Pain Management In Emergency Department Research Articles

Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, “nurses influence ED pain management” and “adjustments in ED pain management”, and an overarching message that “pain management depends on the care team.” By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.

Observational, Retrospective Evaluation of a New Nurse-Initiated Emergency Department Pain Management Protocol

BackgroundTriage nurses are important in pain management and in early relief of pain among patients admitted to the emergency department (ED). AimsTo assess a new nurse-initiated pain management protocol, without the requirement for medical prescription, wich was implemented in October 2016 for patients with moderate or severe pain in the ED. It allows the administration of oral acetaminophen and oral oxycodone chlorydrate during the first evaluation of the patient by a nurse and eliminates the use of codeine or tramadol. MethodsWe conducted a comparative, single-center, retrospective study that looked at the outcomes of a new nursing protocol for patients aged ≥16 years with moderate to severe pain. The primary outcome was the percentage of increase of analgesics delivered by the nurse. ResultsA total of 756 patients were included: 377 before and 379 after protocol implementation. Oral analgesic use on admission increased from 44.3% to 57.8% (p < .001), and from 50.2% to 76.6% among patients with severe pain (p < .001). Strong opioid analgesic administration increased from 2.1% to 41.2%. This increase was also observed among those with moderate pain (1.4% to 13.3%; p < .001) and those with severe pain (2.6% to 62.6%; p < .001). Analgesic prescriptions added by the clinician decreased from 28.6% to 21.4% (p = .028). ConclusionsWe observed an increase in analgesic administration after the implementation of a new nurse-initiated pain treatment protocol, especially an increase in oral opioid analgesics, for patients with moderate to severe pain.

Discordance between patient-reported and actual emergency department pain management.

To determine patient knowledge of the nature of their pain management in the ED. This was a planned sub-study of data collected during a randomised, controlled trial of the nature of the informed consent process in a single ED. Patients aged ≥18 years, with a triage pain score of ≥4, were enrolled. Forty-eight hours post-ED discharge, patients were asked if they had declined analgesia or if a range of pain management options had been administered. The primary outcome was discordance between the patient report and the ED report (proportion of cases where these reports differed). Outcome data were collected on 655 patients. There was significant discordance for all variables examined (P < 0.001). Discordance for patients declining analgesia was lowest at 8.9% (95% confidence interval [CI] 6.8-11.4). Discordance for administration of pain management 'other' than analgesia was highest at 32.6% (95% CI 29.0-36.4). Discordance for the administration of oral analgesia or 'any' analgesia was 17.1% (95% CI 14.3-20.3) and 14.4% (95% CI 11.8-17.3), respectively. For both of these outcomes, patients with chest pain and lower triage pain scores were more likely to report discordant responses. With the exception of 'other' pain management, smaller proportions of patients incorrectly reported not receiving management than incorrectly reporting that they did receive it. Patients are often unaware of the nature of their pain management. They are most often unaware of management other than analgesia. Patients with chest pain and lower triage pain scores had the least knowledge of their pain management.

Planning Development Level of Evidence Pain Management in Pre-hospital Emergency Department: A Systematic Review

Introduction: Regarding pre-hospital pain management focus on the emergency department, safety of analgesics used is one of the concerned areas to be developed clearly. However, the current level of evidence in pre-hospital pain management of injured patients, focusing on the safety and effect of pre-hospital analgesia has not been explored. The aim of this study was to analyze the level of evidence in pre-hospital pain management of injured patients, focusing on the safety and effect of pre-hospital analgesia. Methods: A systematic review was performed in this study with inclusion criteria adult-elderly injured patients in pre-hospital setting and used analgesic agents. Articles were sourced from electronic database Scopus, PubMed, Science Direct, Springer Link and ProQuest, which were searched to identify all the relevant articles published over the last five years in English. Fifteen studies were included are qualified as articles assessment with Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Results: Nine studies were Randomized Control Trial, two studies cross-sectional and retrospective, and one study prospective descriptive and cohort. The result showed that many types of analgesic are used or planned in emergency areas, such as morphine, ketamine, fentanyl, NSAID with different route intravenous, intramuscular and subcutaneous with safety and monitoring continuously by healthcare professionals. Conclusion: The use of pre-hospital analgesia for injured patient in pre-hospital setting is commonly used by health workers according to pain management standard and guidelines; planning developments are needed for safety and management as a concern for focus on quality of pain management status.

