Pain Management In Emergency Department Research Articles

Nonpharmacologic Pediatric Pain Management in Emergency Departments: A Systematic Review of the Literature

Children account for numerous ED visits each year, with the majority of children reporting pain or requiring painful procedures. The fast-paced, noisy environment, varying resources, and staff trained in taking care of pediatric patients make the ED a unique place to care for children in pain. Nonpharmacological interventions are an essential part of pain management. The purpose of this review was to examine what nonpharmacological interventions EDs are using for pain management in children ages birth to 18 years. A systematic literature search was conducted to examine nonpharmacological interventions used for pain management of children in EDs. Fourteen articles met the inclusion/exclusion criteria. Ten studies used distraction, 2 examined the use of sucrose, 1 explored cold application, and 1 looked at parental holding and positioning. Benefits of using nonpharmacological methods included decreased pain, distress, and anxiety reported by the parent, child, and/or observer. Findings suggest nonpharmacological interventions such as distraction, positioning, sucrose, and cold application may be helpful in pediatric pain management in the ED. Nurses can implement these methods independently when caring for children and their families. In addition, nonpharmacological methods are relatively inexpensive to organizations.

Patient anxiety may influence the efficacy of ED pain management

ObjectiveThe aim of this study was to evaluate the incidence of anxiety and rates of anxiety treatment in emergency department (ED) patients presenting with pain-related complaints. MethodsWe prospectively evaluated patients in an urban academic tertiary care hospital ED from 2000 through 2010. We enrolled a convenience sample of adult patients presenting with pain and recorded patient complaint, medication administration, satisfaction, and pain and anxiety scores throughout their stay. We stratified patients into 4 different groups according to anxiety score at presentation (0, none; 1-4, mild; 5-7, moderate; 8-10, severe). ResultsWe enrolled 10 664 ED patients presenting with pain-related complaints. Patients reporting anxiety were as follows: 25.7%, none; 26.1%, mild; 23.7%, moderate; and 24.5%, severe. Although 48% of patients described moderate to severe anxiety at ED presentation and 60% were willing to take a medication for anxiety, only 1% received anxiety treatment. Thirty-five percent of patients still reported moderate/severe anxiety at discharge. Severe anxiety at ED presentation was associated with increased demand for pain medication (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10-1.79) and anxiety medication (OR, 4.34; 95% CI, 3.68-5.11) during the ED stay and decreased satisfaction with the treatment of pain (β coefficient = −0.328; P < .001). After adjusting for age, sex, and presentation pain scores, patients who reported severe anxiety were more likely to receive an analgesic (OR, 1.33; 95% CI, 1.19-1.50) and an opioid (OR, 1.25; 95% CI, 1.11-1.41) during the ED stay. ConclusionAnxiety may be underrecognized and undertreated in patients presenting with pain-related complaints. Patients reporting severe anxiety were less likely to report satisfaction with the treatment of their pain, despite higher rates of analgesic administration.

Sickle Cell Disease Patients' Perceptions of Emergency Department Pain Management

Patients with sickle cell disease (SCD) experience painful crises that often require admission to the emergency department (ED) for pain management. Factors such as ED overcrowding and negative perception and stigmatization of SCD may impact patients' perceptions of the quality of pain management in the ED. Data from a multisite prospective cohort study was assessed to determine whether demographic (age and sex), clinical (time to administration of initial analgesia, number of analgesic doses, discharge disposition, and clinical site), or interpersonal factors (separately measured perceptions of being treated with trust and respect by ED triage nurses, nurses, and physicians) were associated with patient ratings of their pain management in the ED. Patients were adults with SCD seen at 3 EDs (2 urban and 1 rural). Demographic and clinical information was derived from medical record review; interpersonal and ED pain management ratings were derived from interviews conducted 1 week post ED visit. A total of 209 interviews by 98 patients were analyzed. Results indicated significant differences among the ED sites on the demographic, clinical, and interpersonal factors. Overall, patients reported being treated with trust and respect by ED clinicians. Adjusted logistic regression analyses indicated that ED clinical site 1 (odds ratio [OR], 10.42; 95% confidence interval [Cl], 1.44-7.36) and being treated with trust and respect by the ED physician (OR, 25.53; 95% CI, 2.07-314.96) predicted good ED pain management ratings. Interpersonal health care experiences may be an important indicator of patient satisfaction and quality of care received by patients with SCD in the ED.

