Elsevier

Annals of Emergency Medicine

Volume 59, Issue 2, February 2012, Pages 134-138.e2
Annals of Emergency Medicine

Pain management and sedation/brief research report
Mandatory Pain Scoring at Triage Reduces Time to Analgesia

Presented at the Australasian College for Emergency Medicine annual scientific meeting, November 2010, Canberra, Australia.
https://doi.org/10.1016/j.annemergmed.2011.08.007Get rights and content

Study objective

We study whether mandatory triage pain scoring and an educational program reduces the time to initial analgesic treatment.

Methods

We performed a prospective interventional study in the emergency department (ED) of an adult tertiary referral hospital and major trauma center. After an observational assessment of baseline time to analgesic administration, we mandated the recording of triage pain scores through our computerized information system. In a second separate phase, we administered a staff educational package on the importance of timely analgesia. We measured time to initial analgesia after each phase and at 12-month follow-up.

Results

We studied 35,628 patients (8,743 baseline, 8,462 after mandating pain scoring, 9,043 after the educational program, and 9,380 at follow-up), with 12,925 patients (36.3%) overall receiving analgesics. At baseline, the median time to analgesia was 123 minutes (interquartile range [IQR] 58 to 231 minutes), which reduced with pain scoring (95 minutes; IQR 45 to 194 minutes) but no further with the educational package (98 minutes; IQR 45 to 191 minutes). At 12-month follow-up, the median time to analgesia was 78 minutes (IQR 45 to 143 minutes), 45 minutes (36.4%) faster than at baseline.

Conclusion

The simple act of altering our ED computerized information system to require pain scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at 12 months.

Introduction

Pain is the most common presenting complaint to emergency departments (ED) worldwide.1, 2, 3, 4 Most research has focused on the overall rate of analgesia, with higher rates indicating a better-functioning department.5, 6 Recent studies have focused on how quickly pain relief is received by patients, with time to analgesia evolving as the primary focus.7, 8 The delivery of timely analgesia is not only expected by patients9 but also linked to improved biological outcomes and reduced anxiety.2, 10

Previous literature has shown that patients expect to wait only 30 minutes for analgesia in an ED,11 but a 2007 audit of 74 EDs across Australia showed that median waiting times were more than 60 minutes.12 Similar delays have been reported in American and Israeli studies.13, 14 It has been demonstrated that time to analgesia can be reduced if pain is formally rated and recorded at triage.6, 15, 16 Several methods of pain assessment, including the Faces Pain Scale—Revised,17 visual analog scale,18 verbal descriptor scale,19 and the numeric rating scale20 have been used and evaluated. The numeric rating scale is the most accurate and applicable in an adult ED setting, requiring patients to score their pain on a numeric scale between zero (no pain) and 10 (most severe pain).20, 21 Although such judgment is subjective and nonqualitative, it helps circumvent underestimation of pain by medical personnel.6, 10

In a bid to improve ED time to analgesia, The Joint Commission mandated collection of numeric rating scale pain scores by triage nurses in the United States.22 The College of Emergency Nursing Australasia has also published guidelines mandating that triage nurses collect pain scores from all patients, stating that self-reports represent the criterion standard of pain measurement.21 Current adherence to this guideline is uncertain. Several studies have been conducted about mandatory evaluation of triage pain assessment to improve time to analgesia but have a limited patient spectrum or have not shown sustained effect of their intervention.6, 15, 16

A proven means to reduce time to initial analgesia will reduce patient discomfort and move ED performance toward the expectations of staff and patients.

We studied whether mandatory triage pain scoring and an educational program reduced the time to initial analgesic treatment. As a secondary objective, we stratified these results by triage category, drug class, and initial pain score.

Section snippets

Study Design and Setting

Our study had a pre-post design with 4 stages: a baseline observation stage, 2 interventions, and a follow-up stage conducted at 12 months. It was undertaken at Royal Melbourne Hospital, an adult tertiary referral and major trauma center with approximately 58,000 attendances per annum and an admission rate of 40%. Our ED has 17 staff emergency physicians providing continuous coverage and supervising multiple junior physicians. Triage is performed by senior nurses certified in emergency medicine

Characteristics of Study Subjects

During the study period, 35,628 patients attended the ED (8,743, 8,462, 9,043, and 9,380 in phases 1 through 4, respectively) and 12,925 patients (36.3%) received analgesia (35.7%, 39.3%, 36.6%, and 33.8% in phases 1 through 4, respectively). Patient characteristics were mostly similar across the study period, although some shift toward lower acuity was observed in the follow-up phase (Table).

