| | Level of Pain and Waiting Time in the Emergency DepartmentReceived 19 September 2008; received in revised form 23 February 2009; accepted 23 June 2009. published online 22 September 2009. Abstract Pain is the leading reason individuals seek emergency care. Studies have concluded that acute pain conditions are underevaluated and undertreated in the emergency department (ED). There is a paucity of information about how the severity of pain influences the time spent in the ED before being seen by a physician. Therefore, this study focuses on what role pain plays regarding time to treatment in the ED, i.e., to examine the effects of patients' perceived level of pain on wait time in the ED. The CDC's National Hospital Ambulatory Medical Survey 2003 data were used in this study. The sample consisted of 12,860 caucasians and African Americans with a mean age of 44.52 years. Analysis of covariance was used to explore differences in length of waiting time in ED based on race, triage nurses rating of the immediacy of the need to be seen by a physician, and the level of pain the patient reported. The findings showed that patients' reports of pain had very little effect on the length of waiting time. Given the sample size, we feel there is adequate power to detect the effect of pain in determining the length of waiting time to see a physician if it were present. In addition, African Americans had a statistically significant longer wait (15.29minutes) than Whites. The effect of race might be interpreted as another example of health disparities or could be a hospital-level effect which was not examined within this model. Pain is the leading reason individuals seek emergency care. The Joint Commission on Accreditation of Healthcare Organizations stated that patients had the right to have their pain assessed, treated, and monitored (Joint Commission, 2006). However, research indicated that acute pain conditions were underevaluated and undertreated in the emergency department (ED) (Beel, Mitchiner, Frederiksen, & McCormick, 2000; Rupp & Delaney, 2004; Stalnikowicz, Mahamid, Kaspi, & Brezis, 2005). Pain is a subjective, individual, and highly complex phenomenon. Temperature, respiratory rate, pulse, and blood pressure are the four most widely accepted vital signs used in patient assessment. Pain, recently promoted as the fifth vital sign, is more difficult to measure, because it includes a subjective component that is based on individual interpretation (Douglas, 1999; Walid, Donahue, Darmohray, Hyer, & Robinson, 2008). Furthermore, individual characteristics that include social, economic, and cultural factors affect the assessment of pain. Research studies indicate that as many as 70% of those entering the ED with acute pain received no analgesia (Beel et al., 2000; Stalnikowicz et al., 2005). One study showed that only 6% of hospitals have written policies in place for the administration of pain medication with an acute abdomen (Wolfe, Lein, Lenkoski, & Smithline, 2000) and that 27% used published guidelines for the practice of pain management (Jiang, Lagasse, Ciccone, Jakubowski, & Kitain, 2001). In addition, nurses have a significant knowledge deficit in the areas of pain assessment and management in the ED (Nocera, 2002; Tanabe & Buschmann, 2000). Given these facts, accurate assessment and appropriate management of pain in the ED can be a challenge (Graham, 2002). Little information is available on how individual patient factors (e.g., age, ethnicity) or nursing triage assessments affect wait times in the ED. Long wait time in the ED is common (Kennedy, Rhodes, Walls, & Asplin, 2004; Schafermeyer & Asplin, 2003; Singer, Garra, Chohan, Dalmedo, & Thode, 2008). Several studies have shown that 6%-9% of patients in the ED leave without being treated (Lee, Endacott, Flett, & Bushnell, 2006; Rowe et al., 2006; Vieth & Rhodes, 2006). In one study, overcrowding in the ED was reported to compromise quality of care, increase wait times, and decrease patient satisfaction (Vieth & Rhodes, 2006). Although the demand for emergency care has increased, the total number of EDs and number of hospital beds have declined. Rowe et al. (2006) conducted telephone interviews with almost 500 individuals who left overcrowded emergency departments before being seen by a physician. The most common reason that respondents provided for leaving was that they were “fed up with waiting.” The researchers noted that the median waiting time for triage-matched control subjects was almost 90 minutes. Fosnocht, Swanson, and Bossart (2001) compared patient expectations for pain