-
ED
patients frequently present with painful conditions that require
aggressive treatment by emergency health care providers.
-
Use
of ED therapies by Emergency Physicians should be relatively consistent,
because of the use of a limited number of therapeutic agents.
-
The
ACEP board has recently approved a Policy statement developed by
the ACEP Clinical Policy Committee, one that includes five statements
regarding the management of ED patients who have painful conditions.
-
Despite
the fact that clinicians have been treating ED patients with acutely
painful conditions for many years, many critical questions remain
regarding how to optimize the care of these patients and their pain.
-
Efficient
care of ED patients who present with pain involves both the treatment
of the disease that is causing the pain and the pain itself, which
is of equal concern to our patients.
-
ED
patient care can be optimized by improving understanding in the
areas of pain epidemiology, therapeutics, clinical practice and
policies, ED systems, research, and advocacy.
TOP
Questions
Regarding Pain Management in the ED
Introduction
Pain is the most commonly treated patient complaint in the Emergency
Department (ED).(1;2) Despite the fact that patient pain is ubiquitous
in the ED, the inadequate use of analgesics, or oligoanalgesia, is
a problem that is significant and still relevant in 2004.(3;4) The
management of pain in hospitals and in the ED has been the focus of
recent JCAHO efforts to standardize and optimize patient care. Recent
studies have looked at the issue of pain management and documentation
of patient pain in the ED. These studies suggest that patients have
significant pain requiring treatment, and that the documentation of
efforts to alleviate this pain can be enhanced. It is hoped that these
efforts will enhance the ED care of patients who present with painful
conditions.
This document addresses
the issue of ED patient pain as it relates to recent research data
and the upcoming publication of the ACEP policy statement regarding
the management of these patients. Through the generation of clinically
relevant questions, it is hoped that researchers, educators, and practitioners
can improve the way in which ED care is provided to patients who are
in pain.
Clinical Cases
Clinical cases that describe
the management of patients who present to the ED with painful conditions
are quite variable. Patients can be described based on specific disease
states, demographic variable such as age, the chronicity of the pain,
and the way in which patients present. Important specific disease
states include renal colic, headache, abdominal pain, sickle cell
pain, and the pain associated with fractures or multiple trauma. Pain
is especially important at the extremes of age, both in children and
in elderly patients, both of whom must be managed carefully with analgesics.
Patients with chronic pain
often require acute pain management in the ED for conditions such
as radiculopathies, fibromyalgia, low back pain, migraine headache
pain, and the chronic pain associated with cancer and its treatment.
Especially challenging are patients who present to the ED for the
management of painful conditions that have caused a state of dependency
on one or more analgesics. In this situation, the ED staff must be
careful to address patient pain without further complicating the patients'
overall health.
ED Practice
In examining the current
practice of Emergency Medicine as it related to patient pain, it is
important to consider several questions:
-
How
much pain do patients perceive when they present to the ED?
- What pain medications
are being used by EM practitioners?
-
What
is the effect of these interventions?
-
To
where are patients dispositioned following their ED care?
Data from two separate
databases will be discussed in today's lecture. The first is data
from the NHAMCS database, which includes outpatient data from EDs
that are believed to be representative of and generalizable to overall
US ED care. Although this dataset contains the demographic, treatment,
and diagnosis data for each patient encounter, it is somewhat limited
in its scope.
The second dataset includes
patient data from six hospitals affiliated with the EM residencies
at the Emory University, Resurrection Hospital, the University of
Illinois, and Wayne State University. This dataset, which was developed
based on 1800 patient encounters for pain related to abdominal pain,
fractures, migraine headache, and renal colic, is more extensive in
that is contains data abstracted from the full ED medical record.
ACEP Policy Statement
The ACEP Clinical Policy
Committee has developed a policy statement that has been approved
by the ACEP Board of Directors. In this statement, there is a preamble
followed by five statements. The preamble addresses the fact that
the majority of ED patients do, indeed, present with painful conditions
that are a priority for practicing ED physicians.
The five policy statements
suggest the following:
-
ED
patient pain should be quickly treated without significant delay.
-
Hospital
should develop unique strategies to address ED patient pain.
-
Hospital
policies should promote safe analgesic use and prescription writing.
-
Effective
educational strategies should promote effective ED pain management.
-
Ongoing
research in the area of ED patient pain is supported.
ACEP Clinical Policy
The next step in the process
of improving ED patient care in the area of pain management is to
develop a full clinical policy that addresses relevant clinical questions
using the support of the medical literature. If clinically useful
answers can be provided that promote more consistent clinical practice
patterns, it should be possible to improve patient care and enhance
patient satisfaction and outcomes.
Relevant Clinical Questions
Relevant clinical questions
in several areas exist that could be addressed with an ACEP clinical
policy. These areas include pain epidemiology, therapeutics, clinical
practice and policies, ED systems, research, and advocacy. Some of
these questions include:
-
Are
there subsets of patients who are greatest risk for oligoanalgesia?
