affiliation(s)
- Jenni Hämäläinen
- Department of Nursing Science, Finland University of Eastern Finland, Kuopio, Finland
| | - Tarja Kvist
- Department of Nursing Science, Finland University of Eastern Finland, Kuopio, Finland
| | - Päivi Kankkunen
- Department of Nursing Science, Finland University of Eastern Finland, Kuopio, Finland
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Clinical Interpretation of Self-Reported Pain Scores in Children with Acute Pain. J Pediatr 2022; 240:192-198.e2. [PMID: 34478746 PMCID: PMC8712366 DOI: 10.1016/j.jpeds.2021.08.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/06/2021] [Accepted: 08/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify self-reported pain scores that best represent categories of no pain, mild, moderate, and severe pain in children, and a pain score that accurately represents a child's perceived need for medication, that is, a minimum pain score at which a child would want an analgesic. STUDY DESIGN Prospective cross-sectional cohort study of children aged 6-17 years presenting to a pediatric emergency department with painful and nonpainful conditions. Pain was measured using the 10-point Verbal Numerical Rating Scale. Receiver operating characteristic -based methodology was used to determine pain scores that best differentiated no pain from mild pain, mild pain from moderate pain, and moderate pain from severe pain. Descriptive statistics were used to determine the perceived need for medication. RESULTS We analyzed data from 548 children (51.3% female, 61.9% with a painful condition). The scores that best represent categories of pain intensity are as follows: 0-1 for no pain; 2-5 for mild pain; 6-7 for moderate pain; and 8-10 for severe pain. The area under the curve for the cut points differentiating each category ranged from 0.76 to 0.88. The median pain score representing the perceived need for medication was 6 (IQR, 4-7; range, 0-10). CONCLUSIONS We identified population-level self-reported pain scores in children associated with categories of pain intensity that differ from scores conventionally used. Implementing our findings may provide a more accurate representation of the clinical meaning of pain scores and reduce selection bias in research. Our findings do not support the use of pain scores in isolation for clinical decision making or the use of a pain score threshold to represent a child's perceived need for medication.
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Lvovschi VE, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices. J Clin Med 2021; 10:jcm10215089. [PMID: 34768612 PMCID: PMC8584399 DOI: 10.3390/jcm10215089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.
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Affiliation(s)
- Virginie Eve Lvovschi
- Emergency Department, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France
- Correspondence:
| | - Karl Hermann
- Rouen University Hospital, INSERM CIC-CRB 1404, F-76000 Rouen, France;
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, INSERM U 942, Hôpital Avicenne, F-93009 Bobigny, France;
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, F-76031 Rouen, France;
| | - Marie-Pierre Tavolacci
- Normandie University, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France;
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Senger A, Bryce R, McMahon C, Baerg K. Cross-sectional study of pediatric pain prevalence, assessment, and treatment at a Canadian tertiary hospital. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2021; 5:172-182. [PMID: 34616998 PMCID: PMC8489950 DOI: 10.1080/24740527.2021.1961081] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Painful experiences are common among hospitalized children. Long-term negative biopsychosocial consequences of undertreated pain are recognized. Aims The study benchmarks pain prevalence, assessment, and treatment as first steps to improve pain care in a Canadian tertiary hospital. Methods Single-day audits were undertaken on the pediatric ward (PW), pediatric emergency department (ED), and maternal services (MS). Participants (child or caregiver proxy) reported hospital pain experiences in the preceding 24 h; medical records were reviewed for assessment and treatment. Results Among 84 participants, pain prevalence ranged from 75% to 88%; mean pain intensity ranged from 5.7 to 6.5/10. Prevalence of moderate to severe pain was 78% on PW, 65% in ED, and 55% on MS; needle pokes were the most frequent cause of worst pain. Documentation of pain assessment varied by setting (PW, 93%; ED, 13%; MS, 0%). Documented maximum pain scores were significantly lower compared to participant report (mean difference 4.5/10, SD 3.1, P < 0.0001). A total 29% (6/21) of infants with heel lance or injection received breastfeeding or sucrose, and 29% (7/24) of participants receiving other needle procedures had documented or reported topical lidocaine use. All participants on MS underwent needle procedures. Conclusions Pain is experienced commonly by infants and children in PW, ED, and MS. Pain assessment documentation is not routine and underestimates participant report. Evidence-based pain management strategies are underutilized. An institution-wide quality improvement approach is required to address pain care. Pain assessment and needle pain prevention and treatment should be prioritized in these pediatric acute care and newborn care settings.