An Intervention to Improve Pain Management in the Pediatric Emergency Department

The objective of this study was to measure the impact of a structured intervention on pain management in a pediatric emergency department (ED). Data were prospectively collected from children presenting to an urban tertiary care pediatric ED before and after intervention. Data were collected on the rate and timeliness of analgesic administration, the assessment and reassessment of pain, periprocedural anesthesia, and patient satisfaction. The intervention was developed by a multidisciplinary committee composed of physicians, nurses, and child life specialists and was focused on correcting deficiencies identified before intervention data collection. It consisted of a policy defining pain, pain-appropriate analgesia, age-appropriate pain assessment, and adequate preprocedural and periprocedural analgesia. Implementation occurred through provider education, organizational changes, and patient empowerment. One hundred two patients were enrolled during the preintervention period, and 109 were enrolled in the postintervention period. The percentage of patients in pain receiving any analgesic increased from 34% to 50%, an increase of 16% (95% confidence interval [CI], 1%-30%). The median time to medication administration decreased from 97 minutes to 57 minutes, a decrease of 40 minutes (95% CI, -84 to 4 minutes). The percentage of children receiving preprocedural analgesia increased from 10% to 62%, an increase of 52% (95% CI, 12%-74%). Reassessment of pain by physicians increased from 6% to 76%, an increase of 70% (95% CI, 59%-78%). A structured intervention, tailored to pain management shortcomings commonly found in the pediatric ED, can lead to improvements in the treatment and prevention of pain in childhood emergencies.

Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.

The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED.

Characteristics of effective interventions supporting quality pain management in Australian emergency departments: An exploratory study

It is well established that pain is the most common presenting complaint in Emergency Departments. Despite great improvements in available pain management strategies, patients are left waiting for longer than 60min for pain relief on arrival to the emergency department. The aim of this study was to describe interventions that lead to successful implementation of the National Health and Medical Research Council approved guidelines Acute Pain Management: Scientific Evidence (2nd Edition) that include specific recommendations for best practice pain management. A two-phased, mixed-method, exploratory study of all 52 Australian hospital emergency departments participating in the National Emergency Care Pain Management Initiative incorporating interview and document analysis was undertaken. Interventions used by clinicians to improve pain management included nurse initiated analgesia, intranasal fentanyl for paediatric patients and lignocaine, and facio illiaca block. Education formed a major part of the intervention and the development of a working group of key stakeholders was critical in the successful implementation of change. Staff perceptions of patients' pain level and attitudes toward pain assessment and pain management were identified as barriers. This study highlighted how an effective framework to plan and implement practice change and tailored interventions, including education and training systems and products using the best available evidence, best equipped clinicians to manage pain in the ED.

Pain management in Australian emergency departments: Current practice, enablers, barriers and future directions

To explore current pain management practice in Australian EDs and identify enablers and barriers for best-practice pain management. Five focus groups and two in-depth interviews were held with ED clinical staff (n= 47) from six hospitals in three states. Participants were asked open-ended questions to determine current pain management practices, enablers and barriers to implementing best-practice pain management, and understand change in practice within the ED setting. Emergency department staff identified a gap between evidence-based pain management recommendations and everyday practice. Perceived barriers to improving pain management included a lack of time and resources, a greater number of urgent and serious presentations that place pain management as a lower priority, organizational protocols and legislative issues. All groups noted difficulty in applying pain management guidelines in the context of competing priorities in the challenging ED environment. A culture of learning clinical practice from respected senior staff and peers was perceived to be a key enabler. Participants consistently expressed the view that evidence-based practice improvement should be championed by senior clinical staff, and that evidence to demonstrate the benefits of change must be presented to support the need for change. Effective and sustainable system change requires a strategy that is initiated within the ED, targets opinion leaders, is supported by evidence, and engages all levels of ED staff.

