Pain in the Emergency Department: Results of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study

Todd, Knox H.; Ducharme, James; Choinière, Manon; Crandall, Cameron; Fosnocht, David E.; Homel, Peter; Tanabe, Paula

doi:10.1016/j.jpain.2006.12.005

Cited by 566 publications

(477 citation statements)

References 15 publications

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“…[1][2][3] Optimal pain management is lacking in most EDs, as many patients do not receive analgesia [3][4][5][6][7][8][9][10][11][12] and time to analgesic administration is often too long. 3,[5][6][7][8][10][11][12][13][14][15][16][17][18][19] Most health care professionals underestimate pain intensity. 20,21 In the absence of tachycardia or hypertension, we observed that ED staff tend to discredit self-assessments of severe pain when patients do not appear to be suffering.…”

Section: Introductionmentioning

confidence: 99%

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department

Daoust

Paquet

Bailey

et al. 2015

CJEM

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Objectives: This study aimed to ascertain the association between self-reported pain intensity and vital signs in both emergency department (ED) patients and a subgroup of patients with diagnosed conditions known to produce significant pain. Methods: We performed a retrospective analysis of real-time, archived data from an electronic medical record system at an urban teaching hospital and regional community hospital. We included consecutive ED patients ≥16 years old who had a self-reported pain intensity ≥1 as measured during triage, from March 2005 to December 2012. The primary outcome was vital signs for self-reported pain intensity levels (mild, moderate, severe) on an 11-point verbal numerical scale. Changes in pain intensity levels were also compared to variations in vital signs. Both analyses were repeated on a subgroup of patients with diagnosed conditions recognized to produce significant pain: fracture, dislocation, or renal colic. Results: We included 153,567 patients (mean age of 48.4 ± 19.3 years; 55.5% women) triaged with pain (median intensity of 7/10 ± 3). Of these, 8.9% of patients had diagnosed conditions recognized to produce significant pain. From the total sample, the difference between mild and severe pain categories was 2.7 beats/minutes (95% CI: 2.4 − 3.0) for heart rate and 0.13 mm Hg (95% CI: -0.26 − 0.52) for systolic blood pressure. These differences generated small effect sizes and were not clinically significant. Results were similar for patients who experienced changes in pain categories and for those conditions recognized to produce significant pain. Conclusion: Health care professionals cannot use vital signs to estimate or substantiate self-reported pain intensity levels or changes over time. RÉSUMÉObjectif: L'étude visait à confirmer l'existence d'une association entre l'intensité de la douleur autodéclarée et les signes vitaux enregistrés chez des patients au service des urgences (SU) ainsi que dans un sous-groupe de malades souffrant d'affections connues pour causer de fortes douleurs. Méthode: Les auteurs ont procédé à une analyse rétro-spective de données enregistrées en temps réel et archivées dans un système de dossiers médicaux électroniques, dans un centre hospitalier universitaire urbain et dans un hôpital communautaire régional. Ont participé à l'étude des patients consécutifs, âgés de ≥16 ans, qui ont fait état, au SU, de douleurs d'une intensité ≥1, mesurée durant le triage, de mars 2005 à décembre 2012. Le principal critère d'évaluation était les signes vitaux associés à différents degrés d'intensité (légère, modérée, forte) de la douleur autodéclarée sur une échelle numérique, verbale, de 11 points. Les variations de l'intensité de la douleur ont également été comparées aux variations des signes vitaux. Les deux analyses ont été reprises dans un sous-groupe de patients souffrant d'affections connues pour causer de fortes douleurs: fracture, luxation ou colique néphrétique. Résultats: Ont participé à l'étude 153 567 patients (âge moyen: 48,4 ± 19,3 ans; femm...

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Section: Introductionmentioning

confidence: 99%

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department

Daoust

Paquet

Bailey

et al. 2015

CJEM

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“…The statement essentially pinpoints the current dilemma in the ED: alleviation of suffering in an individual may expose that patient or others (through misuse or diversion) to the risk of opioid analgesic (OA) abuse, addiction, overdose, and death. Pain-related complaints are the most common reason for Emergency Department (ED) visits [2,3], and ED providers are among the top five medical specialist groups writing prescriptions for OAs in patients under 40 years of age [4]. However, only 17 % of ED patients are given a prescription for an OA on discharge and the majority of prescriptions dispensed are for a small number of immediate release pills [5,6].…”

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confidence: 99%

Opioid Prescribing: How Well Do We Know Ourselves?

