Is pain management lacking in your ED? Here’s what you need to do

Studies show there is a lot of room for improvement for pain management in the ED; managers must develop protocols, stay current on new approaches

Pain is often poorly managed in emergency medical services (EMS) and emergency departments (EDs) for both pediatric and adult patients, says Emory M. Petrack, MD, MPH, director of the department of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland, OH. "Of all the various types of help that we can offer people in the ED, effective management of pain is an area where we often fall short of our potential," he notes.

Every ED manager should make improvement of pain management a priority, argues Gregory Henry, MD, FACEP, chief of the department of emergency medicine at Oakwood Hospital-Beyer Center in Ypsilanti, MI. "People may expect to sit, waiting in pain, when they come to the ED, but I think we ought to exceed expectations," he says.

Make pain management a priority with staff, urges Petrack. "The ED manager plays an important role in providing leadership to ensure that patients in pain, either from disease or injury or from painful procedures, are helped with their pain as much as possible," he says. "Addressing the need for pain relief leads to both better quality of care and enhanced patient and family satisfaction."

Audit and use protocols. At Ravenswood Hospital’s ED in Chicago, IL, a patient satisfaction survey revealed that patients were dissatisfied with pain control. An audit was done to track the use of pain medication in patients with fractures, sprains, and contusions. "We also studied the use of topical LET (lidocaine, epinephrine, and tetracaine) in the use of appropriate pediatric lacerations. We found we did not use much topical anesthetic in kids even though it was available" says Bruce McNulty, MD, medical director of the ED.

The results of the audit were shared with ED physicians, including doctor-specific data. "Each doctor on staff saw what his or her rate of use of these pain relievers was," says McNulty. "We have found, as have others, that peer review comparison data is a powerful tool for change. No physician wants to be the low outlier in an audit such as this."

Repeat audits are an effective way to track progress. "After we collected data initially, we again carefully documented use or even the offering of pain relievers," McNulty says. "We created a very simple protocol giving nurses the authority to order analgesics for fractures, sprains, and contusions. Previously, pediatric fever was the only time medications were given at triage."

The protocol also included applying LET at triage for appropriate pediatric lacerations. "It takes about 15 minutes or so to work, so if you need to wait two hours for the doctor to do it, that is an unnecessary delay," says McNulty.

Progress is tracked on an ongoing basis. "We track the numbers frequently and give feedback to the individuals involved, so that they are invested in the improvement," says McNulty.

A third audit will be conducted, with the goal of tracking increased use for each step in the process. "We hope this will reflect in improved scores on this part of our customer satisfaction data, as well as overall improved satisfaction with the care we provide," says McNulty.

The idea is for staff to embrace the concept of pain control as an important issue, McNulty explains. "Once the issue of pain control is embraced, our goal is to create protocols for renal stones, migraines, and other painful conditions to standardize and speed care," he says.

Adhering to specific guidelines makes pain management more consistent, says Murphy. "If the algorithm states to use this amount of morphine on a patient with pain, then it’s not up to the judgment of an individual," he explains. "If a physician doesn’t follow the algorithm, it’s not acceptable to say they forgot it. They have to justify that in the record."

Protocols for specific medications can also reduce risks. (See protocol for Ketamine inserted with this issue.) "Many painful procedures in the ED require the use of IV or IM sedation and/or analgesia," says Petrack. "Protocols or guidelines should be established for the use of these agents to ensure high quality and safety."

Target patients at high risk. "Patients at high risk for inadequate pain management in the ED include those with abdominal pain, burns, and eye injuries, and children and the elderly," says Henry. Here are some things to consider for these patient populations:

Elderly. Inadequate pain management is particularly dangerous for elderly patients, stresses Henry. "Severe pain causes a release of epinephrine, which raises blood pressure. That can stimulate an elderly patient to the point of vasoconstriction and heart attack," he says. "Treating pain allows other body functions to continue normally."