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Affiliation(s)
- Alex Senger
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rhonda Bryce
- Clinical Research Support Unit, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Casey McMahon
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Krista Baerg
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Saskatchewan Health Authority-Saskatoon, Saskatoon, Saskatchewan, Canada
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Brigo F, Zaboli A, Rinaldi F, Ausserhofer D, Nardone R, Pfeifer N, Turcato G. The Manchester Triage System's performance in clinical risk prioritisation of patients presenting with headache in emergency department: A retrospective observational study. J Clin Nurs 2021; 31:2553-2561. [PMID: 34608700 DOI: 10.1111/jocn.16073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/07/2021] [Accepted: 09/16/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Non-traumatic headache is a frequent reason for visits to the emergency department (ED). We evaluated the performance of the Manchester Triage System (MTS) in prioritising patients presenting to the ED with non-traumatic headache. METHODS In this single-centre observational retrospective study, we compared the association of MTS priority classification codes with a final diagnosis of a severe neurological condition requiring timely management (ischaemic or haemorrhagic stroke, subarachnoid haemorrhage, cerebral sinus venous thrombosis, central nervous system infection or brain tumour). The study was conducted and reported according to the STROBE statement. The overall prioritisation accuracy of MTS was estimated by the area under the receiver operating characteristic (ROC) curve. The correctness of triage prediction was estimated based on the "very urgent" MTS grouping. An undertriage was defined as a patient with an urgent and severe neurological who received a low priority/urgency MTS code (green/yellow). RESULTS Over 30 months, 3002 triage evaluations of non-traumatic headache occurred (1.7% of ED visits). Of these, 2.3% (68/3002) were eventually diagnosed with an urgent and severe neurological condition. The MTS had an acceptable prioritisation accuracy, with an area under the ROC curve of 0.734 (95% CI 0.668-0.799). The sensitivity of the MTS for urgent codes (yellow, orange and red) was 79.4% (95% CI 74.5-84.3), with a specificity of 54.1% (95% CI 52.9-55.3). The triage prediction was incorrect in only 6.3% (190/3002) of patients with headache. CONCLUSION The MTS is a safe and accurate tool for prioritising patients with non-traumatic headache in the ED. However, MTS may need further specific tools for evaluating the more complicated symptoms and for correctly identifying patients with urgent and severe underlying pathologies. RELEVANCE TO CLINICAL PRACTICE The triage nurse using MTS may need additional tools to improve the assessment of patients with headache, although MTS provides a good safety profile.
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Affiliation(s)
- Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Fabrizio Rinaldi
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Dietmar Ausserhofer
- College of Health Care Professions Claudiana, Bolzano-Bozen, Italy.,Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Raffaele Nardone
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
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Hughes JA, Chiu J, Brown NJ, Hills A, Allwood B, Chu K. The documentation of pain intensity and its influences on care in the emergency department. Int Emerg Nurs 2021; 57:101015. [PMID: 34166989 DOI: 10.1016/j.ienj.2021.101015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/19/2021] [Accepted: 04/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Assessment and reassessment of self reported pain intensity scores form the basis of acute pain care in the emergency deprtment (ED), however are frequently undocumented. The effects of not documenting pain assessments on time to first analgesic medication (TTA) and ED length of stay (EDLOS) are unknown. METHODS This is a retrospective cross-sectional study to investigate the association between documented evidence of pain intensity scores, TTA and EDLOS in the ED. It also examined the factors associated with the documentation of pain intensity scores. Univariate and multivariable modelling was used on a random sample of presentations. RESULTS There were no statistically significant associations between the documented evidence of pain intensity scores and TTA or EDLOS. Modelling suggests that patients were less likely to have documented evidence of pain intensity scores if they were male, were streamed to the fast-track treatment area, had a lower burden of co-morbidities, or when the general departmental workload was increased. CONCLUSIONS The documentation of pain intensity scores was not associated with TTA or EDLOS. Some demographic, illness and workload factors are associated with the lack of pain intensity score documentation, however, the effect on patients outcomes needs further investigation.