234 Facilitators of Evidence-Based Pediatric Pain Management in Emergency Departments: Similarities and Differences between Critical Access, Rural-Rural Referral, and Urban Hospitals

234 Facilitators of Evidence-Based Pediatric Pain Management in Emergency Departments: Similarities and Differences between Critical Access, Rural-Rural Referral, and Urban Hospitals

418 Patient Anxiety May Influence Efficacy of Emergency Department Pain Management

418 Patient Anxiety May Influence Efficacy of Emergency Department Pain Management

Evidence-Based Pediatric Pain Management in Emergency Departments of a Rural State

Evidence-based pediatric pain management (EBPPM) has been identified as a practice too often overlooked in Emergency Departments (EDs). Studies show EBPPM is practiced inconsistently in urban EDs, and even less is known about the practice in rural EDs. The objectives of this study were: A) Determine the frequencies with which specific EBPPM practices are used in EDs of a primarily rural state; and B) Explore the differences in EBPPM practice in Critical Access, rural, and urban hospital EDs. A web-based survey, measuring the use of 14 EBPPM practices, was offered to all licensed independent providers (Medical Doctors, Doctors of Osteopathy, Physicians’ Assistants, and Advanced Registered Nurse Practitioners) and nurses from the 118 hospital EDs in a rural state. Responses from 259 providers and 1,177 nurses revealed that the majority of respondents infrequently used any type of topical analgesic before venipuncture or IV insertion in children, or oral sucrose for infant procedures. Tests for group differences show that providers from urban EDs more frequently used a topical analgesic for suturing lacerations, provided analgesics for blood draws, and gave pain medication to children with abdominal pain. Nurses from urban hospitals used significantly more EBPPM practices than nurses from Critical Access and rural hospitals ( P < .001). Perspective In hospitals of all types, ED providers and nurses fail to take advantage of EBPPM practices. This study reveals that health professionals in rural settings are particularly in need of improving the use of recommended pediatric pain management practices.

Factors affecting and strategies to improve pain management in emergency departments: a comprehensive systematic review.

Factors affecting and strategies to improve pain management in emergency departments: a comprehensive systematic review.

Factors affecting and strategies to improve pain management in emergency departments: a comprehensive systematic review.

Review question/objective The objectives of the review are to determine the best available evidence on strategies to improve pain management and factors affecting pain management in emergency departments. More specifically, the review questions are to identify: - What are the best strategies to improve pain management in emergency departments? - What are the factors improving pain management in emergency departments? - What are the factors hindering pain management in emergency departments? Inclusion criteria Types of participants This review will consider both qualitative and quantitative publications that include patients, their family members, physicians, or nurses in emergency departments. Types of intervention(s)/phenomena of interest The quantitative component of the review will consider studies that evaluate the strategies to improve pain management and factors affecting pain management in emergency departments. The qualitative component of this review will consider studies that explore the experiences of patients, family members, physicians or nurses in emergency departments regarding the pain management. Types of outcomes Quantitative: The quantitative component of this review will consider studies that include, but not limited to, the following outcome measures: patient satisfaction, relief or reduction of pain, and time to first analgesia.

Pain management in emergency departments: a review of present protocols in The Netherlands

This descriptive study presents availability and content of acute pain protocols in emergency departments (EDs) in The Netherlands. Current acute pain protocols were collected and an a priori list of questions was used for analysis. Findings were compared with current international standards. Sixty-six of the 108 EDs responded. Fifty-six percent of the protocols did not address adults and 35% did not address children. Protocols were rather conservative and showed poor multidisciplinary approach. Seventy-three percent required a diagnosis before pain relief. Six percent did not include opioids, 36% did not allow intravenous opioids and only 49% allowed direct administration of opioids in severe pain. Pain measurement was included in 55% and in only 5% a target score was defined. Nonpharmacological approaches were mentioned in 6%. Acute pain protocols are lacking in many EDs. Most protocols did not apply current standards. We exposed an area with space for leadership.

Pain Management in Emergency Departments has Improved but Can Still be Better

Pain Management in Emergency Departments has Improved but Can Still be Better

Intravenous opioid dosing and outcomes in emergency patients: a prospective cohort analysis

Objectives Pain management in emergency department (ED) patients is variable and often inadequate. This study sought to (1) describe the variability in intravenous opioid dosing and (2) compare the outcomes that result from the most commonly prescribed opioid doses. Methods This prospective cohort study enrolled emergency patients who were prescribed intravenous morphine or hydromorphone as their initial analgesic. Subjects were interviewed at the time of opioid administration and 1 to 2 hours after opioid administration. Outcomes included the numeric pain score change (using a 0-10 scale), the proportion achieving a 50% pain score reduction, and the proportion developing side effects. Logistic regression was used to assess the effects of demographic, clinical, and treatment variables on outcomes. Results Six hundred ninety-one patients were analyzed. Initial equianalgesic dosages varied by a factor of 27 (from 1 mg morphine to 4 mg hydromorphone). Opioid dose titration occurred in only 21% of patients. Outcomes were similar across the range of opioid dosages before and after adjusting for potentially confounding variables. Among patients not taking opioids at home who received a total of 4 mg of morphine or less. 48% achieved at least a 50% pain score reduction and 60% did not want additional analgesics. Conclusions We found marked opioid dosing variability and infrequent opioid dose titration. A substantial number of ED patients with severe pain responded well to relatively low opioid dosages. Improved ability to predict opioid dose requirements and strategies that increase the use of opioid dose titration in ED patients are needed.

