Search

Introduction Prospectively assessing factors that influence triage nurse assignment of patients to the higher risk level 2 compared to the lower risk level 3 has not previously been explored within the 5-level Emergency Severity Index (ESI) triage system. Considering the large amount of information available about the patient, less experienced triage nurses often struggle in deciding what patient information is truly relevant when assessing if a high-risk situation exists. The primary aim of this study was to identify specific factors used by triage nurses to differentiate level 2 patients from level 3 patients. Methods A convenience sample of triage nurses was recruited from 2 ED sites. If at the completion of the nurse-patient triage interaction the nurse assigned the patient to either level 2 or level 3, the triage nurse then completed a questionnaire related to factors that influenced patient assignment. Results Overall, 18 triage nurses participated in the study with a total of 334 nurse-patient triage interactions collected. Patient age, vital signs, and need for a timely intervention were found to be significant factors that influenced patient assignment to level 2 while expected number of resources influenced patient assignment to level 3. Discussion Utilizing experienced triage nurses on average, this study identified specific, objective factors that, combined with factors already delineated in the ESI Version 4 Implementation Manual, have useful implications for less experienced triage nurses by providing a more comprehensive and relevant foundation for data gathering and decision making.

Introduction Abdominal pain is the leading cause of patient visits to the emergency department. Although patients present to the emergency department in search of relief from pain, few experience complete pain relief. The purpose of this study was to describe patients' expectations for pain relief and how communication of their pain to nurses and physicians affected their overall pain relief. Methods Questionnaires were completed by patients who reported abdominal pain and by their primary nurse and physician. Numeric rating scales were used to rate pain intensity from 0 (no pain) to 10 (worst possible pain) and actual and expected pain relief (0 = no pain relief, 10=complete relief). Results Forty-four percent of patients reported that they expected complete relief of their abdominal pain. Over 98% of the patients told a provider that they were in pain, but only 33.3% asked for pain medication. No significant differences were found between the patients who asked for pain medication and those who did not in patients' expectation scores or relief scores. Discussion The results of this study showed that patients with abdominal pain have high expectations for pain relief; however, their expectations were not associated with their tendency to ask for pain medication or report actual relief of pain.

The aim of this study was to explore factors influencing emergency department (ED) clinicians’ use of opioids in treating selected patients. Patients who either received or did not receive opioids in the ED, as well as their nurses and physicians, were interviewed before patient discharge. We found that the decrease in patients’ mean (SD) pain intensity from the time of admission to the ED (7.3 ± 2.4 on a 0 to 10 numeric rating scale) to discharge (5.0 ± 2.9) was statistically significant (t93 = 8.4, p < 0.001, 95 percent CI = 1.7, 2.8) for all groups except those with trauma-related pain. The factor that most frequently led physicians of patients with abdominal pain and nurses in general to administer no opioids was that the patient was “not in that much pain.” However, the patients in question had self-reported pain scores that indicated moderate pain. Our findings lead us to conclude that clinicians inaccurately infer severity of patient pain. This in turn can influence the prescription of opioids and the patient’s decrease in pain.

Objectives: Studies of emergency department (ED) pain management in patients with trauma have been mostly restricted to patients with fractures, yet the potential for undertreatment of more severely injured patients is great. The authors sought to identify factors associated with failure to receive ED opioid administration in patients with acute trauma who subsequently required hospitalization. Methods: At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study of trauma team activation patients requiring hospitalization between January 1 and December 31, 1999, was conducted. The authors excluded patients receiving opioids only within ten minutes of chest tube insertion or fracture manipulation. The main outcome measure was ED opioid administration. Results: A total of 540 charts of hospitalized first-tier trauma team activation patients were reviewed. A total of 258 (47.8%) received intravenous opioid analgesia within three hours of ED arrival. The median time to receiving the first dose of opioids was 95 minutes. Patients were independently less likely to receive opioids if they were younger or older, were intubated, had a lower Revised Trauma Score, or did not require fracture manipulation. Patients with these factors were less likely to receive opioids independent of the amount of time they spent in the ED. Conclusions: Many trauma activation patients requiring hospitalization do not receive opioid analgesia in the ED. Patients at particular risk for oligoanalgesia include those who are younger or older and those who are more seriously injured, as defined by a lower Revised Trauma Score, lower Glasgow Coma Scale score, and intubation.

