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Innovations in Process Management / Optimizing Patient
Management
Introduction
Pain Assessment
It is well known that emergency
physicians (EPs) do not accurately perceive a patient's level of pain.
Therefore, proper assessment of pain is necessary to provide appropriately
aggressive pain treatment in the emergency department. Appropriately,
aggressive pain treatment is not only good medical care with improved
customer service but also improves patient compliance. There is some
data to suggest that aggressive treatment of acute pain reduces the
progress to chronic pain. Whether one agrees with the edicts of the
Joint Commission of Healthcare Organizations (JCAHO) or not, pain
assessment is essential to ensure that physicians are properly addressing
the patients' need for pain relief
There are various means
to assess pain in patients including behavioral, physiologic and subjective
approaches. Behavioral approaches include observation, vocalization,
facial expression and body movement; whereas physiologic approaches
include heart rate, blood pressure, sweating, stress hormones levels.
Subjective approaches include self-reported numerical, visual and
categorical methods. More extensive pain assessments such as the McGill
Pain Questionnaire and Short Form 20 Health Survey better differentiate
pain syndromes and effect on lifestyle but have limited value in the
emergency departments (ED).
Numerical scales use verbalization
of pain from 0-10 or 0-100 with end points as no pain or worst pain.
Visual analog scales measure pain with a 10 cm line with similar end
points and categorical scales use pain intensity on a 4 point scale
from "no pain" to "severe pain". Other scales
are available for use in special populations such as those used for
illiterate and cognitively impaired persons that take into account
their disabilities.
Although the commonly used
methods in the EDs are numerical scales, the studies suggest that
visual scales are a better method of pain assess. Visual pain scales
have the advantage of ratio scale property, ease and brevity of administration,
minimal intrusiveness, and conceptual simplicity [1-2]. Visual scales
usually use a horizontal 10 cm line without gradations is recommended.
Thirteen to sixteen millimeters difference is considered clinically
significant on this scale.
On the other hand, scales
for children need to be age and developmentally appropriate [3-4].
Scales for infants are primarily behavioral observation or physiologic.
One example of a tool for assessing pain in the infant is the Neonatal
Facial Coding System that evaluates facial muscle groups for preterm,
full term, neonates or infants. Physiologic assessment includes heart
rate, blood pressure, respiratory rate and level of diaphoresis. Pre-school
children tend to do better with faces, the Ocher test, color poker
chip or behavioral scales.
The facial expression test, Oucher test, is for 3-12 years old with
three different ethnic version. In the faces test, the child chooses
the face that represents their level of pain. Behavioral observations
scales such as CHEOPS and the Procedure Behavioral Rating Scale are
useful tests in this age group but are too extensive for use in the
ED. Older children perform well on similar tests as those tests for
adults including visual, numerical, and categorical.
The choice of pain assessment
tools used in the ED is based on ease of use, familiarity and cost.
Numerical rating scales for adults, although limited, and some type
of facial pain assessment for pediatric patients are recommended to
determine need for and effectiveness of treatment.
Adjunct Therapy
The World Health Organization
disseminated a pain treatment ladder going from non-opoid to opoid
treatment with or without adjuncts depending on pain severity [5].
The choice of adjuncts depends on the type and severity of pain and
the age of the patient. Adult's adjuncts are usually medication related
and pediatric adults are usually behaviorally related.
The most common pharmaceutical
adjunct used in emergency medicine is topically anesthesia. Topical
anesthesia is frequently used prior to procedures such as suturing
of a wound. There are many different topical anesthesia preparations
including EMLA cream, lidocaine, and tetracaine with or without epinephrine
and in combination. Unfortunately, it is not used frequently for routine
procedures performed in the ED. Singer and others found emergency
physician and nursing do a poor job of rating patients procedural
pain [6]. Patients, in this study rated the most painful procedures
as a placement of a nasogastric tube, incision and draining of an
abscess, fracture reduction and urethral catheterization.
Other pharmaceutical adjuncts
for pain treatment include anxiolytics, anticonvulsants, antidepressants
and skeletal muscle relaxers. Benzodiazepine are used in anxiety related,
muscle injury and spasms but it is limited due to its side effects.
