Sunday, February 10, 2008

Pain in the Emergency Department

Overcrowding in the Emergency Room causes many problems. Untreated pain is an emergency.

See article below regarding very poor pain management in overcrowded ER's. If OSF's administration had a little more untreated pain during their ER visits, that may have helped the general public in Peoria.

ED Crowding and Pain Management

Crowding is associated with nontreatment and delayed treatment of severe pain.

Inadequate pain management in the emergency department has received much attention recently, including by the Joint Commission. ED crowding is one of the many postulated contributors to inadequate or delayed emergency pain management. In a retrospective study of nearly 14,000 patients who presented to an urban ED with severe pain (score of 9 or 10 on a 10-point scale), the authors examined whether ED crowding contributed to delayed pain management. The two measures of delay were administration of pain medication more than 1 hour after triage and administration more than 1 hour after arrival in a treatment area. Measures of crowding were ED occupancy, total number of patients in the waiting room, and aggregate number of patient hours (length of stay) for all patients in the ED at the time the study patient presented.

During the 17-month study period, 49% of patients who reported severe pain received analgesia. Of those, 79% experienced delays: 59% waited more than 1 hour after triage, and 20% waited more than 1 hour after arrival in a treatment area. Number of patients in the waiting room and ED occupancy were independently associated with both nontreatment of pain and delayed treatment.

Comment: ED crowding, in addition to being a growing problem and a symptom of a struggling healthcare system, might be associated with delay in pain treatment. Strategies to address severe-pain treatment in the setting of ED crowding include providing physicians or physician extenders at triage to initiate therapy and instituting standing orders for the administration of analgesia. As we all struggle to find creative ways to treat time-dependent disease in an increasingly constrained environment, we must keep in mind that 10/10 pain is a true emergency, every bit as pressing as chest pain, symptoms meeting "trauma team" criteria, or community-acquired pneumonia. The mystery in this study, though, is why 51% of patients who reported 9/10 or 10/10 pain did not receive any analgesia at all, crowded ED or not!

— Richard D. Zane, MD, FAAEM

Published in Journal Watch Emergency Medicine February 8, 2008

Pines JM and Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med 2008 Jan; 51:1.

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