Optimizing telehealth pain care after COVID-19.

Optimizing telehealth pain care after COVID-19.

Emergency department pain management in older patients.

Emergency department pain management in older patients.

Behavioral Conditioning, the Placebo Effect, and Emergency Department Pain Management.

Animals and humans can be readily conditioned to associate a novel stimulus (often a unique taste) by pairing it with the effects of a drug or other agent. When later presented with the stimulus alone, their body's systems respond as if the drug or agent were given. The earliest clinical applications demonstrated both conditioned suppression and enhancement of immune processes. Unique benign stimuli, paired with chemotherapy, come to elicit T-cell suppression when administered alone. The beneficial immune responses to an antigen can be conditioned in the same manner. Further study of what came to be called "psychoneuroimmunology" led to the understanding that the familiar placebo effect, previously attributed to suggestion and expectation, is at least equally dependent on the same sorts of behavioral conditioning. The demonstrated ability to manipulate the immune system by a conditioned taste stimulus is, by definition, a placebo: a therapeutic effect caused by an inactive agent. The purpose of this analysis was to stimulate research in, and the application of, placebo-response conditioning to emergency medicine. Clinical and experimental studies confirm the usefulness of conditioned placebos in analgesia and in placebo-controlled dose reduction. Such conditioning paradigms demonstrate "one-trial learning," making them potentially useful in pain and addiction management within a single emergency department encounter.

Hip fracture pain management in a regional Australian emergency department: A retrospective descriptive study

BackgroundHip fractures are a common and painful emergency presentation amongst elderly patients and are associated with significant morbidity and mortality. This study observed the frequency of documentation of pain scores and use of nerve blocks in hip fracture patients in a regional Australian ED and describes current practice in relation to national guidelines. MethodsThis was a retrospective single-site observational study and included all patients with a recorded ED diagnosis of fracture neck of femur over the age of 18 presenting between 1 July 2017 and 31 December 2017 to a regional ED. Data collection included patient demographics, pain scores and analgesia administered. ResultsNinety-three patients were included in analysis. This population had a high proportion of patients who had a residential address remote to the base hospital. Thirty-eight patients (41%) had a documented pain score within 30min and the frequency of nerve blocks was 45%. ConclusionManagement of pain for patients with hip fracture in this regional ED varied from Australian guidelines and practice in other Australian EDs, demonstrating potential areas for further research and quality improvement in assessing and treating pain in older adults. Geographic remoteness may be an important factor.

Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures.

To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. We performed a 3-year retrospective cross-sectional study of children <18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≥2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain). In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51-1.95]; Hispanic: 1.32 [1.16-1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14-1.76]; Hispanic: 1.38 [1.04-1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77-0.95]; Hispanic: aOR 0.86 [0.76-0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67-0.90]; Hispanic: aOR 0.80 [0.67-0.95]). There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.

Implicit Bias in Pediatrics: An Emerging Focus in Health Equity Research.

* Abbreviation: ED — : emergency department Despite large-scale investments in research, health policy, care delivery models, and medical school curricula, inequities along the continuum of child health care and health persist.1,2 The study “Racial and Ethnic Differences in Emergency Department Pain Management of Children with Fractures”3 in this issue of Pediatrics contributes new insights into the field of pediatric health equity research with a focus on pain in the emergency department (ED) setting. Goyal et al3 find that although racial and/or ethnic minority children were more likely to receive analgesics and achieve a ≥2-point reduction in pain, they were less likely to receive opioids and experience optimal pain reduction. This work builds on a well-established body of literature in adult care and an emerging evidence base in pediatrics demonstrating inequities in analgesic administration.4 Studies in pediatric EDs have demonstrated racial and/or ethnic disparities in analgesic management for children presenting with acute abdominal pain and appendicitis.5,6 The current study adds to the field by combining process and outcome measures in assessing analgesic management. As the authors and other researchers in the field have highlighted, there … Address correspondence to Jean L. Raphael, MD, MPH, Texas Children’s Hospital, 6701 Fannin St, Suite D.1540.00, Houston, TX 77030. E-mail: raphael{at}bcm.edu

The success rate of posterior tibial nerve block in the ankle with and without ultrasound guidance: A clinical trial study for pain management in emergency departments