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Affiliation(s)
- James A Hughes
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Nursing, Queensland University of Technology, Brisbane, Australia.
| | - Jacqui Chiu
- Facility of Medicine, The University of Queensland, Brisbane, Australia
| | - Nathan J Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; Facility of Medicine, The University of Queensland, Brisbane, Australia
| | - Angela Hills
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Brandon Allwood
- School of Nursing, Queensland University of Technology, Brisbane, Australia; Emergency Department, Mater Public Hospital, Brisbane, Australia
| | - Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; Facility of Medicine, The University of Queensland, Brisbane, Australia
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Xu KT, Morris JE, Piel C. The Utility of Pain Scale to Assess Verifiable vs Non-Verifiable Pain in United States Emergency Departments. West J Emerg Med 2021; 22:156-162. [PMID: 33856295 PMCID: PMC7972390 DOI: 10.5811/westjem.2020.11.49030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/01/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction We sought to examine the utility of self-reported pain scale by comparing emergency department (ED) triage pain scores of self-reported but non-verifiable painful conditions with those of verifiable painful conditions using a large, nationally representative sample. Methods We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2015. Verifiable painful conditions were identified based on the final diagnoses in the five included International Classification of Diseases 9th revision codes. Non-verifiable painful conditions were identified by the five main reasons for visit. Only adults 18 years of age or older were included. The primary outcome variable was the pain scale from 0 to 10 at triage. We performed descriptive and multivariate analyses to investigate the relationships between the pain scale and whether the painful condition was verifiable, controlling for patient characteristics. Results There were 55 million pain-related adult ED visits in 2015. The average pain scale was 6.49. For verifiable painful diagnoses, which were about 24% of the total visits, the average was 6.27, statistically significantly lower than that for non-verifiable painful conditions, 6.56. Even after controlling for the confounding of patient characteristics and comorbidities, verifiable painful diagnoses still presented less pain than those with non-verifiable painful complaints. Older age, female gender, and urban residents had significantly higher pain scores than their respective counterparts, controlling for other confounding factors. Psychiatric disorders were independently associated with higher pain scores by about a half point. Conclusion Self-reported pain scales obtained at ED triage likely have a larger psychological component than a physiological one. Close attention to clinical appropriateness and overall patient comfort are more likely to lead to better health outcomes and patient experiences than focusing on self-reported pain alone.
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Affiliation(s)
- K Tom Xu
- Texas Tech University Health Sciences Center, Department of Surgery, Division of Emergency Medicine, School of Medicine, Lubbock, Texas
| | - James E Morris
- Texas Tech University Health Sciences Center, Department of Surgery, Division of Emergency Medicine, School of Medicine, Lubbock, Texas
| | - Christopher Piel
- Texas Tech University Health Sciences Center, Department of Surgery, Division of Emergency Medicine, School of Medicine, Lubbock, Texas
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19
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Carius BM, April MD, Pedersen CS, Schauer SG. Historical Alternans in the Emergency Department (H.A.t.E.D.) for Pain: An Analysis of Patient Pain Descriptors to Attending and Trainee Clinicians. South Med J 2021; 114:23-27. [PMID: 33398356 DOI: 10.14423/smj.0000000000001195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The concept of "historical alternans" (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain. METHODS We conducted a prospective observational pilot study comparing pain descriptions given to attending and trainee clinicians in the ED using a five-question pain description survey. Trainees included emergency medicine physician residents, emergency medicine physician assistant residents, off-service residents, and students. Trainees completed the first survey and attending clinicians repeated survey questions after at least a 10-minute washout. Surveys include descriptions of pain as part of patients' primary concern, severity indicated by a verbal numerical rating score (VNRS), and pain location, quality, and duration. RESULTS During a 10-day period, surveys were completed for 97 patient encounters. Most trainee clinicians were emergency medicine physician residents (53%), followed by emergency medicine physician assistants (32%), students (13%), and off-service residents (2%). Pain complaints centered on the abdomen (18.5%), chest (12%), and knee (6%). Differences in pain description were found in the majority of cases (55%), with most having one categorical difference. The majority of categorical differences were VNRS (38%), although the difference in scores was not statistically significant (P = 0.20). Medical students had the highest variance in VNRS difference compared with attending clinicians. There was no significant difference in described duration (P = 0.99) or quality of pain (P = 0.99) between trainee and attending clinicians. CONCLUSIONS Most patient encounters had at least one difference in categorical pain descriptors between trainee and attending clinicians. Although differences in severity of pain were present, they were not significant. HA does occur in the ED setting, but the magnitude of difference may be minimal.
