Pain Management In Emergency Department Research Articles

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

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

Pain management in Emergency departments. Evaluating the efficacy of an improving method

Pain is a very common symptom for patients admitted to Emergency departments (EDs) and its undertreatment represents a widespread problem. A pre-post study on 249 patients (128 pre and 121 in the post phase) assessed the effectiveness of the implementation of a pain assessment scale to obtain a reduction of its intensity in patients discharged from an ED of Turin. Pain was self assessed by the patient (pre) and after the implementation of the scale its intensity was recorded on triage clinical record (post). After the implementation of the NRS, patients with severe pain had a statistically significant reduction of mean pain values (-1,4 points, p < 0,001). Analgesics were administered to 7 patients (5,5%) before and to 16 patients (13,2%) after the adoption of the NRS (p < 0,03) but 91 (72%) patients before and 73 (60%) after were discharged with the same level of pain experienced at admission.

Oral sucrose for pain management in the paediatric emergency department; a review

Summary Provision of effective analgesia for infants and children is important during painful procedures performed in emergency departments. Although small volumes of sweet-tasting solutions have been extensively shown to be analgesic during minor painful procedures in newborn infants, there have been fewer studies of sucrose use in infants beyond the neonatal period, and in children. This review of sucrose effectiveness in infants beyond the neonatal period highlights that sucrose continues to provide some analgesia, resulting in procedural pain reduction, however the effects may be less marked. There is inadequate evidence to support the use of sucrose during painful procedures in school-aged children. Oral sucrose should be included in paediatric emergency department pain management guidelines as one of the possible strategies to utilise for infants during minor painful procedures. Careful assessment of pain and distress during procedures is required to evaluate the effectiveness of sucrose analgesia. Appropriate comfort measures should always be used, and adjunct analgesics should be utilised as required.

Barriers to pain management in emergency departments

Barriers to pain management in emergency departments

Factors influencing pain management by nurses in emergency departments in Central Africa

Objective: To observe pain management practices by nurses in emergency departments (EDs) in Central Africa and to study the various factors influencing these practices. Methods: Time to first analgesic treatment was recorded in 53 patients presenting to the ED of a Central African hospital in February 2005. A survey was simultaneously conducted on the attitudes and commitment of nurses towards the management of pain. All 28 nurses assigned to the ED agreed to participate in the survey. Results: Severity of pain was the factor most influencing the time to first analgesia following admission to the ED. Severe pain was assessed as a score of ⩾7 on a 1–10 visual analogue scale. The median time to first analgesia in patients with severe pain was 150 min, which was considerably longer than in patients without severe pain (p = 0.003). A quarter of the 28 nurses had no official training in pain management and most (>80%) were unable to carry out a formal assessment of pain. The majority (>90%) were confident of their ability to treat pain. Thirteen (48%) were of the opinion that cultural factors influenced their management of pain and 67% admitted that they had some fears about administering morphine to patients in the ED. Conclusion: Pain management by nurses in the ED in Central Africa is inadequate. Cultural factors greatly influence how nurses manage pain in the emergency room. Patients would benefit considerably if nurses received additional education about the diagnosis and management of acute pain in EDs in Central Africa.

Factors influencing pain management by nurses in emergency departments in Central Africa

Objective: To observe pain management practices by nurses in emergency departments (EDs) in Central Africa and to study the various factors influencing these practices. Methods: Time to first analgesic treatment...

The national trend in quality of emergency department pain management for long bone fractures

Background Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving. Objectives To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001. Methods The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998–2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment. Results There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998–2000 and 1,230 from 2001–2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates. Conclusions Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.

Pain in the Emergency Department: Results of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study

Pain is the most common reason for emergency department (ED) use, and oligoanalgesia in this setting is known to be common. The Joint Commission on Accreditation of Healthcare Organizations has revised standards for pain management; however, the impact of these regulatory changes on ED pain management practice is unknown. This prospective, multicenter study assessed the current state of ED pain management practice. After informed consent, patients aged 8 years and older with presenting pain intensity scores of 4 or greater on an 11-point numerical rating scale completed structured interviews, and their medical records were abstracted. Eight hundred forty-two patients at 20 US and Canadian hospitals participated. On arrival, pain intensity was severe (median, 8/10). Pain assessments were noted in 83% of cases; however, reassessments were uncommon. Only 60% of patients received analgesics that were administered after lengthy delays (median, 90 minutes; range, 0 to 962 minutes), and 74% of patients were discharged in moderate to severe pain. Of patients not receiving analgesics, 42% desired them; however, only 31% of these patients voiced such requests. We conclude that ED pain intensity is high, analgesics are underutilized, and delays to treatment are common. Despite efforts to improve pain management practice, oligoanalgesia remains a problem for emergency medicine. Despite the frequency of pain in the emergency department, few studies have examined this phenomenon. This study documents high pain intensity and suboptimal pain management practices in a large multicenter ED network in the United States and Canada. These findings suggest that there is much room for improvement in this area.

