Pain treatment in the emergency department: what do patients think?
*Sylweriusz Kosiński1, Bogusława Siudut2
1Therapy, Specialist Hospital of Lung Diseases in Zakopane
2Emergency Department, County Hospital in Zakopane
Background. Pain on admission, especially after trauma, is the most common complaint (over 80%) of patients in the emergency department. During a four-week period, an anonymous, voluntary survey on the quality of pain management was conducted among adult patients reporting to the emergency department.
Methods. Five hundred questionnaires were distributed during admission, and 260 were returned. Patients were asked about localisation and severity of pain (NRS – Numerating Rating Scale), the quality and speed of assistance in the emergency department, and the effectiveness of analgesia.
Results. Ninety percent of patients reported pain of varying intensity. The median pain scores on admission were 5.2, 7.3 during management, and 3.8 on discharge. Over 90% of patients were questioned about pain, but only 20% received some medication. Nevertheless, 80% of those surveyed were satisfied, and there was no correlation between the severity of pain and administration of analgesics. Fifty percent of patients received analgesics for home use, and 66% were instructed about further treatment.
Conclusions. Despite the frequency and intensity of pain, analgesics were rarely offered in the emergency department. A surprisingly high level of satisfaction was reported, despite suboptimal pain management. This indicates either that non-pharmacologic methods of pain treatment play an important role, or that the severity of pain is overestimated by patients.
According to estimates, up to 80% of patients reporting to emergency departments complain of pain of various severities [1, 2]. Only about half of them receive pharmacological pain treatment, whose effectiveness is often dubious [3, 4]. The reasons are not fully clear yet the key impediment to effective analgesia is thought to be lack of understanding of the problem on the part of medical personnel and anachronistic opinions concerning the role of pain in the diagnostic process [5, 6, 7]. Moreover, the individual ways of experiencing pain by patients and their preferences may be of importance .
A questionnaire study was conducted among patients reporting to the hospital emergency department (ED) to determine the opinions and feelings of patients about pain and its treatment as well as the analgesic efficacy of pain management.
A specially designed questionnaire included instructions how to use the numerical rating scale (NRS) and questions about the nature of pain sensations and their treatment.
Patients participated on a voluntary basis; questionnaires were available in several places of ED throughout the period of 24 h. The medical staff responsible for initial segregation and admissions to ED was to suggest the participation and explain the incompressible terms. The remaining members of staff were not informed about the objectives and details of the project. Children, patients under the influence of alcohol and those with suspected acute coronary syndrome were not asked to participate. Respondents left the questionnaires on leaving ED.
Descriptive statistics were presented as means and standard deviation or percentages. The significance of differences was evaluated using the Wilcoxon`s test for dependent samples. For estimation, the confidence interval of 95% was assumed. The correlations were assessed using the Spearman’s rank, V Cramer or φ Yule coefficients as the majority of variables were discrete or qualitative. P=0.05 was considered statistically significant in all tests.
Five hundred questionnaires were distributed and 260 were returned (Table 1). In most of them some items were not filled; 51 (19.6%) questionnaires were fully completed. During the study period of 28 days 1384 patients were admitted to ED. The majority of them were male patients – 157 (60.4%), the mean age was 39.1±16.25 (range 16-85) years. The study group consisted of 97 individuals living in the Tatra county and 160 (61.5%) from other regions; 239 (91.9%) respondents reported to ED unaided and 21 (8.1%) were brought by emergency teams.
In the study group, 230 (88.5%) were asked about pain complaints during ED stay. The question about pain was most frequently asked by physicians (157 times), 55 times by paramedics, 46 times by nurses and 19 times by administrative personnel (medical secretaries). Forty respondents (15.4%) asked for analgesics and 215 (82.7%) did not. In total, analgesics were administered to 58 (22.3%) patients. The cumulative number of respondents assessing the efficacy of treatment as satisfactory (moderately satisfied, satisfied and very satisfied) was 216 (83.1%) (Table 2). One hundred and ten patients (42.3%) received prescriptions for analgesics and 171 (65.8%) were instructed about drugs and/or methods of pain treatment after discharge.
Trauma-related pain was reported by 235 respondents (90.4%); in the remaining patients, the aetiology of pain was different. In almost half of respondents, pain was located in the lower limbs (Table 3).