medication delivery and actual administration times in the ED. Patients expected a (mean) time of 23 minutes as a reasonable waiting period to receive pain medication. This compared with an actual mean wait time of 78minutes. The time that patients waited for pain medication was dictated by the system itself, which followed an orderly process of triage, evaluation by a physician, and administration of analgesia. Despite several studies done on waiting time in the ED, there is a paucity of information about how severity of pain influenced the amount of time spent in the ED before patients are seen by a physician. The purpose of the present study was to examine the effects of patients' perceived level of pain on wait time in the ED. Pain in ED Patients  The ongoing problem of oligoanalgesia (inadequate analgesia) in the ED may be tied to triage practices that have been developed to improve patient flow and increase patient satisfaction (Cheung, Heeney, & Pound, 2002). Wuerz, Milne, Eitel, Travers, and Gilboy (2000) described a five-level triage instrument in which patients were rated by acuity level (1=most acute; 5=least acute), using specific criteria, during initial clinical screening. After the initial acuity level was determined, patients who were rated with an acuity ≥3 were evaluated according to the number of resources they might require (e.g., laboratory tests, x-rays, intravenous medication). Vital signs were required for patients who needed two or more ED resources. A computerized five-level algorithm-driven triage system was developed to facilitate patient transit in the ED (Maningas, Hime, Parker, & McMurry, 2006). This system required vital signs and pain assessment for all patients except those designated as level 1 (i.e., required immediate medical attention). The five-level triage system was an effective mechanism to determine patients who required immediate care and those who did not. Triage level category was found to be associated with 6-month survival, with patients in the less acute triage categories having better survival statistics (Wuerz et al., 2000). Undertreatment of Pain The reasons for under treatment or inadequate pain management in the ED include the following: 1) underestimation and inaccuracy of rating patient pain (Rupp & Delaney, 2004); 2) belief that intensity of pain reported by the patient was exaggerated (Hazelett, Powell, & Androulakakis, 2002) 3) lack of knowledge regarding pain medications (Rupp & Delaney, 2004); 4) belief that treating the pain interfered with diagnostic testing (Thomas et al., 2003); 5) concerns regarding addiction (patients thought to be seeking drugs because they were addicted or fear that patient will become addicted) (Rupp & Delaney, 2004); and 7) effects of age and gender (e.g., younger patients are more likely to receive pain management and females appear to be in more pain than males) (Jones, Johnson, & McNinch, 1996). These findings suggest the need for better assessment tools and provider education related to pain management. Treating pain before diagnostic testing proved to not interfere with the results of diagnostic tests, according to one report (Pasero, 2003). Relief of pain is a major cause of seeking emergency medical care; therefore, it is important. Sample Data from the Centers for Disease Control's 2005 National Hospital Ambulatory Care Survey (NHAMCS) of ED patient records was used for this study. The basic sampling unit for the NHAMCS was the patient visit or encounter. Only visits made in the United States to EDs and outpatient departments (OPDs) of nonfederal short-stay or general hospitals were included. Within EDs or OPDs, patient visits were systematically selected over a randomly assigned 4-week reporting period. The sample included in this study were those ED patients, ≥18 years of age, who self-reported race as White or African American. Patients who experienced zero wait times were excluded from the sample. This exclusionary criterion was based on the assumption that patients with zero wait time required immediate care. Pain may have been a factor in a zero wait time for patients, but this component of variance could not be disaggregated from the available data. The sample included 14,293 subjects (10,784 White; 3,509 African American). Other ethnic groups were not included in the model owing to low base rates. Data Analysis Analysis of covariance was used to explore the impact of select factors and covariates on length of waiting time in the ED. In addition to patient self-report of pain, triage nurse rating, race (White vs. African American), and