Impact of an Emergency Department Pain Management Protocol on the Pattern of Visits by Patients with Sickle Cell Disease

This study explores how implementation of pain management guidelines in concert with clinic case management affected emergency department (ED) utilization, clinic visits, and hospital admissions for patients with sickle cell disease. A pain management guideline that eliminated meperidine and encouraged timely use of morphine or hydromorphone for pain control in sickle cell crisis was introduced as a quality improvement project. This study is a retrospective review of ED visits, clinic visits, and admissions from 1 year before and 3 years after the guideline implementation. Working with the ED, the Hematology Clinic began to proactively seek the return of their patients for clinic follow-up. A formal case management program for sickle cell patients was initiated in June 2003. A total of 1584 visits by 223 patients were collected, 1097 to the ED and 487 to the Hematology Clinic. Total hospital visits did not change significantly in any of the 4 years, p > 0.10 for each comparison. Total ED visits decreased significantly over the 4-year study period ( p < 0.001), whereas clinic visits steadily increased ( p < 0.001). Return visits to the ED within 30 days also declined significantly, p < 0.001. Both the absolute number of admissions per year and the total admissions per hospital visit per year declined significantly over the study period, p = 0.001. Although total admissions per hospital visit did not change, the proportion of ED visits that resulted in admission in year 1 (29%) was significantly lower than the proportion admitted in year 2 (43%), p = 0.04. A pain protocol using morphine or hydromorphone coupled with increased access to outpatient clinics decreased ED visits, hospitalizations, and increased utilization of a more stable primary care clinic setting by patients with sickle cell disease.

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving. To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001. The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998-2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment. There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998-2000 and 1,230 from 2001-2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates. Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

Schmerzprävalenz und Patientenpräferenzen bezüglich Schmerzbehandlung in Notfallstationen

Pain is one of the most common problems for patients who present to the Emergency Department (ED), thus a timely and effective pain management intervention is essential for quality patient care. A comprehensive literature review was undertaken in an effort to document the prevalence of pain and to increase knowledge about patients' preferences regarding pain management in emergency situations. Results indicated that the prevalence of pain is high and pain management, including treatment, is often unsatisfactory in the ED. Common procedures, such as offering pain medication after medical consultation or when diagnostic intervention is completed, were shown not be effective in meeting patient needs. Patients prefer that their pain is treated upon admission to the ED; their need for effective treatment increases with pain intensity. Reasons that patients may refuse pain medication include fear of addiction and side effects. While most patients do not expect being to be pain-free upon discharge, most do expect more effective pain relief than they are currently receiving. Relationships between sociodemographic factors and patient preferences could not clearly be elicited from the literature. A weakness is that the reviewed studies were descriptive and published primarily in the United States in the last five years. There is a need for further research in this area, particularly studies that investigate patients' preferences regarding pain management in European EDs.

405: Impact of Patient Gender on Pain Management Practices in the Emergency Department: A Multi-Center Study

Prior emergency department (ED)-based studies have shown that women present with greater pain than men and get more pain medications. Our goal was to assess the influence of patient gender on ED pain management practices and outcomes in a large multi-center study.

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 (N 2O) 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 N 2O (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.

Emergency Department Pain Management for Extremity Injuries in Older Adults

Emergency Department Pain Management for Extremity Injuries in Older Adults

Pain Relief in the Emergency Department

Two studies shed light on the management of acute pain in the emergency department (ED).In a randomized, double-blind trial from a Hong Kong ED,

Pain in the Emergency Department

Although 78% of emergency department (ED) patients present with a pain-related complaint, few published studies address treating, rather than diagnosing, this complaint. This study correlated initial, discharge and post-discharge ED pain assessments, and examined ED pain management and potential treatment barriers. Objectives: To examine the correlation of patient, accompanying adult, nurse and physician pain assessments; determine the characteristics of patients presenting with pain; evaluate the effectiveness of ED pain intervention.

Disparities in Emergency Department Pain Management

Disparities in Emergency Department Pain Management

Factors Affecting Emergency Department Assessment and Management of Pain in Children

To evaluate statewide emergency department assessment and management of pain in pediatric patients as a quality improvement initiative. 2002 Survey of Illinois Hospital emergency department's pediatric pain assessment and management strategies, in conjunction with a retrospective chart review of children, ages 0 to 15 years, treated for an extremity fracture. Survey results were available for 123 (59.4%) hospitals; 933 charts (107 hospitals) were reviewed for pain management. Survey results were compared with practices identified by chart review. Use of a pain assessment scale estimated by the survey was 92%, compared with 59% use by chart review. Use of pain assessment scales for infants was limited. Fifty percent of patients in moderate to severe pain would be offered an analgesic. Six- to 15-year-old children would be offered opioids more often than children aged 0 to 1 and 2 to 5 years. Offering higher potency narcotic analgesics was associated with patient's age, geographic location of the facility, and emergency department volume. Providing an analgesic (odds ratio 4.53, 95% confidence interval 2.89-7.10), offering supportive care (odds ratio 2.37, 95% confidence interval 1.44-3.89), and pediatric-focused annual nurse competencies (odds ratio 1.90, 95% confidence interval 1.18-3.06) correlated with reduction of the patient's pain. Disparity exists between perceived and documented emergency department pain management practices for children. Quality improvement initiatives should focus on improving pain assessment in infants, treating moderate to severe pain in children of all age groups, and education of health care providers in pain management strategies. Resources should target health care processes effective in decreasing pediatric pain.

Clinical Guidelines and Policies: Can they Improve Emergency Department Pain Management?

The prevalence of pain in patients presenting to Emergency Departments (ED) has been well documented by both Cordell and Johnston. Equally well documented has been the apparent failure to adequately control that pain. In 1990 Selbst found that patients with long bone fractures received little analgesia in the ED, and Ngai, et al., showed that the under-treatment of pain continued after discharge. In a prospective study, Ducharme and Barber found that up to one third of patients presented with severe pain and were often unrelieved at discharge. Even though specific patient subgroups appear to be at greater risk, all patients are potential victims of oligoanalgesia - the under-treatment of pain. Despite an ever increasing volume of research about pain in emergency medicine, dissemination of relevant information with widespread change in practice patterns has not been witnessed. Recent studies continue to affirm that pain management in the ED is suboptimal.