Objective: The purpose of the current study was to assess the success rate of posterior tibial nerve block in the ankle with and without ultrasound guidance for pain management in emergency departments. Methods: This clinical trial was conducted on 80 individuals who needed posterior tibial nerve block in the ankle at the emergency department of Hashemi Nejad hospital and Edalatian emergency center in Mashhad, Iran. The eligible individuals were randomly assigned to one of two groups, designated the control (landmark-based nerve block) and the case group (ultrasound-guided nerve block). The two groups were compared in terms of the main measurable outcomes. The data were analyzed using SPSS software (version 20) by nonparametric tests. Results: According to the findings, the mean and median of nerve block success in the landmark-based and ultrasound-guided methods were significantly different between the two groups, both 15 (P=0.02) and 30 (P=0.001) min post-intervention. In this regard, nerve block with ultrasound guidance had a higher success rate compared to the landmark method. However, no significant difference between the two interventions was found in terms of the mean and median of the procedure duration (P=0.8) and injection frequency (P=0.4). On the other hand, the two groups were significantly different regarding the median and mean of patient satisfaction (P=0.00), duration of analgesia (P=0.004), and nerve block-related complications (P=0.03). Conclusion: The findings revealed that the relatively new technique of nerve block by ultrasound-guide resulted in better outcomes than the landmark-based method. Consequently, this method could be adopted to control acute pain in the emergency departments and improve patient care.

Pain management in children has significantly improved in the Italian emergency departments.

Pain in children is often poorly assessed and treated in Italian emergency departments (EDs) as found in a survey conducted among the centres of the "Pain in Pediatric Emergency Room (PIPER)" Study Group in 2010. Our aim was to evaluate the changes in pain management in Italian EDs in the last years. A structured questionnaire about pain assessment, protocols, use of local anaesthetics before venipuncture, opioids and adjuvants was mailed to 46 Italian EDs between November 2017 and April 2018. Pain was always assessed at triage in 34 centres (73.9%). Algometric scales were used in over 90% of EDs. Triage protocols were available in 37 centres (80.4%). Local anaesthetics before venipuncture were always used in six centres (13.0%). Protocols included opioids and adjuvants in 73.0% and 47.2%, respectively. Triage pain assessment was always done in 91.0% of the centres joining the PIPER Study Group up to 2015 and 56.5% in ones that joined the Group after 2015 (P=.017). Local anaesthetics before venipuncture were given in 39.1% of the centres joining until up to 2015 and 13.0% in ones that joined the Group after 2015 (P=.003). Paediatric pain management has significantly improved in Italian EDs in the last 8years. The centres joining the PIPER Study Group for longer time have shown better results for the indicators considered in the survey.

Ultrasound-Guided Serratus Anterior Plane Block for Rib Fracture-Associated Pain Management in Emergency Department.

Context:Traumatic Rib fractures are common and painful conditions to present in the emergency department. Ultrasound-guided serratus anterior plane block (SAPB) is a newer technique which is being used for managing postthoracotomy, thoracoscopic surgery, or post mastectomy pain by the anesthetists. However, we have recently started utilizing this novel technique in our emergency department for rib fracture patients with severe pain.Settings and Methods:We present a case series of 10 patients of multiple rib fractures (MFRs) with persistent Defense and Veterans Pain Rating Scale 7 or more even after intravenous analgesics where this block was applied by trained emergency physicians (EP).Results:Following SAPB median (± IQR) pain score reduction was 5 (±4) at 30 min and 7.5 (±2) after 60 min of administering the block. There were no incidences of block failure or block-related complications in our series.Conclusions:Ultrasound-guided SAPB can be used safely by trained EP in the emergency department to relieve acute severe analgesic-resistant pain in MFR patients.

Procedural pain management in a community emergency department: A pilot study of feasibility and efficacy

Abstract Introduction: Pain is a common reason for presentation to the Emergency Department, and non-opioid therapies to relieve pain are desirable. Access to pain management programs may be limited in community

Emergency nurses\xb4 knowledge, attitude and perceived barriers regarding pain Management in Resource-Limited Settings: cross-sectional study

