Pain Assessment Instruments for Use in the Emergency Department
Section snippets
Barriers to assessment
Pain is inherently subjective and inevitably complex. Our patients experience pain and suffering as individuals; we assess it only indirectly. Our clinical and research task is to use a commonly understood vocabulary and classification system in assessing pain, so that our findings can be communicated consistently. Only by quantifying the pain experience in meaningful ways can we move beyond myth and idiosyncratic opinions toward a more scientific approach to questions regarding the pain
Reliability and validity
As the author discusses specific measurement instruments, he will refer often to validity and reliability. Validity asks the question: “Does this instrument measure what it is supposed to measure?” Common aspects of validity that can be assessed include content validity, criterion validity, or predictive validity. In judging content validity, we question how relevant specific questions are to the aims of the instrument. This is often done informally by asking experts their opinions of the
Pain intensity
We will consider four single-item instruments used to rate pain intensity: the numerical rating scale (NRS), visual analog scale (VAS), graphical rating scale (GRS), and verbal rating scale (VRS). The integration of pain intensity as a “vital sign” within health care institutions has been promoted with some success by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), and in most US emergency departments today, a single-item rating of pain intensity (usually some
The numerical rating scale
A typical NRS consists of a range of numbers, from which one is selected by the patient as most representative of their level of pain intensity (Fig. 2). Although the range of numbers used is usually 0 to 10, other ranges may be used, such as 0 to 20, or 0 to 100. Patients are told that zero represents “no pain” and that the highest number represents some maximal measure of pain. The verbal descriptor for this extreme state may vary; however, phrases such as “pain as intense as you can imagine”
The visual analog scale
The VAS typically consists of a 100-mm line, oriented horizontally and bounded at each end by verbal descriptors of pain intensity severity (Fig. 3). The descriptor “no pain” is situated to the left of the line, and a phrase describing an upper pain intensity limit, such as “worst pain possible” or “pain as bad as it could be,” appears to the right of the line. Patients are asked to place a mark at the point on the line that best represents their pain intensity level. The distance from the left
Visual analog scale versus numerical rating scale
Given the similar psychometric properties of the VAS and NRS, which instrument is preferred? As mentioned above, the VAS has been used more frequently in the past; however, patients appear to prefer the NRS, and comprehension of the VAS is problematic in the elderly population and in those with cognitive impairments. Patients unable to complete the VAS were found to be older than those able to complete the measure (73 versus 54 years) [6]. Other investigators have found that patients prefer the
Picture scales
These instruments include a series of facial images or illustrations of facial expressions meant to represent various pain states [14]. They are presented to the patient, who is asked to choose the facial expression that best matches his or her pain intensity. Each image is assigned a number, which becomes the patient's pain intensity score (Fig. 4).
Picture scales demonstrate both criterion and predictive validity, and may be particularly useful for populations with limited literacy, including
Verbal rating scales
Verbal rating scales (VRS) consist of a number of adjectives or phrases describing increasing pain intensities (Fig. 5). Patients are told to choose the adjective or phrase that best describes their pain intensity. The pain intensity score is the number assigned to the descriptor chosen by the patient. The number of descriptors used has ranged from four (none, mild, moderate, severe) [7] to 15 [19]. The four-descriptor scale is widely used in clinical settings, is easy to administer, and has
Temporal characteristics
Pain in the emergent setting tends to be severe; thus measures of time to pain relief are of particular importance. These measures are relatively underused in pain research, and are a promising area of investigation for emergency medicine pain researchers. For emergency medical in general, and pain management in particular, minutes count.
One method of assessing this temporal quality of pain experience uses a “double stopwatch” technique [21], [22], [23], [24], [25], [26]. Patients are given two
Pain-related physical function—the Brief Pain Inventory
Pain is a multidimensional experience. The impact of pain on the patient's function and mood is particularly important to understand and has relevance to multiple stakeholders, including his or her family, social contacts, and employer, and workmen's' compensation entities. Although measures of physical function are commonly incorporated into studies of chronic pain, the author was unable to identify emergency medicine studies assessing the impact of pain on function. Given that emergency
Summary
Each patient's pain experience is uniquely his or her own. Standardized pain assessment methodologies and procedures provide a window to this experience and constitute a necessary first step to our understanding of pain, in both clinical and research settings. All too often, emergency department pain assessment is cursory—performed more to satisfy regulatory requirements than to guide our therapies or evaluate our practices. This article provides information on a number of assessment techniques
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Cited by (55)
What adult patients prefer for reporting their pain levels, and frequency of reassessment when in the emergency department?
2023, American Journal of Emergency MedicineEffectiveness of lidocaine spray on radial arterial puncture pain: A randomized double-blind placebo controlled trial
2021, American Journal of Emergency MedicineThe verbal numeric pain scale: Emergency Department patients' understanding and perspectives
2021, American Journal of Emergency MedicinePalliation, end-of-life care and burns; practical issues, spiritual care and care of the family – A narrative review II
2020, African Journal of Emergency MedicineAtomized intranasal vs intravenous fentanyl in severe renal colic pain management: A randomized single-blinded clinical trial
2020, American Journal of Emergency MedicineCitation Excerpt :The validity of NRS system is similar to the Visual Analog Scale (VAS). Patients with severe renal colic pain (i.e. NRS ≥ 8) were included in this study [15]. The severity of pain was measured by the senior emergency medicine resident at baseline, as well as 10, 20, 30, 40, and 60 min after the interventions.
Pragmatic evaluation of an observational pain assessment scale in the emergency department: The Pain Assessment in Advanced Dementia (PAINAD) scale
2018, Australasian Emergency CareCitation Excerpt :A systematic review identified that four adult observational pain assessment instruments, including the PAINAD, developed to assist people who are unable to self-report pain were superior to many others and were potentially appropriate for use in EDs.30 Despite limited evidence of the validity and reliability of the PAINAD,31,32 it has been recommended as an appropriate ED pain assessment tool in people with CI.33 The only published evaluation of PAINAD in an Australian setting was conducted in 2003 in an aged care facility.22
This work is supported, in part, though a generous grant from The Mayday Fund, New York, New York.