Emergency Medicine: Emergency Department Protocols
It is easy for health care practitioners to identify with the patient who has severe pain resulting from a kidney stone or an acute femur fracture. However, it may be difficult to identify with a patient who has chronic back pain, yet has no obvious findings on exam. Clinicians need to believe the patient’s assessment of pain. This is not always easy but is extremely important.
Pain is always subjective1 and for many health care providers this is a difficult concept. Clinicians are more comfortable with problems that can be diagnosed on exam or by ordering a test. However, there is no test that can prove or disprove a patient’s complaint of pain. Not vital signs, a patient’s facial expressions, or “gut instincts” can be used to invalidate a patient’s rating of his or her pain.
Pain is the most common presenting symptom in the Emergency Department (ED). More than 60 percent of ED patients have pain as their main symptom or a major part of their symptoms. When a patient in pain enters the ED he or she has two main concerns (not necessarily in this order):
- How quickly can I get relief from my pain?
- What is causing this pain?
The major focus of health care professionals is:
- What is the diagnosis?
- What is the treatment for the underlying disease process?
Often a lower importance is placed on relieving the pain. This leads to discordance between the expectations of the patient and the focus of the health care provider.
So how good a job are most practitioners doing at treating and assessing pain in the ED?
In a recent study of patients presenting to an ED with a complaint of pain, two-thirds never had an assessment of their pain documented. Of these patients, only one-third ever had a re-assessment of their pain (i.e. “Did the analgesic we gave you help?”). Upon discharge from the ED, 43 percent of patients were still in moderate or severe pain.2
Many studies have shown that there are inadequacies in how pain is treated. In a post-operative study, approximately 50 percent of patients felt that their post-operative pain management was inadequate. A study of a busy urban emergency department shows that in patients with a long bone fracture, the risk of receiving no analgesic while in the ED was 66 percent higher for African-Americans than for white patients.3
Barrier to Effective Pain Management
One of the large barriers to effective pain management is lack of formal education on this subject in training. Unfortunately many medical schools designate only one to four hours (over the four years of medical school) to the subject of analgesia. Many physicians are left to “pick-up” knowledge on this subject while on clinical rotations. Residents tend to follow the example set by the resident who is one year ahead. They in turn gain their knowledge of analgesia from the residents one year ahead of them, and so on. Most of training on treating pain is anecdotal and passed down from generation to generation. It is because of this system that many doctors still prescribe propoxyphene, codeine, meperidine, and stadol instead of medicines with a much better benefit to risk ratio.
New Pain Management Standards
Recognizing difficulties, several organizations have set guidelines for pain management. These guidelines include those from the American Pain Society, the World Health Organization (WHO), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). These standards apply to emergency medicine as much as they do to surgery and other specialties. Recently enacted JCAHO standards set forth several basic principles that are consistent with effective pain management. Essentially these guidelines guarantee patients the right to effective pain management. In addition, health care practitioners should ask patients a screening question to identify those patients in pain. For those presenting pain, an assessment of this pain should be performed and documented. Relevant staff should be educated in pain assessment and management and patients should be involved in making decisions about the treatment of their pain.
Finally, the health care facility should establish policies and procedures that support appropriate prescription or ordering of effective pain medication.4
Now that JCAHO will evaluate health care facilities for compliance with these standards, it is important that these guidelines be followed. Many hospitals are setting their main focus on “being in compliance” with the standards. Clinicians should change their focus to setting goals on practicing excellent pain management including choice of medications/therapies, assessment, documentation, and education of staff and patients.
Pain Management Improvements
There are many ways in which pain management can be improved upon in the ED.
Simplistically, this can be divided into two main areas. The first area deals with the clinician’s approach toward pain management. This includes concepts, preconceived notions, biases, and habits as well as the approach toward and feelings about patients in pain. The second area deals with specific technical details about pain management (medicines, route of administration, etc).
There are many options available to practitioners, many which are simple and effective to implement.