Assessment of pain management skills in emergency medicine residents: the role of a pain education program1

The Journal of Emergency Medicine, Vol. 17, No. 2, pp. 349 –354, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/99 $–see front matter

PII S0736-4679(98)00180-2

Education

ASSESSMENT OF PAIN MANAGEMENT SKILLS IN EMERGENCY MEDICINE RESIDENTS: THE ROLE OF A PAIN EDUCATION PROGRAM James B. Jones,

MD, PHARMD, FAAEM

Indiana University School of Medicine, Purdue University School of Pharmacy, and Methodist Hospital–Clarian Health Partners, Indianapolis, Indiana Reprint Address: James B. Jones, MD, PHARMD, Emergency Medicine and Trauma Center, Methodist Hospital of Indiana–Clarian Health Partners, Indiana University School of Medicine, 1701 N. Senate Boulevard, Indianapolis IN 46202

e Abstract—A prospective study of Emergency Medicine (EM) residents was conducted over two consecutive 1-month periods at a rural tertiary-care teaching hospital with a residency in EM to evaluate the effect of a 4-h pain management education program on the assessment and management of acute pain in the emergency department (ED). All patients presenting to the ED with an acute, painful condition were eligible to participate in the survey. Patients were excluded if they had taken any pain medication within 4 h of presenting to the ED, or had any condition requiring immediate resuscitation, suspected cardiac pain, or pain from a potential surgical abdomen. Baseline and 30-min pain scores were evaluated using a 100-mm, unnumbered visual analog scale (VAS). A 4-h pain management educational program (EP) aimed toward the EM residents was conducted. Comparisons were made with respect to the overall treatment of pain as evaluated by the change in VAS score between baseline and 30 min as well as the global assessment of treatment. A total of 126 surveys were completed, 54 before (Group 1) and 72 after (Group 2) the EP. The mean DVAS score for patients in Group 2 was significantly better than the DVAS score for patients in Group 1. Only 65% of the patients studied before the EP had significant reduction in their pain scores after 30 min in the ED; after institution of the EP, 92% had a significant reduction in their pain scores at 30 min. Similarly, a significant improvement was seen in the patients’ global evaluation of

treatment after the educational program was instituted. It appears that the use of a 4-h educational program on pain assessment and management directed toward EM residents in their training can improve their skills at recognizing and treating painful conditions. © 1999 Elsevier Science Inc. e Keywords—pain management; emergency medicine education; emergency department

INTRODUCTION The most common presenting complaint in the Emergency Department (ED) is pain (1). Many retrospective and prospective studies have shown that pain is severely undertreated and even goes untreated (2– 6). Despite this, relatively few studies have evaluated how the treatment of acute pain in the ED can be improved. The etiology behind the mediocre evaluation and treatment of pain appears to be multifactorial. Lack of a formal educational process has often been cited. In a review of over 25,000 pages in 50 major textbooks covering medicine, surgery, pediatrics, and emergency medicine, Bonica determined that only 54 pages were devoted to the treatment of pain (7). Ineffective recognition and assessment of pain by nurses and physicians may also lead to its inadequate treatment. Ducharme et al. determined that both physicians and nurses routinely underestimate the amount of

Presented at the ACEP Annual Meeting, New Orleans, Louisiana, September 1996.

Education is coordinated by Stephen R. Hayden, San Diego, California

RECEIVED: 22 August 1997; FINAL

SUBMISSION RECEIVED:

MD,

of the University of California San Diego Medical Center,

24 March 1998; ACCEPTED: 10 April 1998 349

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pain a patient is experiencing (6). This may be due in part to the fact that the use of any objective pain measure by healthcare providers appears to be lacking. Occasionally, a poor choice of analgesics, including a non-preferred route of administration, appears to alter the effectiveness with which acute pain is treated in the ED (8). Gender, age, and ethnic biases also have been found to contribute to the lack of analgesic administration in the ED (7,9 –11). To improve the treatment of acute pain in the ED, the need for further education has often been suggested (12). This study was a prospective evaluation of Emergency Medicine (EM) residents to determine the effect of a 4-h educational program on the assessment and management of pain in the ED.

Objective This is a prospective, single-blinded study to evaluate the effect of a 4-h pain management education program, directed toward EM residents in an EM training program, on the assessment and management of acute pain in the ED.