Pain is a common complaint in Emergency Departments. Inpatient studies have shown discrepancies between patients' and nurses' pain assessments. The accuracy of emergency nurse assessments of their patients' pain has not been well investigated. Using a 0 to 10 numeric rating scale (NRS), researchers asked patients to rate their pain intensity in triage. Separately, the triage nurse was asked to rate the patient's pain. This process was repeated with the same patients but different nurses after patients were taken back to a clinical area within the Emergency Department. At triage, patients' average pain intensity score was 7.5 +/- 2.2. The triage nurses' ratings were significantly lower at 5.1 +/- 2.4 (p

Objective: To determine whether IM ketorolac is superior to oral ibuprofen in patients presenting to an ED in moderate to severe pain. Methods: This prospective, randomized, double-blind study involved a convenience sample of 119 patients aged a 18 years who presented to an urban teaching hospital ED with a self-assessed pain intensity score of 5, 6, 7, or 8 (on a numerical rating scale of 0–10). Patients were randomized to receive either 60 mg of IM ketorolac and a placebo capsule or 800 mg of oral ibuprofen and a saline injection. Pain scores were measured at 0, 15, 30, 45, 60, 90, and 120 minutes after dosing. Supplemental analgesics were allowed in accordance with standard medical practice. Results: There were 18 patients excluded who did not remain in the ED for the full 2-hour study period. Of those completing the trial, 53 patients received ketorolac and 48 patients received ibuprofen. There were no significant differences in pain scores between ketorolac and ibuprofen at any time during the study. However, there was a statistically significant decrease in pain over time in both treatment groups. Yet, 40% of the patients continued to report pain intensity scores of 5–8 at 2 hours after treatment. Conclusions: IM ketorolac and oral ibuprofen provide comparable levels of analgesia in ED patients presenting with moderate to severe pain. Unfortunately, 40% of all the patients had inadequate pain relief (pain score ≥5) from either ketorolac or ibuprofen.

Substance users are commonly perceived to overstate their pain. Few data exist comparing pain intensity, perception, and related psychiatric comorbidities in the emergency department (ED) population.To compare pain severity, duration, interference with function, and psychiatric and mood disturbance in substance-using (SU) and non-substance-using (NSU) patients in the ED.This is a cross-sectional study. The setting is in an urban ED. Participants are SU and NSU patients in moderate to severe pain (numerical rating scale, 5-10). Outcome measures are as follows: pain intensity and duration, other painful conditions, pain-related functional interference (0-10), psychiatric disorders, and mood distress (profile of mood scale, 0-44).Of the 148 patients who enrolled, 28 (19%) reported recent illicit substance use (SU) and 120 (81%) did not (NSU). The SU patients' mean pain intensity was 8.96 (confidence interval [CI], 7.47-8.14) vs 7.81 (CI, 8.48-9.45) for NSU (P = .003). The SU patients reported higher levels of pain interference. Fifty-four percent of SU patients vs 31% of NSU patients reported a psychiatric illness (P = .02). Mean Profile of Mood State score was higher in SU (32.3; CI, 27.4-37.1) than in NSU (22.5; CI, 20.2-24.8; P.001). Chronic pain was reported by 29% of SU patients vs 16% of NSU patients, and 75% of SU patients vs 58% of NSU patients reported another concurrent painful condition (P = .10).The SU patients report more severe pain and functional interference, more psychiatric illness and mood distress, and more chronically painful conditions. Given the complex interplay between pain, substance use, and mood disorders, increased attention should be paid to identifying patients with these associated conditions and to facilitating appropriate referrals. Effective treatment of this challenging patient population requires treating the entirety of their medical, psychiatric, and addictive diseases.

Introduction Little is known about how continued pain after discharge from the emergency department is managed by patients, and how it may interfere with the functional status of patients. The purpose of this pilot study was to evaluate pain management practices, patient satisfaction with pain medications, and how continued pain after ED discharge may influence the functional status of patients who presented with chief complaints of abdominal, chronic, abscess, or trauma-related pain. Methods This prospective, descriptive study was conducted at 2 Level 1 trauma hospitals. Twenty-nine patients completed an emergency department discharge questionnaire and follow-up phone survey. Data were collected via telephone interviews an average of 72 hours after discharge. Results On emergency department discharge, patients reported pain intensity that had not decreased significantly at the time of the home interview. Most patients (78%) used ED-prescribed medications and reported a high level of satisfaction with their pain relief (7.2 ± 2.1). Continued pain after ED discharge primarily interfered with patient's ability to work (7.3 ± 3.8), to go outside for social activities (6.5 ± 4.1) and to ambulate (5.0 ± 4.1). Discussion Patients in this study, on average, continued to experience pain for up to 96 hours after discharge from the emergency department. They reported a high level of pain relief from their ED-prescribed medications. However, interference with functions of daily living due to continued pain was substantial. Further studies are needed to examine the paradoxical reports of high satisfaction with pain relief yet substantial functional limitations experienced by patients after ED discharge.