An Australian audit of Emergency Department pain management patterns

An Australian audit of Emergency Department pain management patterns

Impact of Physician and Patient Gender on Pain Management in the Emergency Department—A Multicenter Study

Pain is a complex experience influenced by factors such as age, race, and ethnicity. We conducted a multicenter study to better understand emergency department (ED) pain management practices and examined the influence of patient and provider gender on analgesic administration. Prospective, multicenter, observational study. Consecutive patients, >or=8-years-old, presenting with complaints of moderate to severe pain (pain numerical rating scale [NRS] > 3) at 16 U.S. and three Canadian hospitals. Receipt of any ED analgesic, receipt of opioids, and adequate pain relief in the ED. Eight hundred forty-two patients participated including 56% women. Baseline pain scores were similar in both genders. Analgesic administration rates were not significantly different for female and male patients (63% vs 57%, P = 0.08), although females presenting with severe pain (NRS >or=8) were more likely to receive analgesics (74% vs 64%, P = 0.02). Female physicians were more likely to administer analgesics than male physicians (66% vs 57%, P = 0.009). In logistic regression models, predictors of ED analgesic administration were male physician (odds ratio [OR] = 0.7), arrival pain (OR = 1.3), number of pain assessments (OR = 1.83), and charted follow-up plans (OR = 2.16). With regard to opioid administration, female physicians were more likely to prescribe opioids to females (P = 0.006) while male physicians were more likely to prescribe to males (P = 0.05). In logistic regression models, predictors of opioids administration included male patient gender (OR = 0.58), male patient-physician interaction (OR = 2.58), arrival pain score (OR = 1.28), average pain score (OR = 1.10), and number of pain assessments (OR = 1.5). Pain relief was not impacted by gender. Provider gender as opposed to patient gender appears to influence pain management decisions in the ED.

Minimizing the ‘ouch’—A strategy to minimize pain, fear and anxiety in children presenting to the emergency department

Summary This paper will discuss the role of distraction in reducing pain and anxiety during medical procedures and examinations for children. Specifically the implementation and evaluation of ‘distraction boxes' into emergency departments throughout Hunter New England Health Southern Sector, NSW, Australia, will be discussed. In recent years significant advances have been made in the assessment and management of children's pain when they are hospitalized. However, despite these advances, studies and reviews continue to indicate that pain management, particularly procedural pain management in emergency departments is poorly managed. The predictive nature of procedural pain provides an excellent opportunity for health care professionals to minimize the pain and anxiety experienced by children by intervening appropriately before, during and even after the procedure or examination with developmentally appropriate distraction techniques.

Management of pain in a surgical emergency unit—Underlying factors affecting its delivery

Pain is an important symptom in emergency departments. The purpose of this study was to evaluate possible obstacles to pain management in a surgical emergency department. All patients arriving in the ED (N = 100) during the time period were asked to participate in an interview. Information about medication, patient history, and documented pain intensity were extracted from patient records. In addition, a questionnaire with six demographic and 31 pain-related items was distributed to 50 physicians and 82 nurses. Pain was the most important symptom of 60.3% (N = 46) of the respondents. Severe pain was reported by 45.8% of the patients. Analgesics were administered to 46.6% of the respondents (N = 34). None of the patients received nonsteroidal anti-inflammatoric analgesics (NSAIDs). Male gender, lower educational level and high age correlated with reluctance to accept analgesics. Experience of pain and the healthcare system correlated with unwillingness to talk about pain. The nurses were more positive towards measurement of pain (p < 0.05) and encouragement (p < 0.001) than the physicians. The physicians were less concerned about problems with analgesics than the nurses (p < 0.01). The patients should be encouraged to talk about their pain. The emergency department personnel needs education about measurement of pain and pain medication.

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.