MATERIALS AND METHODS The study of Emergency Medicine residents’ pain management skills was conducted over two consecutive 1-month periods at a rural tertiary-care teaching hospital with an annual volume of 42,000 visits. All resident physicians in EM-1, 2, and 3 were asked to participate in a pain management survey of patients who presented to the ED with an acute, painful condition during the study period. The project was conducted under an expedited approval by the Institutional Review Board. Prior to initiation of the study, an acute, painful condition was defined as suspected fractures, sprains, strains, cephalgia (migraine, tension), biliary colic, and renal colic. Patients were excluded if they had taken any pain medication within 4 h of presenting to the ED, had any condition requiring immediate resuscitation (traumatic or non-traumatic), or had suspected cardiac pain or pain from a potential surgical abdomen. During the triage assessment, patients were identified by the triage nurse according to these guidelines, and a pain management questionnaire (Figure 1) was attached to the patients’ charts. Residents and nursing staff members were blinded to the significance of the survey. After patients were identified for inclusion in the study, the patient’s age, sex, and presenting complaint were recorded on the pain management survey. In addition, the use of alternate measures of pain control (e.g.,

Figure 1. Pain Management Questionnaire.

ice, elevation, immobilization) was documented on the survey. Baseline pain scores were obtained by a member of the nursing staff using an unnumbered horizontal 100-mm incremental visual analog scale (VAS) labeled “No Pain” on the left and “Worst Imaginable Pain” on the right (Figure 1) (9,12). Pain medication was then ordered by the treating resident physician, supervised by an attending physician. The medication administered, the dosage, and the route of administration were documented on the pain management survey. No interventions by the attending physician were made during the study period with respect to the resident physician’s prescribing habits. The orders for pain medication were taken off the ED chart and administered to the patient by the registered nurse assigned to that patient, a nurse who did not obtain the VAS score. After 30 min, a follow-up VAS was obtained by the same member of the nursing staff who had obtained the baseline VAS score. The administration of additional medication after 30 min was based on the patient’s request because of persistent pain. The time, medication, dose, and route of administration for additional medications were documented. A VAS was administered by the same staff nurse and completed by the patient every 30 min while in the ED.

Pain Management Skills Table 1. Topics Covered in Educational Program Review of the common causes of pain in our Emergency Department Cephalgia, musculoskeletal, colic Review the literature with particular attention to identifying problem areas with respect to pain management in the ED Describe the pathophysiology of pain—peripheral events, pain fibers, and pathways Impulse conduction and augmentation, upregulation of receptors, define nociception and common terminology in pain literature Review the principles of pain management Include time to treat, discuss the various pain syndromes– mild, moderate, severe; review the Canadian Association of Emergency Physician policies on pain management in the ED; review commonly used pain scales, pain relief scores, and patient satisfaction studies Review the types of treatments available for pain management in the Emergency Department–pharmacological and nonpharmacological Nonpharmacologic entities including ice, elevation, immobilization, room atmosphere, positive reassurance, music. Pharmacologic entities including peripheral nerve block, regional nerve blocks, conscious sedation. Detail pharmacokinetic and pharmacodynamic review of commonly used analgesics including opioids, nonsteroidal anti-inflammatory agents, and simple analgesics Review special considerations including pediatric analgesia, the elderly, the acute abdomen

351 Table 2. Baseline Characteristics Surveys completed prior to educational program

Surveys completed after the educational program

36 18 42 (8–78)

46 26 45 (8–80)

Sex Male Female Mean Age (range)

ment of pain as evaluated by the change in VAS score (DVAS) between baseline and 30 min as well as the global assessment of treatment. Treatment differences before and after the educational program were compared using an unpaired, 2-tailed Student’s t-test with a predetermined alpha level of 0.05. Results were broken down by years of training (EM 1–3). A nonstatistical relationship between the use of nonpharmacologic therapeutic adjuncts before as compared with after the EP was evaluated.

RESULTS Global evaluation of treatment scores, a scale to summarize the physician and patient satisfaction with the treatment administered, was completed by both the physician and the patient before discharge. These ranged on a scale from 0 (treatment not effective) to 3 (treatment completely effective). The principal investigator reviewed the pain surveys and medical records after the patients were discharged from the ED to identify problem areas with respect to the recognition and management of pain. Criteria used to make this judgment included the lack of adjunctive pain therapies when indicated, not administering and titrating medication by the i.v. route when an i.v. was available, and inadequate analgesia after 30 min. A reduction in the VAS score from baseline of 13 mm or more was viewed as clinically significant (13). Based on these observations, a 4-h educational program (EP) consisting of three lectures and quizzes on pain management skills was presented to the EM residents by two EM faculty members 4 weeks into the 2-month study period. The topics covered are listed in Table 1. After the educational program, the pain survey was distributed for an additional 30 days, and the same data were collected. Statistical evaluation of the data collected included a Chi square analysis to examine the distribution of categorical data between the study groups, those surveys completed before the EP (Group 1) compared with the surveys completed after the EP (Group 2). Comparisons were made with respect to the overall treat-