Objectives To compare the use of opioid analgesia in the treatment of emergency department patients with acute right lower quadrant (RLQ) abdominal pain between 1998 and 2003 and to explore the relationship between opioid use and abdominal computed tomography (CT) scanning. Methods This was a retrospective cohort study of patients presenting in 1998 and 2003 to an urban emergency department with a triage complaint of RLQ pain. The authors abstracted use and timing of abdominal CT scanning and opioid analgesia. Other predictor variables were patient demographics. Risk ratio for receiving opioids with CT scan versus without CT scan, stratifying by year, were calculated. Proportional-hazards analysis was used to control for time in the emergency department. Results Of the 187 patients seen in 1998, 38 (20%) underwent CT scanning and 43 (23%) received opioids. Of the 137 patients seen in 2003, 77 (56%) underwent CT scanning and 72 (53%) received opioids. In 1998, the risk ratio for receiving opioids in patients who underwent CT scanning (vs. without) was 3.7 (95% confidence interval [CI] = 2.3 to 6.1); in 2003, it was 1.5 (95% CI = 1.0 to 2.1). Opioids were overwhelmingly given before CT scanning in those patients who received both (81% in 1998 and 98% in 2003). The mean time to administration of the first opioid dose in 1998 was 155 minutes and in 2003 was 94 minutes. The proportional-hazards analysis confirmed a strong association between CT scanning and opioid administration in 1998 (relative hazard, 2.7; 95% CI = 1.5 to 5.1) and substantial attenuation of the association in 2003 (relative hazard, 1.3; 95% CI = 0.8 to 2.1). The hospitalization rate was not significantly different in 2003 (33%) versus 1998 (27%) (p = 0.28). The risk ratio of receiving opioids in admitted patients was 2.8 (95% CI = 1.7 to 4.6) in 1998 and 2.0 (95% CI = 1.5 to 2.7) in 2003. Conclusions Opioid administration to patients with RLQ pain has dramatically increased between 1998 and 2003. During these five years, the number of patients receiving opioids more than doubled and the time to first administration of opioids decreased by one hour. The authors show that this cannot be attributed to an increased use of CT scanning.

Ethnic and racial differences in the provision of emergency department (ED) analgesia for long-bone fractures have recently been reported in two large cities. The authors sought to determine, in a third city, whether nonwhite patients with long-bone fractures were less likely to receive analgesics than white patients with similar injuries.At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study was conducted of all ED patients aged 18 to 55 years seen from July 1, 1998, through June 30, 1999, with an ED discharge diagnosis of isolated long-bone fracture identified by ICD-9 codes 812, 813, 821, and 823. Exclusion criteria included injury more than 12 hours prior to presentation or a Glasgow Coma Scale score of less than 14. The main outcome measure was ED analgesia administration.Three hundred twenty-three patients met inclusion criteria; 181 were white, 58 African American, 46 Hispanic, 38 Asian. All ethnic/racial groups were equally likely to receive no analgesia or no parenteral analgesia. The overall risk for no analgesia was 20% and for no parenteral analgesia was 31%. Stratification and multiple logistic regression to control for gender, bone fractured, and need for reduction failed to identify any trend toward reduced analgesia administration in any ethnic/racial group.In contrast to two recently reported studies, at this urban trauma center and teaching hospital ED, there was no difference in the administration of analgesics to white and nonwhite patients with long-bone fractures.

Introduction Each year emergency departments see millions of patients' many with moderate to severe pain. The use of valid, language-sensitive pain assessment methods is a critical prerequisite to selection and evaluation of pain treatment interventions. However, scant research has been conducted on the validity of pain intensity measurements in English-speaking and non-English-speaking ED patients. This study validated two measures of pain intensity—a 0 to 10 numerical rating scale (NRS) and a word descriptor scale (WDS)—in English-speaking and Spanish-speaking ED patients and determined patient preferences for the pain rating scales. Methods ED patients with various medical conditions were asked to rate their pain intensity using both scales, in their language, seven times during a 2-hour study period. Patients were then asked to choose the pain scale that they preferred to use. Results Moderate to strong correlations were found between the NRS and WDS pain scales. In addition, the NRS and WDS were equally preferred by patients, whether they spoke English ( n = 95) or Spanish ( n = 21). Discussion We demonstrated in this study that both the NRS and the WDS scales were valid instruments for measuring pain in English-speaking and Spanish-speaking ED patients. In addition, very little difference was found in patient preference for one of the scales. ED patients in acute pain were able to use both ways of communicating their pain to health professionals. Therefore patients could be offered their choice of either of these simple pain rating scales to evaluate pain and the effectiveness of pain-relieving interventions.

1Department of Emergency Services, San Francisco General Hospital, and Department of Medicine, University of California, San Francisco, 2Department of Physiological Nursing, School of Nursing, University of California, San Francisco, 3Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, and 4Pain and Emergency Medicine Institute, Beth Israel Medical Center, New York On behalf of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study