Wightman

Nelson

2016

J. Med. Toxicol.

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Get your facts first, then you can distort them as you please.-Mark Twain BI would rather over-prescribe and risk some medication diversion or non-medical use, than under-prescribe and not treat a patient's pain.^This statement, taken from a survey published in the current issue of JMT by Pomerleau et al. 2016 [1], was used to assess clinicians' self-reported attitude about the challenge in meeting individual patient needs while balancing public health risk. The statement essentially pinpoints the current dilemma in the ED: alleviation of suffering in an individual may expose that patient or others (through misuse or diversion) to the risk of opioid analgesic (OA) abuse, addiction, overdose, and death. Pain-related complaints are the most common reason for Emergency Department (ED) visits [2,3], and ED providers are among the top five medical specialist groups writing prescriptions for OAs in patients under 40 years of age [4]. However, only 17 % of ED patients are given a prescription for an OA on discharge and the majority of prescriptions dispensed are for a small number of immediate release pills [5,6]. Still, iatrogenic opioid abuse and addiction remain a concern, because half of ED patients with opioid-use disorders were first exposed to an opioid by a prescription from a medical provider [7].Responsible opioid analgesic prescribing is paramount in our efforts to combat the epidemic of opioid abuse and promote safe opioid use, but little is currently known about which factors drive decision-making among emergency department (ED) prescribers of OAs. Pomerleau et al. highlights the complexity of the decision-making process and brings forth a number of interesting issues. Through a series of queries, the study explores the factors providers believe affect their OA prescribing practices, as well as their attitudes toward OA prescribing. Of course, individual provider opinions and attitudes cannot provide the complete picture. Patient age, race, type of insurance, provider training and experience, functionality of PDMPs, and geographic location are a few of the many factors highlighted in the literature to affect OA prescribing decisions.Whether to prescribe an OA for any given patient not only depends on the aforementioned patient and provider factors and the culture of the work environment, but also on the quality and type of patient doctor communication. One study showed that when faced with identical hypothetical case scenarios, ED physicians' decisions whether to prescribe an OA varied greatly [14]. For the same clinical scenario, subtle differences in the patient-doctor interaction (for example, a patient requesting a specific drug or an additional dose of pain medication) could change the likelihood of prescribing substantially [18]. To support this unconscious bias, Pomerleau, et al. uncovered some interesting paradoxes. For example, survey respondents report that they would be less likely to write a prescription for a patient with an opioid use disorder, but they also state their skills to identify pat...

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“…Emergency physicians care for patients with pain on an extremely frequent basis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Th e prevalence of pain as the presenting complaint of patients seeking eme rgen cy department (ED) care ranges from 38 % [3] to as high as 78 % [1].…”

Section: Introductionmentioning

confidence: 99%

“…Th e prevalence of pain as the presenting complaint of patients seeking eme rgen cy department (ED) care ranges from 38 % [3] to as high as 78 % [1]. As a result, evidence-based use of analgesics should be a foundational skill of emergency physicians.…”

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confidence: 99%

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Analgesia in the Emergency Department: A GRADE-based Evaluation of Research Evidence and Recommendations for Practice

Lipp

Dhaliwal

Lang

2013

Annual Update in Intensive Care and Emergency Medicine 2013

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Emergency physicians care for patients with pain on an extremely frequent basis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Th e prevalence of pain as the presenting complaint of patients seeking eme rgen cy department (ED) care ranges from 38 % [3] to as high as 78 % [1]. As a result, evidence-based use of analgesics should be a foundational skill of emergency physicians. However, the literature consistently reports that emergency physicians are ofte n poor at treating pain [1,2,8,13,14,16,19,20] . Notwithstanding the prevalence of pain in the ED, many patients often report that their pain was no t pr oper ly t reated [3,7,20]. I n addi tion to a compromised patient experience, sub-optimal treatment of pain will result in decreased department fl ow, increased wait times, more return visits to the ED, and increased hospitalization rates.Very few evidence-based resources and guideli nes exis t to inform emergency physicians on how to treat pain. One recent guideline on acute pain management compiled by the college of Anaesthetists of Australia and New Zealand [21] was focused primarily on treating pain perioperatively and did not include stratifi ed or graded recommendations based on the literature, highlighting the paucity of emergency medicine-specifi c guidance. Emergency physicia ns need an eff ective, evidenced-based approach to analyze and apply the options available for acute pain management.Th e objective of this article is to synthesize and evaluate the quality of medical literature surrounding analgesia delivery in the adult ED using the Grading Assessment, Development and Evaluation (GRADE) framework. We further strived to provide emergency physicians with graded recommendations upon which analgesics should be used to treat adults with acute pain in the ED. Question formulationPrior to searching the literature we developed seven clinically-oriented questions based on a scoping of the literature and a review of locally utilized ED analgesic order sets. Th is initial surveying of medical literature and our local practice environment allowed us to identify the most commonly prescribed intravenous and oral analgesics used in adult EDs in our health care region.We then used the patient-intervention-comparisonoutcome (PICO) approach to develop our seven research questions (Table 1). Th is approach has been adopted by many authors of systematic reviews and guideline panels, including the Internati onal Liaison Committee on Resuscitation (ILCOR) and the American College of Chest Physicians (ACCP) [22][23][24]. It involves identifying a specifi c population or setting to which recommen dations may be applied. Subseq uently each question compares two specifi c management strategies (intervention and comparison). Fi nally, we defi ned important patient oriented outcomes (e. g., change in pain) as well as any adverse eff ects of the medication or other safety concerns.All seven draft questions were reviewed and revised through an iterative process involving all authors. Th ese seven cl...

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Pain in the Emergency Department: Results of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study

Cited by 566 publications

References 15 publications

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department

Opioid Prescribing: How Well Do We Know Ourselves?

Analgesia in the Emergency Department: A GRADE-based Evaluation of Research Evidence and Recommendations for Practice

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