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Affiliation(s)
- Brandon M Carius
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
| | - Michael D April
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
| | - Craig S Pedersen
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
| | - Steve G Schauer
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
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20
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Wong A, Potter J, Brown NJ, Chu K, Hughes JA. Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review. Australas Emerg Care 2020; 24:127-134. [PMID: 33187935 DOI: 10.1016/j.auec.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.
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Affiliation(s)
- Alixandra Wong
- Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Joseph Potter
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Logan Hospital, Meadowbrook, Australia
| | - Nathan J Brown
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Kevin Chu
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - James A Hughes
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Australia.
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Price D, Edwards M, Carson-Stevens A, Cooper A, Davies F, Evans B, Hibbert P, Hughes T, Rainer T, Siriwardena N, Edwards A. Challenges of recruiting emergency department patients to a qualitative study: a thematic analysis of researchers' experiences. BMC Med Res Methodol 2020; 20:151. [PMID: 32522265 PMCID: PMC7288546 DOI: 10.1186/s12874-020-01039-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/01/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND At times of increasing pressure on emergency departments, and the need for research into different models of service delivery, little is known about how to recruit patients for qualitative research in emergency departments. We report from one study which aimed to collect evidence on patients' experiences of attending emergency departments with different models of using general practitioners, but faced challenges in recruiting patients. This paper aims to identify and reflect on the challenges faced at all stages of patient recruitment, from identifying and inviting eligible patients, consenting them for participation and finally to engaging them in interviews, and make recommendations based on our learning. METHODS A thematic analysis was carried out on field-notes taken during research visits and meeting minutes of discussions to review and improve patient recruitment throughout the study. RESULTS The following factors influenced the success of patient recruitment in the emergency department setting: complicated or time-consuming electronic health record systems for identifying patients; narrow participant eligibility criteria; limited research nurse support; and lack of face-to-face communication between researchers and eligible patients. CONCLUSIONS This paper adds to the methodological evidence for improving patient recruitment in different settings, with a focus on qualitative research in emergency departments. Our findings have implications for future studies attempting to recruit patients in similar settings.
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Affiliation(s)
- Delyth Price
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales.
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Andrew Carson-Stevens
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Alison Cooper
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Freya Davies
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Bridie Evans
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Thomas Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, England
| | - Tim Rainer
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
| | - Niro Siriwardena
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales
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Sampson FC, O'Cathain A, Goodacre S. How can pain management in the emergency department be improved? Findings from multiple case study analysis of pain management in three UK emergency departments. Emerg Med J 2019; 37:85-94. [PMID: 31831588 DOI: 10.1136/emermed-2019-208994] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Inadequate pain management in EDs is a worldwide problem, yet there has been little progress in understanding how pain management can be improved. There is only weak evidence and limited rationale to support interventions to improve pain management. We used naturalistic, qualitative methods to understand the factors that influence how pain is managed within the adult ED. METHODS We used a multiple case study design incorporating 143-hour non-participant observation, documentary analysis and semistructured interviews with 37 staff and 19 patients at three EDs in the North of England between 2014 and 2016. We analysed data using thematic analysis. RESULTS Our analysis demonstrated that pain management was not well aligned with the core priorities of the ED and was overlooked when other works took priority. We identified that (1) pain management was not perceived to be a key organisational priority for which staff were held accountable and staff had limited awareness of their performance, (2) pain management was not a core component of ED education and training, (3) ED processes and structures were not aligned with pain management and pain reassessment was overlooked unless staff escalated pain management outside of normal processes and (4) staff held embedded beliefs that conceptualised pain management as distinct from core priorities and limited their capacity to improve. However, EDs were able to improve pain management by aligning processes of pain management with other core works, particularly patient flow (eg, nurse-initiated analgesia at triage). IMPLICATIONS EDs may be able to improve pain management by ensuring pain management processes align with key ED priorities. Undertaking multifaceted changes to structures and processes may enable staff to improve pain management and develop a culture in which pain management can be prioritised more easily. Future interventions need to be compatible with the wider work of the ED and enable patient flow in order to be adopted and maintained.
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Wehner L. Pain assessments in emergency departments lack consistency and validity, and this impacts effective pain management. Evid Based Nurs 2019; 23:85. [PMID: 31302600 DOI: 10.1136/ebnurs-2019-103139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2019] [Indexed: 11/04/2022]
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