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ED Pain Protocol Based on Yes-or-No Question to Patient

BRONX, NY – Want to know if patients in your emergency department need more pain medication? Just ask them.

That’s part of a new evidence-based protocol to treat acute severe pain in ED patients, published online recently by Annals of Emergency Medicine. It recommends a straightforward, yes-or-no question instead of a 1-to-10 scale or drawings of happy and sad faces.

During the study of the protocol, researchers from Montefiore Medical Center administered 1 milligram of intravenous (IV) hydromorphone to adult patients who answered in the affirmative. A half hour later, the patient again was asked, "Do you want more pain medication?"

The process was repeated at 30-minute intervals, and patients were given an additional 1 milligram IV hydromorphone each time they answered "yes". Patients responding in the negative received no additional opioid at that point but were asked again 30 minutes later, so that every patient was queried four times.

"The crowded conditions in most emergency departments in the U.S. are not conducive to fully individualized pain treatment," said Andrew Chang, MD, MS, of the Department of Emergency Medicine at Montefiore. "Our simple and easy to remember '1 + 1 + 1 + 1' protocol holds promise for safely providing adequate pain relief to patients with acute severe pain."

At the end of the study, satisfactory pain control was defined as declining additional pain medication on one or more occasions.

With 207 patients enrolled in the study, 114 received the initial dose of 1 milligram of hydromorphone, 78 received 2 milligrams, nine received 3 milligrams and six received 4 milligrams. Only two of the patients failed to reach satisfactory pain control within the study’s duration of 2 to 4 hours. Overall, patient satisfaction was high: 67% reported being very satisfied and 29% reported being satisfied.

"Pain perception is highly subjective and not necessarily correlated to pain scores," Chang explained. "Our pain protocol is a departure from the more traditional ways of assessing pain relief, which typically use the visual analog scale or the numerical rating scale. Instead, our use of a non-numerical, simple yes/no question offers patients the ability to decide for themselves whether their pain is adequately controlled and allows them to balance pain relief against medication side effects such as nausea and drowsiness. This likely explains the wide range of pain scores (as much as 0 to 10) for patients who did not ask for pain medication.”

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