Anticonvulsants and antidepressants have benefit in chromic pain.
Amitriptyline and other tricylic anti-depressants are effects in neuropathic
pain but serotonin re-uptake inhibitors (SSRIs) have not been well
studied for pain use. Caffeine and hydroxyzine has limited potentiation
effects in combination with other pain compounds. Muscle relaxants
have some effectiveness but suffer from the same limitation as benzodiazepine.
Narcoleptic agents have not been shown to have a pain benefit.
Targeted pharmaceutical
agents for some headaches, acute gouty arthritis and fractures are
also effective. 5-HT1 receptor antagonists and ergotamines are limited
to migraine and cluster headaches. Although limited by gastrointestinal
side effects, colchicine is quite effective in the treatment of acute
gout. Calcitonin has usefulness in acute vertebral factures in patients
associated with Osteoporosis, Paget's disease and bone malignancies.
Corticosteroids have been found to assist in bone, visceral and neuropathic
pain. For example, corticosteroidal injections are of uncertain benefit
in musculoskeletal problems such as rotator cuff disease and injuries,
adhesive capsulitis and mixed disease.
The standard non-pharmaceutical
adjuncts used in the ED is frequently limited to ice, immobilization
and elevation for musculoskeletal injuries. Although the studies are
limited to the effectiveness of these adjuncts, ice is considered
an effective pain reduction agent. The use of other adjuncts not considered
standard therapy in the emergency department is not as frequently
as the used standard therapy but should be seriously considered. Nonpharmacologic
adjuncts may include psychological, acupuncture, hypinosis and relaxation
training. Ice has been found to be effective prior to the start of
an intravenous catheter or acute musculoskeltal pain [9].
Psychological adjuncts
utilize a common sense approach that is to establish a trusting physician
patient relationship, recognize the patients concerns and fears, explain
the steps of the procedure, provide accurate information about the
procedure and provide realistic expectations of the procedure. In
the pediatric population, studies have demonstrated that parents not
only wish to stay with their child during a procedure but also reduce
both their and their child's distress [10].
Other approaches include
the use of acupuncture, hypnosis, relaxation and distractions. The
use of acupuncture in acute care settings is limited at best. Iserson
has used hypnosis in emergency setting for pediatric fracture reduction
[10]. Relaxation training has merit in the chronic pain setting but
minimal value in the acute care setting. Inexpensive disposable TENS
devices for use in the ED is limited by the time to reduce pain and
administration of the device. The use of music and television distractions
has limited effects in selected environments.
Infants benefit from comfort
measures, children 2-6 years old from distraction, children 5-10 years
old from suggestions and older children from progressive muscle relaxation
and hypnosis.[11] Comfort measures include use of pacifier, swaddling,
massage, touch and sucrose solutions. Distractions include kaleidoscope,
stories, bubbles, counting, pop-up toys and video games. Suggestions
include magic glove, pain switching, breathing techniques, guided
imagery and emotive imagery.
It is difficult to determine
which of these adjuncts are effective and applicable in the ED for
each type of pain. The best means to focus this assessment is by applying
the evaluations performed by the Cochrane Group [12]. The Cochrane
Group has performed an analysis of the effective techniques for the
treatment of low back pain. They evaluated the use of activity, exercise,
bed rest, back school, muscle relaxers and lumbar support. Activity
was found to have small beneficial effect; exercise and bed rest had
no indication for acute pain. Back school is useful for chronic or
recurrent back pain, muscle relaxers are effective but have significant
adverse effects and lumbar support is of uncertain value.
Patient Compliance
The optimal pain outcome
is dependent on a compliant, cooperative patient who can be a partner
in the pain management plan. Compliance factors include psychological,
environmental and social issues, characteristics of a therapeutic
regimen and properties of the physician-patient relationships. There
is little data on the means to improve compliance for pain treatment
in ED patients.
Although there is limited
study about non-compliance of ED patients, compliance, in general,
is related to barriers of compliance and forms of non-compliance.
Barriers to compliance include unresolved concerns, miscommunication
and regime complexity. Forms of non-compliance include original prescription
not filled, refills not obtained and incorrect dosing. Study by Thomas
and others found that 12% of their ED patients did not fill their
prescription and 33% did not follow up [12].