BackgroundPain is a common phenomenon among emergency patients which may lead to chronic pain conditions and alteration of physiological function. However, it is widely reported that proper pain assessment and management, which is often accomplished by adequately trained nurses reduce the suffering of patients. Therefore, the aim of this study was to assess the emergency nurses´ knowledge, attitude and perceived barriers regarding pain management.MethodsA cross-sectional quantitative study design was applied to determine the nurses´ knowledge level, attitude and the perceived barriers related to pain management. Hundred twenty-six nurses from the emergency departments of seven referral hospitals of Eritrea participated in the study. Data were collected in August and September 2017. Both descriptive and inferential statistics were used to summarize and elaborate on the results.ResultIn general, the knowledge level and attitude of the emergency nurses was poor. The participants’ correct mean score was 49.5%. Nurses with Bachelor’s Degree had significantly higher knowledge and attitude level compared to the nurses at the Diploma and Certificate level of professional preparation (95% CI = 7.1–16.7 and 9.4–19.1; p < 0.001) respectively. Similarly, nurses who had previous training regarding pain scored significantly higher knowledge level compared to those without training (95% CI =1.82–8.99; p = 0.003). The highest perceived barriers to adequate pain management in emergency departments were measured to be overcrowding of the emergency department (2.57 ± 1.25), lack of protocols for pain assessment (2.45 ± 1.52), nursing workload (2.44 ± 1.29) and lack of pain assessment tools (2.43 ± 1.43). There was no significant difference in perceived barriers among nurses with different demographic characteristics.ConclusionThe emergency nurses’ knowledge and attitude regarding pain management were poor. Nurses with higher educational level and nurses with previous training scored significantly higher knowledge level. This indicates the need for nursing schools and the ministry of health to work together to educate nurses to a higher level of preparation for pain assessment and management.

A Comparative study of the administration of a single bolus of ketamine versus bolus administration followed by continuous infusion in the management of traumatic limb pain in a low income country

Introduction &#x0D; Ketamine has proven its analgesic efficacy in the management of pain due to limb trauma. There is still doubt about how to integrate ketamine into medical practice in emergency departments, including continuous infusion and bolus. The aim of this study is to compare the efficacy of ketamine administered in a single bolus with ketamine administered in a bolus relayed by a continuous infusion on traumatic limb in a context of under-equipment&#x0D; Methods&#x0D; This was a randomized, double-blind clinical trial. It took place at Ouahigouya teaching hospital over a three-month period. Any adult patient aged 18 to 65 admitted to the emergency room for limb trauma with severe pain ≥ 7 on a numerical scale (EN) was included in the study. Patients were randomized into two groups. Group 1 received a bolus of ketamine relayed by continuous infusion and group 2 received a bolus of ketamine relayed by isotonic saline infusion. The main endpoint was total morphine consumption at the end of treatment (maximum 60 minutes).&#x0D; Results&#x0D; A total of 66 patients were included; 33 in each group. The groups were statistically comparable. There was no significant difference between the two groups in morphine requirements. Indeed, 27.27% of Group 1 patients and 21.21% of Group 2 patients used morphine to relieve their pain (p = 0.29).The average dose of morphine received at the end of management (T + 60 minutes) was 6 ± 2.6 mg in Group 1 and 5.14 ± 1.46 mg in Group 2. There was no significant difference between these doses (p = 0.44). No serious side effects were noted in either group. The patient satisfaction index was on average 7.24 ± 0.75 and 7.3 ± 0.77 respectively in Group 1 and 2 (not significant difference p = 0.74).&#x0D; Conclusion&#x0D; The administration of ketamine as a single bolus is as effective as the bolus followed by continuous infusion. It is therefore up to practitioners to develop protocols for the safe use of this molecule, which will undoubtedly contribute to improving pain management in emergency departments, especially those in low income countries.

Knowledge, attitudes, and practices of Cameroonian physicians with regards to acute pain management in the emergency department: a multicenter cross-sectional study