Abdominal pain. Clinicians are often reluctant to treat patients’ abdominal pain before a diagnosis is reached, says Michael Murphy, MD, associate professor of emergency medicine and anesthesia at Dalhousie University and executive director of Emergency Health Services for the province of Nova Scotia, Halifax, Canada. "Since the early 1900s, a myth has been perpetuated that pain shouldn’t be managed until a diagnosis is made," he says. "That statement was made because if they gave someone morphine and abolished their pain, they didn’t operate and the patient died."

New alternatives make that outlook obsolete, notes Murphy. "Back then, management of pain was an all or nothing phenomenon," he says. "Now our pharmacology is much more precise and the risk of anesthesia is so much lower. In the last 10 years, literature has shown that judicious administration of pain medication actually enhances your ability to make a diagnosis."

However, abdominal pain needs to be treated appropriately, says Murphy. "If there is so much pain that the patient can’t accurately locate the pain because they are in agony, that works against the diagnosis," he notes. "On other hand, if we take away all their pain, that also works against it, so you need to balance the amount that you give."

Orthopedic pain. "For some reason, there is a reluctance to adequately manage orthopedic pain," says Murphy. "That may be because patients may have multiple injuries, so there is concern about masking one that may be life threatening, Also, it requires opioids, and people are concerned about respiratory depression."

Indigent population and drug abusers. "People that are addicted and homeless also have pain," says Murphy. "It’s not unusual for me to administer several hundred milligrams of morphine to an addicted patient."

Pediatric patients. "Children are a special problem and stand by themselves," says Murphy. "For some reason, we don’t consider them as physiologically capable of adults as having pain."

Often, children don’t communicate pain well, and have difficulty in using behavioral scores or visual analog scales, notes Murphy. "Also, they learn that the reward for complaining of pain is a needle, so are reluctant to complain," he adds.

Children should be routinely asked about pain, advises Murphy. "If we ask a child if they have pain, they will tell you, but sometimes we don’t ask," he says. "Otherwise, children with painful conditions, such as sickle cell crisis, may come to the ED and just suffer in silence."

Physicians may be reluctant to give children certain medications. "We use very potent medications to manage pain in adults, such as opioid analgesics," says Murphy. "Some people may feel these drugs are too powerful for kids."

The margin of error for children is very small, Murphy notes. "But that just means you have to be more careful with dosing," he says. "It’s very difficult to give 0.1 of a milligram of morphine. EDs with a lower pediatric volume have less experience managing small children, so they need to pay more attention to details in dosing."

Here are some ways to improve management of pain in the ED:

Measure pain in regular intervals. A regimented approach to pain management includes checking to see how a patient’s pain level is changing, recommends Murphy. "You might have a patient’s blood pressure and pulse checked every five minutes, and you can do the same with pain management," he says. "Note the pharmaceutical interventions, then study the difference between these patients and others to check outcomes."

Be aware of cultural differences in expressing pain. (See sidebar on ethnic bias in the ED on page 125.) "The outward demonstration of suffering, which is often times culturally driven, is no different than a person who wants to eat spicy vs. bland food. It doesn’t mean they are abnormal or that we have to coach them to behave in a more stoic manner," says Murphy. Using numerical scores for pain instead of relying on a patient’s outward expression can improve accuracy of pain severity, he suggests.

Lessen anxiety. "Anxiety and pain run together. If we can reassure patients, often their pain gets better," says Henry. "If a patient is anxious before a procedure such as spinal tap, I give them pain and anti-anxiety medications through an IV before the procedure."

Simple reassurance can lessen a patient’s anxiety. "There are lots of ways of treating anxiety. Even your mannerisms can make pain better or worse," says Henry. "Reassure the patient by saying, I will take care of your pain, immediately,’ or I have more pain medicine than you have pain, and I’ve never met anybody we couldn’t give relief.’"

Diversion strategies are difficult to use in the ED, but they are legitimate, says Murphy. "Patients who are reassured and have confidence in the health care team typically have lower pain scores than those who are anxious," he explains. "If they understand you are there to help them, they don’t need to exaggerate the psychological manifestations of pain."