Open communication with
the patient and the patient's care providers is the essential component
in improving patient compliance. Explanation of the treatment plan
and provision of time for questions are essential but are often delegated
to the nursing staff. Alternative means to fund or provide medications
and follow up to patients without appropriate insurance of funding
resources will also improve compliance. Studies have shown that making
an appointment for a patient in the ED improves patient compliance
with follow up.
Physician Compliance
Physician compliance with
accepted pain treatment has increased by the use of a pain education
programs. Jones described a four-hour course that increased the treatment
of pain that included causes of pain, pathophysiology of pain, principles
of pain management, and types of treatment and customization treatment
plan for pediatrics and elderly patients [11].
Emergency physicians have
a concern about contributing to the disease process of drug seeking
patients that present to the ED. One study demonstrated that starting
narcotics in the hospital does not lead to a life of drug addiction
for a vast majority of patients Four of 11,882 inpatients were found
to become narcotic addicted while an inpatient [12]. Which patients
become drug addicted is a difficult to determine because it is not
a predictable event and represents an adverse idiosyncratic response
in vulnerable individuals.
Drug seeking patients frequently
use EDs, move from one provider to another, have uncoordinated care,
obtain poor follow-up, present with difficult to prove complaints.
Although problematic in addicted patients, agonists-antagonists and
attempting to coordinate long-term care have been recommended. Drug
addicted patients with acute pain is another diagnostic dilemma. Most
Epps would reluctantly treat these patients with large doses of narcotic
agents.
Drug seeking patients are
difficult to identify and deal with. Although studies have tried to
better understand prevent the drug seeking behavior of patients in
emergency medicine, success has been limited. One study tracked the
patients who were substance addicted to prescription drugs and found
that 30 patients who met the definition had 12.6 visit per patient,
visited 4.1 hospitals and used 2.2 alias. Two of these patients died
during this tracking [13]. This study demonstrated that drug-seeking
patients commonly returned to the same hospital and received prescription
medications. Two studies attempted to find techniques to reduce drug
seeking patients' use of an ED. In Calgary, the emergency physicians
found the means to identify and communicate about these patients.
The effectiveness of this process was not evaluated. In another study,
the authors recommended that files of habitual ED users be kept and
shared with other emergency department.
Emergency physicians could
do better with dealing with patients who have acute upon chronic pain
and those that have a pseudo-addiction [14]. It is essential to investigate
why the patients with chronic pain have an acute episode whether from
acute flares, inadequate pain management or desperation. These patients
may need additional medications or are commonly depressed. In the
psuedoaddicted patient, the patient is mistaken for a drug addict
rather than someone who has not received adequate treatment for their
pain. These patients tend to be drug hoarding, requesting specific
drugs, clock watching and dose escalating. Appropriate understanding
and timely analgesics is indicated for this patient type.
Patient Education at Discharge
Proper patient education
begins with an adequate understanding of the options for pain control
and the use of treatment adjuncts. Emergency physicians do a poor
job at judging a patient's level of pain. In a study by Guru and Bobinsky,
they found that physicians and nurses reported lower pain that their
patients, many charts did not have pain scales documented and half
the patients did not have their pain relieved on ED upon discharge
[15]. Patients also do not have an adequate understanding of how to
use over the counter medication. Chan and others found that many patients
were unaware of how to proper use OTC medications, adverse effects
and potentially lethal associations [16].
The fundamentals of patient
discharge from the ED needs to include individualized pain control,
anticipating pain rather than reacting to it, patient controlled medication
decisions and the use of combination therapy including adjuncts [17].
Successful pain relief in the ED may be indicative of appropriate
medications for the outpatient treatment upon discharge. An example
of anticipating pain treatment would be round the clock non-steroid
anti-inflammatory medication with the addition of a narcotic agent
for increased pain at the patient's discretion. Appropriate adjuncts
for home use need to be encouraged as part of the discharge plan.
Patients need to be informed about a treatment plan that entails an
action plan for increased pain, understanding of adverse events and
the use of adjuncts.