Objectives: (1) To assess the proportion of patients of triage category 3–5 presenting to the minor side of an urban emergency department who present without taking prior pain relief, and (2) to describe the reasons why they do not take pain relief for their presenting complaint
Method: By patient interview of a convenience sample of 60 adult patients in the setting of an urban emergency department.
Results: Fifteen of 60 patients had taken analgesia and 45 of 60 (75%) had not. Sixteen reasons were volunteered to the interviewer. Most patients offered one reason only 39 of 45 (87%). The three commonest single reasons cited for not taking pain relief were “don’t like taking tablets” 10 (22%), “run out of tablets” 10 (22%), five (11%) said their “pain not bad enough”. Six (13%) patients cited two reasons for not taking pain relief. Only three (6%) patients indicated that they “did not think about pain relief”. Six (13%) of patients had inappropriate perceptions of how pain killers may interfere with their care.
Conclusion: Most patients presenting with painful conditions to the minor side of an urban emergency department had not taken pain relief. The study highlights there are many different reasons for this and staff should not presume that it was because the patient “did not think about it”. Ongoing education of staff and patients is needed.
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The reasons patients present to the emergency department without having taken analgesia have not been adequately described previously. The aim of this pilot study was to help gain an understanding of these patients by (1) quantifying the proportion of walking wounded patients presenting without taking analgesics and (2) describe why they do not take analgesics for their presenting complaint.
This study focuses on why patients themselves do not take pain relief, in contrast with papers1–11 that have focused on failure of staff to provide pain relief “oligo-analgesia”. The author’s impression from working with doctors and nurses is that staff express frustration when walking wounded patients present in pain, having taken no prior analgesia. This has resulted in patients inappropriately being asked, “why haven’t you taken pain killers”, before the patient has an opportunity to voice their expectations of coming to the emergency department. This may compromise rapport between patient and staff at an early stage of the consultation.
After ethical committee approval a prospective survey of a convenience sample of patients was conducted at a teaching hospital emergency department. Patients were included if they presented to the minor side of the department, who complained of pain/soreness/discomfort, aged over 18, triage categories 3–5 and GCS15, and were willing to be interviewed. Exclusion criteria were GCS14 or less, uncooperative, intoxicated with alcohol or drugs, violent, or in police custody. Ambulance mode of arrival was not an exclusion. The author (DAC) then approached patients and asked them:
“I’m currently running a survey on people’s use of painkillers. I wonder if you had any specific reasons for not taking painkillers? Would you mind sharing them with me?”
In the event of any patient being unable to volunteer a reason, then a questionnaire (appendix 1, see journal web site http://emjonline.com/supplemental) prompt would be provided.
The basis for the questionnaire was from the author’s (MN) own notes, taken over a four month period, February to May 2000, of the reasons patients spontaneously volunteered why they had not taken analgesia.
The convenience sample of 60 patients were surveyed in the period 17 to 21 July and 24 to 28 July inclusive by one author (DAC). All respondents provided a reason and therefore no patient received a questionnaire prompt. Fifteen (25%) had taken analgesics, 45 (75%) had not. The commonest single reason provided was “don’t like taking tablets” 10 of 45 (22%). Only 5 of 60 patients (8%) said they “did not think about taking pain killers”. (See table 1).
The study confirms the impression that a significant proportion of patients present in pain without taking prior analgesia. The results also provide some insight into why patients do not take analgesics, and indeed some have good reasons for not taking oral analgesics. Tanabe12 reported 25 of 203 emergency department patients gave “fear of addiction” as their reason for this refusal. In addition to this fear, Thomason13 described in ambulatory cancer patients three other barriers to effective analgesia. These were: forgetfulness, a belief that pain should be tolerated, and concerns about side effects. Although this was a different patient population the reasons overlap with those provided in our study population. The study objective answered the question “why do patients not take analgesics?” but raised another question “what are the expectations of those patients in pain, who do not take or want pain relief?” An assumption that all patients in pain want tablet analgesia is misplaced. Beel14 indicated that 12% of patients with a verified fracture did not want pain medication.
It had been the authors’ intention to offer a questionnaire survey to those patients who did not offer a reason. However, all the patients surveyed had a reason, and thus no questionnaires were provided. As a bonus, the potential bias of only offering patients a restricted selection of answers, was avoided. The authors acknowledge the weaknesses in study design in respect of convenience sampling, small numbers, no assessment made of non-pharmacological methods, and the results were correlated neither to pain scores nor a diagnosis. Selection bias towards patients presenting to the minor side may have excluded minor triage category patients who could have gone to the major side. In practice the department is busy and sick patients often lodge on minor side rather than the converse: minor patients lodging inappropriately on major side. It is interesting that 13 reasons cited by the patients were listed in, and thus validate, the questionnaire. The three new reasons provided by the sample were “thought they’d be a problem considering I’d been drinking”, “did it at work and thought they [employers] were not allowed to give out any pain killers”, and “ knew getting the pus out would relieve the pain so just wanted to get that done”. It was interesting that six (13 %) of patients held inappropriate perceptions (table 1: F, H, I, L) of how pain killers may interfere with their care. These were: “Had paracetamol but didn’t think they would work”, “thought they’d be a problem considering I’d been drinking”, “didn’t want to mask the pain”; “On methadone—so [simple] pain killers don’t work”. These reasons emphasise a need for patient education. Neither of the authors was involved, directly or indirectly, in the care of the patients surveyed.
Most patients in the study population had not taken pain relief. There are many different and understandable reasons for this and staff should not presume that it was because the patient “did not think about it”. The study raises issues of patient education, patient expectations, and staff education.
Exploring these ideas may produce constructive dialogue in a consultation, better understanding of the patient’s expectations, and more focused advice on achieving pain relief without tablet medication. Qualitative research would help provide a greater depth of understanding to this complex issue. Further quantitative research is required to clarify whether the reasons for not taking analgesia are usually singular or usually multi-factorial; and ascertain whether sex, age, or race differences exist for this issue? The authors acknowledge that this study raises more questions than it answers. A follow up study is planned to answer the question “what are the expectations of the walking wounded patients in pain?”.
M F Nicol, original idea, questionnaire design, analysis and write up, D Ashton-Cleary questionnaire design, data collection, initial data analysis
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