New approaches to pain ease discomfort, distress

Broader definition are keys to better treatment

A growing number of ED managers are coming to realize pain is much more than a physical symptom and taking a more holistic approach to pain can not only ease patient discomfort, but improve satisfaction.

"The advent of competitive forces, most particularly patient satisfaction, has only added to the critical importance of pain," says James A. Espinosa, MD, FACEP, FAAFP, chairman and medical director of the emergency department at Overlook Hospital in Summit, NJ.

"Pain is a premiere dissatisfier when not addressed properly," he points out.

Knox Todd, MD, MPH, director of the Pain and Emergency Medicine Initiative at Beth Israel Medical Center in New York City, agrees. The project, funded by the May Day Fund, also in New York City, through The American College of Emergency Physicians (ACEP) in Irving, TX, is "geared at improving our capacity to both study and improve pain treatment in EDs in the U.S. and Canada," he says.

Commercial satisfaction monitoring companies, such as Press Ganey Associates in South Bend, IN, have started including pain as part of measuring patient satisfaction, he observes. "While the relationship is not that strong, it’s there, and [more effective pain management] will improve satisfaction."

One of the keys to improving pain treatment, asserts Espinosa, is to adopt a broader definition of pain. "The full depth and breadth of effective management of a person’s pain is very much in play now," he says.

For his ED at Overlook, that management includes adopting a new definition of pain used by the Geneva-based World Health Organization (WHO). (For more information, go to That definition addresses total discomfort and includes issues not traditionally associated with pain, such as anxiety or depression, dehydration, and nausea. "We adopted this as a new way of thinking for how we should work with geriatric patients, but it has enriched our thinking for all patients," Espinosa reports.

WHO is seeing pain in a much broader context, and ED managers have to think of pain as much more complex than they are accustomed to thinking, observes Todd. "We think of it as a sensation, but in fact, the patient experience is much more complex," he notes.

For example, the American Pain Society in Glenview, IL, says pain is both a sensory and an emotional experience, Todd says. "It is impacted by how we react to [physical] pain, and how we think about it," he adds.

In 1999, Todd explains, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) revised its standards for pain in response to recommendations by the American Pain Society.

"But JCAHO’s guidelines are largely targeted to the documentation of pain severity," notes Todd, adding that ED managers must move beyond the Joint Commission’s guidelines to significantly improve their treatment of patients with pain.

"For example, although they will document pain on arrival for JCAHO, most EDs do not use them to assess patients with pain after any sort of intervention, and they do not document after the patient leaves the ED," he explains.

There are three common tools for assessing pain, he says. The first is the Visual Analog Scale in which a patient places a mark on the scale to show how severe the pain is. It is more of a research tool. Another, the "Faces" scale, is used for children or illiterate patients who pick the face that most closely represents how they feel.

"I recommend the Numerical Rating Scale, which is used, for example, to rate cardiac chest pain," he says. This scale ranks pain from 1-10, with 10 being the most severe.

In addition, Todd notes, most EDs have no particular policies for how quickly someone in pain should be treated. "It normally takes one to two hours, but it could be reduced to 15 minutes if you introduced the right protocols," he says. "Your door-to-needle time for thrombolytics should be [your benchmark for your] door-to-analgesic time. A simple intervention can improve your patient satisfaction and also get administration off your back [about patient satisfaction]."

Improved education on pain issues also will help ED physician and nurse managers further improve patient care and satisfaction, Todd says. "In California, the state requires all physicians to receive several hours of pain CME," he adds. "Emergency physicians are looking for the same thing."

Finally, he concludes, improving paint treatment will have a far-reaching impact on quality of care in the ED. "Fully 60% to 70% of the patients who come to the ED do so because of pain symptoms," he asserts. "ED managers who are interested in improving quality of care will address [an issue that affects] the majority of folks who come to us."


For information on trends in pain management, contact:

  • James A. Espinosa, MD, FACEP, FAAFP, Chairman, Medical Director, Emergency Department, Overlook Hospital, Summit, NJ. Phone: (908) 522-5310. E-mail:
  • Knox Todd, MD, MPH, Director, Pain and Emergency Medicine Initiative, Beth Israel Medical Center, New York City. Phone: (404) 368-5067. E-mail:
  • American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025. Phone: (847) 375-4715. Fax: (877) 734-8758. E-mail: