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Show Improving Pain Management in the Emergency Department David E. Fosnocht, M.D. and Eric R. Swanson, M.D. Abstract The University of Utah has established a program to improve pain management in the emergency department. Initial work revealed that only 45% of patients presenting with pain receive pain medication in the emergency department. In addition, actual time to delivery of pain medication fell far short of patient expectation for time to delivery of pain medication (78 minutes vs. 23 minutes). Institution of a triage pain protocol has decreased the time to pain medication delivery from 78 minutes to 39 minutes and increased the number of patients receiving pain medication from 45% to 75%. The development of an interactive pain registry is planned in order to establish and test evidence-based standards for the treatment of pain in the acute care setting of the emergency department. Pain is the most common chief complaint for patients in the emergency department (ED), with 70% of ambulatory patients presenting with pain (Ducharme, 1994; Johnston, Gagnon et al. 1998). Inadequate treatment of pain in the ED is common and has been well documented (Wilson and Pendleton, 1989; Ducharme and Barber, 1995; Jones, 1999). The reasons often cited for this lack of pain management in the ED have included inadequate research and a subsequent limitation of options for practicing emergency physicians (Bonica, 1987). Individual emergency physicians and nurses as well as the American College of Emergency Physicians have advocated additional research in the area of pain management for acute injury and illness (Cordell, 1996; Ducharme, 1996; Terndrup, 1996). Results The University of Utah has recently established a program to improve pain management in the ED and lead national research in this area. A quality assurance ED pain survey was initiated in 1999 to assess current pain management practices in the ED and define patient expectations for pain management in the ED. In a review of 458 patients presenting to the to the University of Utah ED in 1999, it was found that only 45% of patients presenting with pain received pain medication in the ED (Fosnocht, Swanson, et al., 2001). This was similar to other sites nationwide (Wilson and Pendleton, 1989; Lewis, Lasater, et al., 1994; Beel, Mitchiner, et al., 2000). The actual time to delivery of pain medication at the University of Utah was a mean of 78 minutes (95% confidence interval (CI) 70-87) after arrival in the ED (time the patient first checks in at the desk or is brought into the ED by ambulance) while patient expectations for time to delivery of pain medication was a mean of 23 minutes (95% CI 20-25) (Fosnocht, Swanson, et al., 2001). Patient satisfaction was a mean of 83 mm (95% CI 80-85) when patient needs for pain relief were met compared to 51 mm (95% CI 44-58) when patient needs for pain relief were not met (Fosnocht, Swanson, et al., 2001). Assessment of an additional 522 ED patients in 2000 found that patients expect a mean of 72% reduction in pain and a relatively large number of ED patients (18%) expect complete relief of pain. All pain assessment and measurement of pain relief was performed using a previously validated 100-millimeter (mm) visual analog scales (VAS) (Huskisson, 1983; Wallenstein, 1984). These expectations have been found to be consistent in both Hispanic and Non-Hispanic White patients (Lee, Burelbach, et al., 2001). The first step to improving pain management in the ED at the University of Utah has been the establishment of pain protocols implemented at triage by nursing staff. All patients presenting to the ED with extremity or back pain are asked to mark Utah's Health: An Annual Review Volume VIII 11 |