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

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Abstract

The assessment and management of acute pain is an essential part of care received in the emergency department (ED). This study was undertaken to measure how ED caregivers interpret and treat acute pain. A convenience cohort of 71 patients in a tertiary care teaching hospital were asked to rate their pain on arrival to the ED using a visual analog scale (VAS) and numerical rating scale (NRS). These ratings were compared with those given by their nurse and physician. Both physicians and nurses gave statistically significantly lower NRS and VAS pain ratings than those reported by the patients. Nurses’ NRS pain ratings were found to be lower than physicians’ ratings of the same patients. On chart review, no pain scale assessments were employed, and only one chart noted that a patient’s pain had been relieved after treatment. Approximately half the patients (49%, n = 35) felt on discharge from the ED that their pain had not been relieved. Pain assessment and treatment in the ED appears to be inadequate. The integration of pain assessment before and after treatment is essential in monitoring the effectiveness of pain management in the ED.

Introduction

Insufficient attention is given to comprehensive acute pain assessment and management in the emergency department (ED) 1, 2, 3, 4, 5, 6, 7, 8, 9. This may compromise patient comfort and exacerbate the already-stressful emergency visit. Unfortunately, little research has been conducted to determine how acute pain assessment and management in the ED can be improved. The few studies that have been done have shown that pain in the ED tends to be undertreated 1, 2, 3, 4, 5, 6. In one of the rare prospective pain studies, Ducharme showed that acute pain was poorly assessed, and little pain relief was achieved, though patient satisfaction was relatively high (1).

The American Pain Society Quality of Care Committee guidelines recommend that the treatment of acute pain include close monitoring as well as encouraging patient communication of pain (7).

A Canadian Association of Emergency Physicians consensus document recommends that evaluation of pain use objective pain scales reported by the patient and not rely on the physician’s impression (7). The document further states that patients should not have to wait for pain treatment while a physician is attempting to arrive at a diagnosis, and highlights the importance of understanding the time course before relief of pain, the half-life of analgesia, and the avoidance of adverse effects through titration (7). We undertook a study to assess how well pain was evaluated and treated in accordance with these recommended guidelines in a tertiary care emergency department.

Section snippets

Materials and methods

An observational prospective convenience cohort study evaluating the quality of acute pain assessment, interprofessional differences in pain assessment, and pain management was conducted in the emergency department of a tertiary care teaching hospital. Since the questionnaire was only observational and involved no intervention, it was exempt from ethics review. Patients 18 years of age or older were eligible. Exclusion criteria included chronic pain state (>48 h duration), life-threatening or

Results

A total of 113 patients were enrolled in the study, but 42 were excluded for the following reasons. One was younger than 18 years of age, two were not seen by an emergency physician because they were directed to a specialty service, one patient’s level of consciousness decreased during the emergency visit to the point that the patient was not able to complete the questionnaire, two patients were unable to grade their pain on a numerical scale because of a language barrier, 13 patients were

Discussion

Our study found that patients in the ED with self-reported mild to moderate pain were unlikely to receive pain medication (Figure 2). Even in the severe pain category, only two-thirds of patients received pain medication (Figure 2). Of 22 patients in severe pain, only 5 patients received i.v. opioids (Table 1), despite the fact that many authorities have stated that the use of i.v. opioids is a rapid and safe route to achieve analgesia for a patient with severe pain (7). A previous

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