On admission to ED, pain was experienced by 233 respondents (89.6%), including 144 male and 89 female patients. The mean intensity of pain on admission assessed according to NRS was 5.2, maximum intensity during ED stay was – 7.3, whereas on discharge – 3.8 (Fig. 1). The interval between segregation and administration of drugs was 37.4±41.2 min (range 3-180 min), duration of ED stay – 76.25±70.4 min (range 0-552 min). There was no correlation found between gender and pain severity at individual stages of ED stay and between age and pain severity.
The hypotheses about the significance of treatment effects on pain reduction were verified using the Wilcoxon`s signed-rank test (two observations – before and after the treatment in the same patient). Pain intensity on discharge was found to be markedly reduced compared to its severity on admission and maximum pain during ED stay (p <0.05).
Four factors, chosen on the basis of earlier observations, which might have affected the use of analgesics were analysed: pain severity, gender, request for pain relief and place of residence. There was not correlation found between pain severity and administration of treatment (V Cramer = 0.157). To test the correlation between pain severity and time to drug administration the Spearman’s rank correlation coefficient was determined; no significant correlation between these variables was observed. The severity of pain did not accelerate analgesia administration on admission (p=0.166) and during the highest intensity of complaints (p=0.064). Moreover, gender was not the factor affecting the administration of analgesics (p=0.066).
A slight relation was observed between requests for analgesics and their administration (coefficient of correlation φ=0.097). Likewise, the place of residence slightly affected the decision about administration of analgesia (φ=0.117). Furthermore, no higher levels of satisfaction in patients who received analgesics were demonstrated (φ=0.1366).
According to the 11-degree numerical scale, the mean intensity of pain on admission was moderate. Up to 60% of respondents experienced severe pain and almost 20% maximum pain at one of the stages of ED stay. The findings are similar to the results of studies carried out in other countries [5, 9, 10].
Only one in 5 respondents could count on administration of analgesics. Noteworthy, this number, so low, might be overestimated as each drug bringing relief, not necessarily an analgesic, could have been considered by patients as an analgesic. Low effectiveness of pain treatment is also visible in increased pain during the final stage of ED stay – almost 1/3 of respondents felt moderate or severe pain on discharge and 5 patients experienced maximum pain. Additionally, it is noteworthy that intensity of pain increased on average by over two ranges of the numerical scale during ED stay, which is likely to evidence the lack or insufficient analgesia during diagnostic procedures and manoeuvres frequently performed in trauma patients.
Our results demonstrated the lack of correlation between pain intensity and time to administration of analgesics and a slight correlation between pain intensity and institution of analgesia. The model of medical segregation applied should enable identification of patients with higher intensity of pain and the use of analgesia without any delay. The analysis, however, shows that the system used in the ED studied was ineffective. Pain intensity, one of the important vital parameters, should be obligatorily assessed during the initial examination. Severe pain sensations should be considered equal the consciousness disturbances, circulatory or respiratory abnormalities; and such patients ought to be provided with proper medical management [11, 12].
Patients who requested for analgesics did not receive them more often than the remaining respondents did. Searching for factors affecting the administration of analgesics, the place of residence and gender of patients were additionally analysed. The hypothesis of possible ‘favouritism’ of the local community and gender was not confirmed.
A relatively high level of satisfaction was found, quite disproportionate to ‘sparing’ use analgesia. This paradox was also demonstrated in other countries [3, 4], which may be associated with the psychological effect influencing the perception of pain achieved thanks to explanations about the causes of pain and mental support. Moreover, non-pharmacological measures might have been of importance – immobilisation, poultices, etc. The questionnaire used, however, did not assess the extent of their use. Furthermore, patients receiving analgesics did not think more highly of analgesic effects compared to the remaining respondents, which appears to confirm a high impact of non-pharmacological methods on the level of patients` satisfaction.
Almost half of respondents received prescriptions for analgesics and 2/3 were instructed about analgesics and/or further pain treatment after discharge. The findings demonstrate that physicians were aware of the pain experienced by patients, which is also confirmed by the fact that almost 90% of patients were questioned about pain; in the majority of cases, such questions were asked by physicians. This poses a question why drugs are received by such a low percentage of patients during hospital stay and why pain management is initiated after discharge. This is likely to be associated with false yet still functioning belief that pain is an inseparable and necessary element of the diagnostic process.