Triage pain scores were recorded in 72.6% during the voluntary baseline. Once mandated, pain scoring

Limitations

We did not collect data on out-of-hospital analgesia, and such therapy may have influenced the time to initial ED analgesia. Because we included the entire ED population, some patients had an initial pain score of 0 and some of these later developed pain and received analgesia. Others with pain on arrival may have refused analgesia only to accept it later. We did not study some drugs that can provide pain relief (eg, lignocaine for local injection, prochlorperazine for migraine,24 oxygen for

Discussion

This study demonstrates our experience in that mandating the scoring of pain at triage was associated with subsequent clinically important improvements in the speed of analgesia delivery. The intervention required only a single change within our computerized information system and a single additional question to each patient at triage. In contrast, the educational program, which required effort and time commitment, afforded no additional benefit. Although previous studies have shown benefit in

References (32)

  • K.H. Todd et al.

    Pain in the emergency department: results of the Pain and Emergency Medicine Initiative (PEMI) multicenter study

    J Pain.

    (2007)
  • P.A. Silka et al.

    Patterns of analgesic use in trauma patients in the ED

    Am J Emerg Med.

    (2002)
  • V. Guru et al.

    The patient vs caregiver perception of acute pain in the emergency department

    J Emerg Med.

    (2000)
  • J.B. Jones

    Assessment of pain management skills in emergency medicine residents: the role of a pain education program

    J Emerg Med.

    (1999)
  • L.F. McCaig et al.

    National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary

    Adv Data.

    (2003)
  • P.A. Silka et al.

    Pain scores improve analgesic administration patterns for trauma patients in the emergency department

    Acad Emerg Med.

    (2004)
  • Cited by (31)

    • A prospective study to compare serial changes in pain scores for patients with and without a history of frequent ED utilization

      2021, Heliyon
      Citation Excerpt :

      Thus, EDs with higher recidivism rates may be at risk for scoring poorly on key pain control and patient satisfaction metrics based on census characteristics that are, clearly, outside the sphere of physician influence. Investigators previously have evaluated the assessment and treatment of pain in the ED from a variety of perspectives 1, 5, 6, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56 Several have evaluated serial assessments of pain and noted a frequent lack of improvement and/or satisfaction despite treatment [11, 12, 13] Todd et al. conducted a telephone survey of 500 adult patients with either chronic or recurrent pain who reported an ED visit within the past two years [11]. Less than half the patients in both groups reported following treatment that they felt “complete” or “a great deal” of pain relief.

    • Ten Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly

      2017, Clinical Pediatric Emergency Medicine
      Citation Excerpt :

      Additionally, prompt treatment of pain has been associated with a reduction of pain scores as well as improved patient outcomes and satisfaction.131,132 Recent literature reports median time to analgesic administration in the ED for painful complaints to be as long as 2 to 3 hours.10,133 Moreover, among pediatric patients evaluated and treated in the ED with a fracture or appendicitis, most patients received inadequate or no analgesic medication within 1 hour of arrival.10,134

    • Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients' satisfaction of pain management

      2016, Scandinavian Journal of Pain
      Citation Excerpt :

      Documentation of pain assessment has been shown to have a positive effect on pain management [12], but there is a large variation between studies, ranging from 57% to 94% [1,9,13]. Mandatory pain scoring included in triage has shown reduced time to analgesia [12] and it has improved the frequency of documented pain assessment in EDs [14]. Despite several attempts to improve pain management at EDs, patients suffering from acute pain do not receive enough analgesics in EDs [15].

    • Actions to improve documented pain assessment in adult patients with injury to the upper extremities at the Emergency Department - A cross-sectional study

      2016, International Emergency Nursing
      Citation Excerpt :

      The result was maintained for 21 months, before a slight decline in the frequency of pain assessment was shown. This result is consistent with the result of Vazirani and Knott concerning the long-term effect of different interventions to improve pain assessment (Vazirani and Knott, 2012). However, our result shows a sustainable effect for a longer period of time than ever shown before.

    • Pain rating in the ED-a comparison between 2 scales in a Swedish hospital

      2015, American Journal of Emergency Medicine
      Citation Excerpt :

      In addition to being a directly uncomfortable feeling for the patient, pain might also cause stress and anxiety, as the cause of the pain might be unknown, and patients need information about the management of their pain [4]. Standardized pain assessment has been shown to reduce the time between arrival at the ED and the treatment of pain [2] and provides a useful tool for the evaluation of the effect of given pain medications [5,6]. There are several tools for rating pain, of which the visual analog scale (VAS) and numeric rating scale (NRS) are commonly used [7,8].

    View all citing articles on Scopus

    Supervising editor: Steven M. Green, MD

    Author contributions: JV and JCK were involved in the design and implementation of the study and article preparation. JV undertook the collation of the data sets. JCK provided all data analysis. JCK takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

    Publication date: Available online September 10, 2011.

    A podcast for this article is available at www.annemergmed.com.

    Please see page 135 for the Editor's Capsule Summary of this article.

    View full text