Factors affecting and strategies to improve pain management in emergency departments: a comprehensive systematic review.

Review question/objective The objectives of the review are to determine the best available evidence on strategies to improve pain management and factors affecting pain management in emergency departments. More specifically, the review questions are to identify: What are the best strategies to improve pain management in emergency departments? What are the factors improving pain management in emergency departments? What are the factors hindering pain management in emergency departments? Background Pain is the most common reason for seeking medical attention in the emergency department.1,2 Although it accounts for up to 78% of visits to the emergency department3,4, management of pain has not received sufficient attention from many emergency department team members.5 Unfortunately, pain may be viewed as consequence of illness and injury that must be tolerated or even in some instances as a punishment for inappropriate behavior.6 Oligoanalgesia refers to the under treatment of pain and in the emergency department is thought to be common; despite the expectation that pain relief is considered to be the emergency department top priority.2, 7-10 A study conducted by Fosnocht and colleagues revealed only 45 % of the emergency department patients received pain medication prescriptions and 70% of those who received medication reported decreased pain that met with their needs.8 Despite the fact that intravenous opioid is the drug of choice recommended for treatment of severe pain, 11 less than one third of patients with severe pain were given the medication in one study.5 Up to 74% of patients who presented at an emergency department were discharged while they were suffering from moderate to severe pain.2,7 Unrelieved pain is a major, yet avoidable, significant health problem.12 Optimal management of pain in emergency department is challenging. Untreated and undertreated pain can have serious physiological and psychological consequences. Unrelieved acute pain stimulates sympathetic activity which can cause tachycardia, hypertension and sweating.6 It may exacerbate myocardial ischemia by increased myocardial work and oxygen consumption, may impair immune function by activation of the metabolic stress response, and can cause reduction in cognitive function.6,13 In addition, untreated and undertreated pain can aggravate the patients’ discomfort and exacerbate an already-stressful situation in the emergency department.5 Pain management is truly an essential nursing and medical responsibility. In application of the ethical principles of beneficence (duty to benefit another) and non-malfeasance (duty to do no harm), health personnel have a role and obligation in providing effective pain management and comfort to all patients. Hospitals are required to inform the patients regarding their rights related to pain management as stated in the Joint Commission on Accreditation of Hospital Organization 2001 Guideline.6,12 Timely and appropriate pain management is an important quality indicator of emergency department performance.14 Meeting the patients’ needs for pain relief certainly influences their satisfaction with emergency department care. Efforts to improve patients’ pain management in all health care settings are supported by the collaboration between the American Society for Pain Management Nursing (ASPMN), the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) and the American Pain Society (APS). Over 25 years of research on pain management conducted in the United States of America, Canada, and Australia, multiple standards/guidelines on pain management and regulatory statutes on pain management have been developed.2 Despite significant efforts to enhance pain management, oligoanalgesia in emergency departments still remains an important problem for emergency professions.2 After the release of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for pain management for accredited health care organizations, pain assessment and management practices in the emergency departments showed some improvements over time.15 This notion was reflected in the study by Herr and Titler.15 Medical records from hospitalised older adult patients with hip fractures admitted through the emergency department of 12 acute care hospitals (N = 1454) were reviewed. Records were categorised into 3 different periods between 2000 and 2002. Pain assessment practices and pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults were reviewed. Results from this study revealed improvements in pain assessment practices over time (99% of patients had pain documentation in 2002). However, up to 34% of patients in this study had no objective assessment of pain (numeric rating scale) documented. Moreover, the mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 time periods. By the end of the study (2002) only 60% of patients had any analgesic ordered and of these 59% had an opioid ordered. Oligoanalgesia still needs to be explored in order to be able to manage pain in a more timely and more appropriate manner. A number of studies have been conducted to elucidate factors affecting pain management in emergency departments.10,16-18 Yet, such information is still inconclusive. Berben and colleagues suggested possible barriers in current pain management in the emergency department could arise from workload, attitudes of staff, knowledge deficits and misconceptions on the need of effective pain management.10 A cross-sectional analysis of documented emergency department visits by elderly patients from the National Hospital Ambulatory Medical Care Survey16 suggested a potential influence of attitudes toward analgesic prescribing, and the recognition of ethnic, racial, and age differences in patients with pain on the effective pain management in the emergency department. Additionally, patients' clinical condition instability may affect the pain management of the injured patients who often experience considerable pain in the emergency department.17 Lack of communication between the patient and healthcare professional, as well as organisational limitations have also been associated with pain management.18 Despite these concerns, strategies to enhance pain management have long been developed in response to the awareness of inadequate emergency department pain management.19-24 Those strategies reported in the literature include, but are not limited to, innovative use of guidelines 22, 25, use of pain protocol 26, nurse-initiated pain management 18, 21, and staff educational interventions.24 Nevertheless, we have not reached agreement on the best strategy to enhance pain management. Improving inadequate pain control is a critical goal in emergency health care. As patients’ primary health care advocators, emergency health personnel play a vital role in resolving under-treated pain in their patients.27 Up till now, the literature shows an unresolved issue of under optimal pain management in the emergency departments, which deserves serious consideration. The Cochrane Library of Systematic Reviews, Joanna Briggs Institute (JBI) Library of Systematic Reviews and CINAHL databases have been searched and no previous systematic reviews on this specific topic were identified as being published or underway. It is anticipated that this systematic review will uncover literature encompassing factors affecting and the strategies to enhance pain management in the emergency department. The aim of this systematic review is to synthesise the best available research evidence on factors that influence pain management in the emergency department, with the aim of providing timely and appropriate emergency department pain management in order to fulfil the needs for pain relief of the patients and increase their satisfaction. Inclusion criteria Types of participants This review will consider both qualitative and quantitative publications that include patients, their family members, physicians, or nurses in emergency departments. Types of intervention(s)/phenomena of interest The quantitative component of the review will consider studies that evaluate the strategies to improve pain management and factors affecting pain management in emergency departments. The qualitative component of this review will consider studies that explore the experiences of patients, family members, physicians or nurses in emergency departments regarding the pain management. Types of outcomes Quantitative: The quantitative component of this review will consider studies that include, but not limited to, the following outcome measures: patient satisfaction, relief or reduction of pain, and time to first analgesia. Types of studies The quantitative component of the review will consider any randomised controlled trials, pseudo-randomised controlled trials, before and after studies, observational analytical studies, and descriptive studies such as surveys to enable the identification of current best evidence regarding the strategies to enhance pain management and factors affecting pain management in emergency departments. The qualitative component of the review will consider qualitative studies that draw on the experiences on pain management and factors that affect pain management including, but not limited to, designs such as phenomenology, grounded theory and ethnography. Search strategy The search strategy aims to find both published and unpublished studies. The search will be limited to English language reports and will be not be limited by year of publication. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: Academic Search Elite CINAHL ProQuest Health and Medical Complete PubMed Science Direct Scopus SpringerLink Wiley InterScience The search for unpublished studies will include: Mednar, ProQuest Dissertations & Theses, Dissertations Full Text, and conference proceedings. Initial keywords to be used will be: pain, pain management, strategy, strategies, factors, barriers, emergency, emergency department, emergency room, satisfaction, and pain reduction. Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix III). Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Quantitative papers will, where possible be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest There are no conflicts of interest in this review.

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