Undertreatment of acute pain in the emergency department: a challenge

Objective. Evaluation and improvement of pain management in our emergency department (ED). Design. This was a 'before-after' study. For each subject, the nurse, the physician, and the patient were asked to rate the initial intensity of the pain on a Visual Analogue Score (VAS). The timing and the type of analgesics administered were then recorded and follow-up VAS was performed. Setting. A teaching, community-based, 400-bed hospital. Study participants. 140 patients admitted for acute pain related to orthopedic injuries. Main outcome measures. The gap between the VAS expressed by the patient and estimated by the staff, the proportion of patients receiving analgesics, and the length of time delays between admission and analgesic administration. Intervention. The intervention included education of medical and nursing staffs, insertion of a VAS template in the patient's chart, initiation of routine VAS assessment and re-assessment, and implementation of a protocol for pain management with standing orders for nurses. Results. The VAS gap between the patient and the nurse decreased significantly from 1.91 +/- 2.04 to 1.03 +/- 1.97 after the intervention (P = 0.01). The percentage of patients receiving analgesics rose from 70 to 82% following the intervention. Time from admission to analgesia decreased from 80 +/- 68 min (mean +/- SD) before the intervention, to 58 +/- 37 min after the intervention (P = 0.05). Conclusion. Inadequate pain management in the ED appears related to poor staff assessment of pain and may be improved by routine VAS recording and by a nurse-based pain protocol.