Use multiple modalities of pain control. Combining multiple pain modalities is a better strategy than using a single modality, says Henry. "For example, Tylenol and Ibuprofen act on two separate sites and have no interaction with each other," he explains. "You get better results using them together than if you use either one independently."

Ask every patient about pain. "Ask about pain every single time as part of the initial history, and determine what you are going to do for pain. If a patient has to ask you for pain medication, you have failed," says Henry. "We tend to think that some patients are whiners and complainers, but other patients may be stoic and not volunteer the fact that they’re in severe pain."

Some conditions are very painful, but are often not considered painful. "For example, a corneal abrasion can be just devastating, and needs to be properly treated," says Henry.

Ask specific questions about the nature and severity of pain. "Ask where the pain is; [ask about] the radiation, timing, and what makes it better or worse," Murphy recommends. "It would be reasonable to ask how intense their pain is on a 5-point scale, and if it’s greater than a 3, treat it."

Give medications IV. "If you are going to use multiple approaches to pain, as with a migraine headache, give all medications IV," Henry recommends. "That way, the patient only has one needle poke and doesn’t have any pain from you. Why give a bunch of shots IM if you don’t have to?"

Know which methods to consider. "There are all kinds of modalities that help with pain. Use whatever you need to. That may mean medication, ice, elevation, or immobilization," says Henry. "There are all different types of pain, and different modalities are more useful in certain situations than others."

Educate residents. "A major problem with young doctors is [that] most of them have never suffered real pain. A lot of specialties are so limited in training that it takes time on the outside to understand pain management," says Henry. "It’s up to the attendings to teach residents about pain management."

Address pain at discharge. "Every checklist should include pain relief," stresses Henry. "Work with the patient to help them decide their pain management, instead of enforcing your beliefs on them."

Provide inservicing to staff. "There are many excellent seminars in pain management offered by the American College of Emergency Physicians, the American Academy of Pediatrics, and others," says Petrack. "The first step toward improving the management of pain is to make a personal commitment to address this area through education and to gain some experience in providing better pain control both for procedures in the ED and for discharge analgesia needs."

Education is extremely important to ensure optimal care, stresses Petrack. "This should include physicians, nurses, and medics if they help with these procedures," he notes. "The American College of Emergency Physicians and the American Academy of Pediatrics have both published guidelines for the provision of procedural sedation and analgesia."

Use child-life specialists. For EDs that provide care to a large pediatric population, child-life specialists can offer a variety of services to help children who are in pain or who need to undergo painful procedures, says Petrack. "Many ED physicians have had the experience of utilizing child-life specialists to do minor, painful procedures without sedatives or analgesics that would otherwise be required," he explains. This significantly enhances both the quality of care provided and customer satisfaction, Petrack says. "I have received more positive letters about the use of child-life specialists for painful procedures than about any other topic," he reports.

Make pain a fifth vital sign. "There is a movement in continental Europe where pain has been added as a fifth vital sign," says Murphy. "A visual analog score is recorded for every patient, with standing orders for nurses to administer analgesics to those patients."

At triage, acutely painful conditions should be scored as emergent problems, says Murphy. "We routinely audit charts for vital signs, with a 100% compliance. Our tolerance is 1% noncompliance," he explains. "This way, recording pain as a vital sign becomes the norm in your day-to-day practice."

Confront misconceptions of colleagues. "Over the past five years, the sophistication of monitoring and pain management has improved substantially in the ED," says Murphy. "Clinical managers of EDs have a responsibility not only to educate themselves, but also the nurses and physicians they work with, and those we rely on as consultants to [help them] understand pain better than they do now."

However, inpatient management of pain is improving, says Murphy. "Surgeons are becoming more and more aware of pain and its consequences. People are realizing that patients in pain are sicker longer," he notes.

If necessary, take steps to update other departments, Henry advises. "Although antiquated thinking has no connection to reality or current ideas of pain management, it does tend to dominate surgery departments," he says. "You should hold grand rounds with the surgeons and make it explicit, explaining what we do and why we do it."