Our respondents received drugs after 37 min, on average, thus relatively quickly compared to other reports [3, 13, 14]. However, a small number of respondents hinders detailed analysis. Since the correlation between pain severity and time of drug administration was not demonstrated, it seems that this tendency is related to organisational rather than diagnostic-therapeutic factors.
Our survey was mainly to determine the opinions of patients about quality and effectiveness of pain treatment. It was assumed that anonymity of respondents should provide more reliable and complete responses. Additionally, it was decided that collection of information by pollsters might affect the quality of data due to suspected impact of the speed and way of advice provision on obtained answers. However, the rule of anonymity excluded the possibility to analyse simultaneously the information contained in medical records, which limited the number of available data. Based on the set of questionnaire questions, the details of treatment could not be reliably assessed, e.g. kinds of drugs, their doses or routes of administration. Although the ED personnel were not informed about the assumptions and goals of the study, it cannot be excluded that the information obtained could have affected the attitude of some staff members towards patients.
1. Although the level of pain intensity experienced by patients in the emergency department is high, pharmacologic methods of its relief are rarely used.
2. Disproportion between the incidence of pain treatment and high levels of patients` satisfaction indicates potential significance of non-pharmacologic methods of analgesia.
3. The system of medical segregation applied in the emergency department does not ensure prioritisation of patients with high levels of pain.
4. In the majority of patients, pharmacologic pain treatment is initiated after discharge.
1. Tanabe P, Buschmann M: A prospective study of ED pain management practices and the patient’s perspective. J Emerg Nurs 1999; 25: 171-177.
2. Karwowski-Soulié F, Lessenot-Tcherny S, Lamarche-Vadel A, Bineau S: Pain in an emergency department: an audit. Eur J Emerg Med 2006; 13: 218-224.
3. Todd KH, Sloan EP, Chen C, Eder S, Wamstad K: Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. Can J Emerg Med 2002; 4: 252-256.
4. Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, Tanabe P: Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain 2007; 8: 460-466.
5. Zohar Z, Eitan A, Halperin P, Stolero J, Hadid S, Shemer J Zveibel FR: Pain relief in major trauma patients: an Israeli perspective. J Trauma 2001; 51: 767-772.
6. Wilder-Smith OH, Mohrle JJ, Martin NC: Acute pain management after surgery or in the emergency room in Switzerland: a comparative survey of Swiss anaesthesiologists and surgeons. Eur J Pain 2002; 6: 189-201.
7. Kosiński S, Siudut B: Oligoanalgezja w medycynie ratunkowej – istota zjawiska, przyczyny i sposoby przeciwdziałania. Anestezjol Ratown 2009; 3: 336-343.
8. Singer AJ, Garra G, Chohan JK, Dalmedo C, Thode HC Jr.: Triage pain scores and the desire for and use of analgesics. Ann Emerg Med 2008; 52: 689-695.
9. Johnston CC, Gagnon AJ, Pepler CJ, Bourgault P: Pain in the emergency department with one-week follow-up of pain resolution. Pain Res Manag 2005; 10: 67-70.
10. Berben SA, Meijs TH, van Dongen RT, van Vugt AB, Vloet LC, Mintjes-de Groot JJ: Pain prevalence and pain relief in trauma patients in the accident & emergency department. Injury 2008; 39: 578-585.
11. Ritsema TS, Kelen GD, Pronovost PJ, Pham JC: The national trend in quality of emergency department pain management for long bone fractures. Acad Emerg Med 2007; 14: 163-169.
12. Silka PA, Roth MM, Moreno G, Merrill L, Geiderman JM: Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad Emerg Med 2004; 11:264-270.
13. Nelson BP, Cohen D, Lander O, Crawford N, Viccellio AW, Singer AJ. Mandated pain scales improve frequency of ED analgesic administration. Am J Emerg Med 2004; 22: 582-585.
14. Decosterd I, Hugli O, Tamchès E, Blanc C: Oligoanalgesia in the emergency department: short-term beneficial effects of an education program on acute pain. Ann Emerg Med 2007; 50: 462-471.
Oddział Anestezjologii i Intensywnej Terapii
Szpital Specjalistyczny Chorób Płuc w Zakopanem
ul. Gładkie 1, 34-500 Zakopane
tel.: +48 602 480 289
received: 15.06.2011 r.
accepted: 22.08.2011 r.