IntroductionPain is the most frequent presenting complaint in patients consulting or admitted to the emergency department (ED). Thus, its acute management is often done by physicians working in the ED. These clinicians are often general practitioners and not emergency medicine physicians in resource-poor settings. Hence, a mastery of pain management by these physicians may be important in relieving acute pain. We aimed to assess the knowledge, to determine the attitudes and practices of physicians in the management of pain in EDs of Cameroon.MethodsWe carried out a prospective cross-sectional study over 4 months in the year 2018. We enrolled all consenting physicians who were neither emergency medicine doctors nor anesthesiologists working at the EDs of five tertiary hospitals of Cameroon. Using a validated and pretested structured questionnaire, data on the knowledge, attitudes, and practices of acute pain management at the ED by these clinicians were studied. We used an externally validated score to assess the knowledge as either poor, insufficient, moderate or good.ResultsA total of 58 physicians were included; 18 interns or residents and 39 general practitioners. Their mean age was 28.6 ± 3 years and their average number of years of practice was 2.9 years. The level of knowledge was rated “poor” in 77.6% of physicians. Being a general practitioner was significantly associated with a poor level of knowledge (p = 0.02; OR = 5.1). We found a negative and significant correlation between knowledge and years of practice (p = 0.04; r2 = 0.06). More than three-quarter (82.8%) of participants used a pain scale to evaluate the severity of pain. The most used scale was the Visual Analog Scale (56.9%). The most frequently used analgesic was paracetamol (98.3%), although only 3.5% of physicians correctly knew its half-life, delay of onset of action and duration of action.ConclusionThese findings suggest that physicians in EDs of Cameroon have poor knowledge and suboptimal practices in pain management. General practice and a greater number of professional experience seemed to favour these attitudes. Overall, there is an urgent need for refresher courses in acute pain management for physicians working in these resource-limited EDs.

Pain management decisions in emergency hospitals are predicted by brain activity during empathy and error monitoring

ObjectivePain undertreatment, or oligoanalgesia, is frequent in the emergency department (ED), with major medical, ethical, and financial implications. Across different hospitals, healthcare providers have been reported to differ considerably in the ways in which they recognise and manage pain, with some prescribing analgesics far less frequently than others. However, factors that could explain this variability remain poorly understood. Here, we used neuroscience approaches for neural signal modelling to investigate whether individual decisions in the ED could be explained in terms of brain patterns related to empathy, risk-taking, and error monitoring. MethodsFor 15 months, we monitored the pain management behaviour of 70 ED nurses at triage, and subsequently invited 33 to a neuroimaging study involving three well-established tasks probing relevant cognitive and affective dimensions. Univariate and multivariate regressions were used to predict pain management decisions from neural activity during these tasks. ResultsWe found that the brain signal recorded when empathising with others predicted the frequency with which nurses documented pain in their patients. In addition, neural activity sensitive to errors and negative outcomes predicted the frequency with which nurses denied analgesia by registering potential side-effects. ConclusionsThese results highlight the multiple processes underlying pain management, and suggest that the neural representations of others' states and one's errors play a key role in individual treatment decisions. Neuroscience models of social cognition and decision-making are a powerful tool to explain clinical behaviour and might be used to guide future educational programs to improve pain management in ED.

(324) Characterizing Expectations for Functional Outcomes in Emergency Department Patients with Musculoskeletal Pain

Over 13% of Emergency Department (ED) visits are for musculoskeletal pain, but little is known about ED patients’ expectations for pain management and pain-related functional outcomes. This cross-sectional study surveyed adults seeking care at an academic ED with a primary complaint of neck, back or extremity pain. Survey data included the previously validated Patient Centered Outcomes Questionnaire to rate pain interference with activities on a scale of 0 (none) to 100 (worst imaginable) across usual, desired, successful, and expected outcome levels, as well as patient-reported use of various pharmacological and non-pharmacological modalities for pain relief. Responses were analyzed from 106 patients, with mean age 42.4 years (SD 15.6); 52% female; 63% African American and 27% Caucasian. For primary location of pain, 46% identified back, 32% leg, 13% arm, and 11% neck. Median duration of pain was 3 days (IQR 1-7), and 36% reported previous episodes of this pain. Reported median usual pain interference with activities in the past week was 66 (IQR 40-94). Patients desired a median 100% reduction (IQR 89-100%) in interference, but considered 77% reduction successful (IQR 49-100%), and only expected a 52% reduction (IQR 9-91%) after treatment. Most patients were willing to take opioid (73%) and non-opioid (79%) pain medications, despite only 32% having taken an opioid and 55% having taken a non-opioid for pain. Most were also willing to engage in non-pharmacological treatments including direct/passive modalities such as heat, cold packs, acupuncture, and massage (84%); indirect/psychosocial modalities such as music, prayer and meditation (80%); and physical/active modalities such as yoga, exercise, and physical therapy (66%). However, current use of non-pharmacological modalities only ranged from 36-50%. This foundational data highlights an opportunity to incorporate patient perspectives in setting treatment goals and expanding treatment options for integrated, multi-modal pain management in the ED.

Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative.

Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain. A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important. Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%). These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.