A total of 60 surveys were distributed before the EP, while 80 were distributed after the EP. Of these, 54 and 72 surveys were completed, respectively. Attendance at the EP was 90%. Surveys not returned or only partially completed were not included in the final analysis. Age and gender were balanced within each group (Table 2). The painful conditions treated and surveyed over the 2-month study period included renal (17%) and biliary colic (11%), back pain (14%), fractured ribs (3%), long bone fractures (15%), migraine headaches (19%), and musculoskeletal chest pain (21%). These presenting complaints were equally balanced between the two groups. Medications, routes of administration, and the mean initial dose are shown in Table 3. To determine whether the data sets followed a Gauss-

Table 3. Medications Used, Routes of Administration, and Initial Doses: Group 1 No. of Patients

Initial Dose (mg)

Medication

i.m.

i.v.

Oral

i.m.

i.v.

Morphine Meperidine Codeine/oxycodone Ketorolac Tromethamine Ibuprofen Prochlorperazine Hyoscyamine Sulfate

0 4 0 18

9 2 0 9

0 0 4 0

0 100 0 60

4 25 0 30

0 1 0

0 2 0

3 0 2

0 10 0

0 10 0

Oral 0 0 30 0 200 0 0.125

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J. B. Jones

complete resolution of pain compared with EM-1s. The use of ice and immobilization as adjuncts to pharmacologic management were routinely started in triage following protocol, both before and after the institution of the EP. There was no difference in this measure between the two groups.

DISCUSSION

Figure 2. Mean DVAS 6 SEM.

ian distribution, normality between the two groups was assessed using a Kolmogorov and Smirnov (KS) evaluation. The KS for Group 1 was 0.1176 (p . 0.1) and for Group 2 was 0.07175 (p . 0.1). This indicates that both groups follow a normal distribution. Baseline pain scores for both groups, those studied before the EP (mean 5 76.7 mm) and those studied afterward (mean 5 80.3 mm), were not statistically different (p . 0.1). An unpaired, 2-sided Student’s t-test was used to evaluate the D VAS scores between the two groups. This analysis assumes that the standard deviations of the two groups are equal, which in this data set is valid (F 5 1.424, p . 0.05). The mean VAS score for Group 2 of 40.53 (95% CI 35.82, 45.23) was significantly higher than that of the pre-program group, Group 1 (mean DVAS 5 21.83) (95% CI 17.26, 29.41) with a p , 0.0001 (Figure 2). This indicates that a greater amount of pain relief was achieved in patients treated after the educational program. The mean difference between the groups was 18.69 (95% CI 12.04, 25.35; R2 5 0.1994). The VAS scores from patients evaluated before the EP were then reviewed using the predetermined clinically significant DVAS of 13 mm (13). Sixty-five percent (35 of 54) of the patients evaluated before the EP had clinically significant reductions in their pain scores at 30 min. In contrast, 92% (66 of 72) of the patients evaluated after the EP had clinically significant reductions in their pain scores. Similar improvement was seen in the global evaluations of treatment by both physicians and patients after presentation of the EP. Ninety-five percent (68 of 72) reported that treatment was either moderately or completely effective at reducing their pain compared with 56% (30 of 54) of those evaluated before the EP. EM-3s had a higher percentage of patients reporting moderate or