- What are the optimal
pain therapeutics that can be used to treat ED patient pain?
- How is ED pain management
optimally conducted and documented?
-
What
clinical policies exist that optimize ED patient pain management?
-
Do
specific ED systems exist that can be used to improve patient care?
-
What
ED research opportunities are available for interested ED physicians?
-
What
groups are active in optimizing the care of ED patients who present
in pain?
Clinical Case Outcomes
The outcomes of patients
who present in pain relate to the fact these patients have two separate
problems. The first is the medical condition that is causing the patient
pain. The second is the fact that the patient is feeling pain and
wants pain relief. The former is the disease, the latter the state
of being ill at ease, or in "dis-ease". If both of these
problems are treated explicitly and aggressively, then patient outcome
and satisfaction can be optimized.
Optimizing the care of
these patients can be enhanced by developing systems that recognize
ED patient pain, prioritize pain relief and minimize delays, reduce
variability and complications, and maximize the documentation of the
ED pain management efforts and their effect.
Conclusions / Impact Assessment
Patient who are need of
pain management present to US Emergency Departments on a regular basis.
All Emergency Physicians must strive to optimize the care of these
patients through the enhanced, systematic use of analgesics and other
pain relief strategies.
By addressing the issue
of ED patient pain, it is hoped that:
1. Clinicians
will better understand the problem of oligoanalgesia and strive to
optimize pain management in patient populations at greatest risk for
this problem.
2. Emergency
Physicians will become more familiar with ways in which ED patient
pain can be optimally treated.
3. Clinicians
will read the ACEP Policy statement and use it to promote hospital
efforts to systematize effective ED patient pain management strategies.
4. The
ACEP Clinical Policy Committee will be able effectively answer some
of the relevant questions regarding ED patient pain management in
order to improve the care that these patients receive.
(1)
Ducharme J. Acute pain and pain control: state of the art. Ann Emerg
Med 2000; 35(6):592-603.
(2)
Tanabe P, Buschmann M. A prospective study of ED pain management practices
and the patient's perspective. J Emerg Nurs 1999; 25(3):171-177.
(3)
Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate
emergency department analgesia. JAMA 1993; 269(12):1537-1539.
(4)
Selbst SM, Clark M. Analgesic use in the emergency department. Ann
Emerg Med 1990; 19(9):1010-1013.
1)
Eder SC, Sloan EP, Todd K. Documentation of ED patient pain by nurses
and physicians. Am J Emerg Med. 2003 Jul;21(4):253-7.
This article
addresses the issue of ED patient pain documentation by emergency
physicians and nurses. It demonstrates that enhancements can be made
in documentation and patient satisfaction with increased attention
to patient pain.
2) Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim
RB,
Kaloukalani DA, Lasch KE, Myers C, Tait RC, Todd KH, Vallerand AH.
The unequal burden of pain: confronting racial and ethnic disparities
in pain.
Pain Med. 2003 Sep;4(3):277-94. Review.
This article gives a recent update on the disparities in the treatment
of patient pain based on patient demographics.
3) Gallagher RM. Physician variability in pain management: are
the JCAHO standards enough? Pain Med. 2003 Mar;4(1):1-3.
4)
Curtiss CP. JCAHO: meeting the standards for pain management.
Orthop Nurs. 2001 Mar-Apr;20(2):27-30, 41.
5)
JCAHO partners to develop pain management measures.
Jt Comm Perspect. 2002 Apr;22(4):2, 4.
These three articles address the recent JCAHO initiatives that strive
to enhance the management of patient pain.
This is the website for the NHAMCS database. The following is provided
from that description page:
"The National Hospital Ambulatory Medical Care Survey (NHAMCS)
is designed to collect data on the utilization and provision of ambulatory
care services in hospital emergency and outpatient departments. Findings
are based on a national sample of visits to the emergency departments
and outpatient departments of noninstitutional general and short-stay
hospitals, exclusive of Federal, military, and Veterans Administration
hospitals, located in the 50 States and the District of Columbia.
The survey uses a four-stage probability design with samples of geographically
defined areas, hospitals within these areas, clinics within hospitals,
and patient visits within clinics. Annual data collection began in
1992.
Specially trained interviewers visit the hospitals prior to their
participation in the survey to explain survey procedures, verify eligibility,
develop a sampling plan, and train hospital staff in data collection
procedures. The survey instrument is the Patient Record form, which
is provided in two versions, one for use in outpatient departments
and another for use in emergency departments. Hospital staff are instructed
to complete Patient Record forms for a systematic random sample of
patient visits during a randomly assigned 4-week reporting period.
Data are obtained on demographic characteristics of patients, expected
source(s) of payment, patients' complaints, physicians' diagnoses,
diagnostic/screening services, procedures, medication therapy, disposition,
types of health care professionals seen, causes of injury where applicable,
and certain characteristics of the hospital, such as type of ownership."
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