Since pain is the most common presenting complaint in the ED (1), emergency physicians need a clear understanding of the evaluation and treatment of pain. Unfortunately, very little formal training in EM is directed toward the management of acute pain, and many studies support a significant lack of adequate analgesia provided in the ED (2,3,10,14,15). Selbst et al. have shown that most patients who seek medical care in the ED for acute painful conditions do not receive analgesics (2). Extremes of age appear to be particularly affected by this practice (2,11,16). Ducharme et al. reported on 11 patients presenting to the ED in severe pain with five receiving medication and only one reporting relief. Twenty-nine percent of the patients studied were discharged home in severe pain. It was noted that physicians and nurses did not document levels of pain or changes in pain during their patients’ stay in the ED. The authors concluded that pain assessment and treatment in the ED may be poorer than previous studies have indicated (6). In a similar study, Wilson reported that only 44% of patients evaluated in the ED for painful conditions received analgesia (3). A lack of pharmacologic knowledge relating to analgesic administration, particularly inadequate dosing and ineffective routes of administration, are identified as factors contributing to the poor treatment of pain in the ED (3,4). Other factors related to oligoanalgesia in the ED include underevaluation of pain by the treating physician or nurse as well as ethnic barriers (6,8). This study was to determine the effects of a formal, 4-h educational program delivered to EM residents. It was geared toward problems in the management of acute pain in the ED, identified from the literature. A primary goal was not only to review these problem areas but also to provide information on the pathophysiology of pain and the pain stimulus, as well as the pharmacology and pharmacokinetic parameters of commonly used analgesics. In addition, general principles outlined in the Canadian Association of Emergency Physicians (CAEP) policy statement regarding the treatment of pain in the ED were presented (17). It is our feeling that a complete understanding of this information is important for many reasons including improving patient care, patient satisfaction, and overall patient outcome. Many studies point

Pain Management Skills

out the deleterious effects of oligoanalgesia on physiologic parameters in both hospitalized and ambulatory patients, including elevated blood pressure, increased heart rate, immobility and splinting, and general deconditioning (18 –20). An important nonphysiologic sequella of undertreated pain involves changes in the pathways associated with pain conduction from the peripheral nervous system to the central nervous system. Repetitive, nonabating pain signals from the periphery have been shown to cause an upregulation of nerve fibers that leads to increased stimulation of the CNS and resulting cognition of pain. This can result in prolonged patient disability and repeated ED visits. For the purpose of this study, a 4-h didactic session was created for the EM residents that would identify acute pain management in the ED as a problem area and specifically address how this can be improved. The list of topics covered is listed in Table 1. We adopted the concepts and general principles put forth by Paris and Ducharme as the foundation for this teaching session (17,21). Pre- and post-tests were administered, and attendance was mandatory. To implement the program, a baseline evaluation on how the residents evaluated and managed pain in the ED was initiated. Surveys were distributed by the triage nurse to patients presenting in pain who met the inclusion criteria. However, because of the nature of the ED and fluctuations in volume, we obtained a convenience sampling of the painful conditions presenting to the ED. This may have added selection bias to the study although the information was collected in a fashion consistent with the everyday operation of the ED. There is always the potential to eliminate patients with severe pain syndromes from completing the survey. If this occurred, the effect of the EP on the management of pain would be exaggerated. However, our baseline VAS score was similar between the two groups. In addition, the analysis evaluating the standard deviations of the two groups shows no significant differences in baseline pain scores. Another potential source of bias identified would be observation bias invoking the Hawthorn effect of being “watched” with the distribution of the survey. Every attempt was made to keep the significance of the survey from the residents and nursing staff. The baseline evaluation showed 65% (35 of 54) of the patients reporting at least a 13-mm decrease in their pain score; however, the magnitude of the decrease in VAS score varied. A reason for this variability may be the fact that we included a variety of pain syndromes in this study. A more precise method to evaluate an intervention on patient outcome, such as the pain management education program, would be to limit the type of pain being treated. It might have been better to limit patients to just those presenting with suspected fractures, thereby elim-

353

inating the variables associated with each type of painful condition. We tried to include all patients to more closely simulate everyday practice in our ED setting. The presentation of the educational program (EP) was well-attended by both residents and faculty. Specific detail was made to the medications commonly used in our ED, including ibuprofen, ketorolac tromethamine, nitrous oxide, and opioids. The non-pharmacologic interventions were also discussed. Our ED has a policy that ice is applied in the triage bay to all suspected fractures. This was consistently practiced over the study period. The policies set forth in the CAEP document were covered in detail, particularly the importance of the VAS score in helping to determine the amount of pain a person is experiencing and the need for frequent reevaluation of patients to determine if adequate analgesia was achieved. It was felt by our faculty that the most appropriate route of administration of medications was the i.v. route, if available. It allows one to titrate the level of analgesia that a patient is receiving. When no i.v. had been established, early oral administration of an analgesic was encouraged. The ideal situation would be to have the oral analgesic beginning to take effect before discharging the patient from the ED. Our goal was to improve patient satisfaction, although pain relief is not necessarily related to satisfaction. Those patients treated after the EP reported a higher percentage of achievement of a 13-mm decrease in their VAS score from baseline as compared with those treated earlier. More interestingly, patients treated after the EP had a greater reduction in their mean pain score (DVAS) as compared with the first group. Better use of analgesics, including i.v. administration and titration of opioid analgesics, the earlier use of oral agents if indicated, the implementation of nonpharmacologic methods of pain control (earlier splinting of suspected fractures), and possibly the use of the VAS to assess pain may have resulted from the EP and contributed to this improved pain management. Another factor may be a greater familiarity with the VAS score as the study progressed. This would include any biases related to observation of pain management practices in the ED. Other factors that may influence the manner in which pain is managed in the ED that could not be controlled for in this study include patient volume, level of training, and patient decisions regarding their treatment of pain (not wanting opioids, etc.). When the data from this study were broken down by years of experience (EM-1, EM-2, EM-3), those physicians in their EM-3 year were more likely to titrate the doses of narcotic analgesic as well as choose more appropriate doses. The number of EM-2s compared with EM-3s varied from shift to shift and may have affected the outcome of this study. Patients also contribute to oligoanalgesia when they decline cer-

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tain medications. Patients’ fear of addiction sometimes limits their request for medication. Patient education is often needed, but again, this can be time-consuming and may not be possible in most busy EDs Further development of an EM curriculum in pain management is needed and is under way. In addition, a unified method of evaluating new pain control measures, whether pharmacologic or not, needs to be addressed. The use of interactive software is an excellent method of bringing the basic principles and pharmacology of pain management to a broad audience in the future. CONCLUSION The use of a 4-h educational series on pain assessment and management in the emergency department, directed toward emergency medicine residents in the course of their training, can improve their short-term skills at recognizing and treating painful conditions. REFERENCES 1. Walsh M. Pain and anxiety in A&E attenders. Nursing Standard 1993;7:40 –2. 2. Selbst SM, Clark M. Analgesic use in the emergency department. Ann Emerg Med 1990;19:1010 –3. 3. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department [see comments]. Am J Emerg Med 1989;7:620 –3. 4. Reichl M, Bodiwala GG. Use of analgesia in severe pain in the accident and emergency department. Arch Emerg Med 1987;4:25– 31. 5. Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset and descriptor patterns related to different injuries. Pain. 1982;14:33– 43.

6. Ducharme J, Barber C. A prospective blinded study on emergency pain assessment and therapy. J Emerg Med 1995;13:571–5. 7. Bonica JJ. Biology, pathophysiology, and treatment of acute pain. In: Lipton S, ed. Persistent pain: modern methods of treatment, Chapter 1. New York: Grune Stratton; 1985. 8. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia [see comments]. JAMA 1993;269:1537–9. 9. Sriwatanakul K, Kelvie W, Lasagna L, et al. Studies with different types of visual analogue scales for measurement of pain. Clin Pharmacol Ther 1983;34:234 –9. 10. Jantos TJ, Paris PM, Menegazzi JJ, et al. Analgesic practice for acute orthopedic trauma pain in Costa Rican emergency departments. Ann Emerg Med 1996;28:145–50. 11. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. Am J Emerg Med 1996; 14:157– 60. 12. Price DD, Bush FM, Long S, et al. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain 1994;56:217–26. 13. Todd KH, Funk KG, Funk JP, et al. Clinical significance of reported changes in pain severity. Ann Emerg Med 1996;27:485–9. 14. Selbst SM, Henretig FM. The treatment of pain in the emergency department. Pediatr Clin North Am 1989;36:965–78. 15. Lewis LM, Lasater LC, Brooks CB. Are emergency physicians too stingy with analgesics? Southern Med J 1994;87:7–9. 16. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of analgesic utilization. Pediatrics 1997;99:711– 4. 17. Ducharme J. Emergency pain management: a Canadian Association of Emergency Physicians (CAEP) consensus document. J Emerg Med 1994;12:855– 66. 18. Wheeler AP: Sedation, analgesia, and paralysis in the intensive care unit [see comments]. Chest 1993;104:566 –77. 19. Warfield CA. Treating traumatic pain. Hospital Practice (Office Edition). 1986;21:48M, 48P-48R, 48T. 20. Gurnani A, Sharma PK, Rautela RS, et al. Analgesia for acute musculoskeletal trauma: low-dose subcutaneous (s.c.) infusion of ketamine. Anaesthesia Intensive Care 1996;24:32– 6. 21. Paris PM, Stewart RD. Pain management in emergency medicine. Norwalk, CT: Appleton & Lange; 1988.