age were included in the model. The waiting time was skewed and transformed using the natural log of each value. A full factorial model was run to examine potential interactions. Those that were nonsignificant (p < .05) were removed from the final model. Results The mean age of the subjects in this study was 44.52 years (SD 19.24). The sample was 57.2% female (n=8,175) and 42.8% male (n=6,118). The mean waiting time in the ED was 60.63minutes (range 1 to 1,155minutes; SD 83.22minutes). Over 77% of patients reported some degree of pain (Table 1). Nursing staff judged the immediacy ratings (to be seen by a physician) for the majority of patients to be <2hours (Table 2). Significant main effects for the immediacy rating by the triage nurse (F=1,392.87; df=4; p < .001) were found for age (F=6.107; df=1; p=.026), level of pain (F=18.983; df=3; p=.002), and race (F=88.04; df=1; p < .001) (Table 3). | | |  | | Type III Sum of Squares | df | Mean Square | F | Sig. | Partial Eta-Squared | |
|---|
| Corrected model | 1,596.10 | 9 | 177.35 | 143.46 | .000 | .083 | | | Intercept | 21,293.72 | 1 | 21,293.72 | 17224.59 | .000 | .547 | | | Pain level | 18.98 | 3 | 6.33 | 5.12 | .002 | .001 | | | Immediacy | 1,392.87 | 4 | 348.22 | 281.68 | .000 | .073 | | | Race | 88.04 | 1 | 88.04 | 71.21 | .000 | .005 | | | Age | 6.11 | 1 | 6.11 | 4.94 | .026 | .000 | | | Error | 17,657.21 | 14,283 | 1.24 | | | | | | Total | 193,225.48 | 14,293 | | | | | | | Corrected total | 19,253.31 | 14,292 | | | | | | | | |
No interactions between the variables were significant, and this information was removed from the final model. The partial eta-squared provided an estimate of how much of the variance was explained by each variable. The analysis of the partial eta-squared suggested that immediacy (triage judgement of how quickly the patient should be seen) was the major explanatory variable in the model. Pain, race, and age were statistically significant (p < .05) but explained very little of the variance (0.1% for pain, <0.001% for age, and 0.5% for race). The overall model explained 8.2% of the variance. Graphic analysis suggested that triage time, rather than perceived pain level, had the largest impact on wait time (Fig. 1). Wait time was not clinically significant between levels of pain (severe, 53.07minutes; moderate, 50.1minutes; mild, 49.43minutes; and none, 48.45minutes), with only a 4.62-minute range from the longest to the shortest average wait time. Despite the low impact of race in explaining model variance, graphic analysis revealed that African Americans were seen approximately 15.29minutes later than their White counterparts at every level of immediacy (Fig. 2). With increasing age, there was a minor reduction in wait time. Discussion The analysis suggests that patient's reports of pain have little effect on the length of waiting time. Given the sample size, we believe there was adequate power to detect the effect of pain (if it were present) in determining the length of waiting time to see a physician. According to the Institute of Medicine (2006), EDs were overcrowded and emergency care was fragmented. A study by Singer et al. (2008) reported pain-related visits to the ED by 392 patients. Two outcomes of interest in the study were whether patients wanted to receive analgesics to relieve their pain and whether pain medication was administered by the ED staff. A majority of the patients who reported pain received analgesics in <93minutes, which reflected similar wait times reported in other studies. There was some evidence that suggested ways to reduce patient wait time in receiving analgesics. In one study, experienced triage nurses were allowed to administer intravenous (IV) morphine to 349 adults who reported initial pain scores of ≥5.0 on a visual analog scale (0=no pain to 10=worst pain) (Fry & Holdgate, 2002). This approach was found to significantly decrease average pain scores over 1hour from 8.5 to 4.5. The average time from initial triage to morphine administration was 18minutes. Another report described a pain management strategy whereby ED nurses administered panadeine forte (codeine plus acetaminophen) to 202 patients who were described as triage code 4 (to be seen within 1hour) (Fry, Ryan, & Alexander, 2004). Median pain score was 7.0 before and 3.5 after analgesia. Mean wait time to analgesia was 23minutes. After initial assessment, registered nurses in an ED in Delaware were allowed to provide analgesics to patients with nonurgent pain (Campbell, Dennie, Dougherty, Iwaskiw, & Rollo, 2004). Nonurgent pain included headaches, minor burns, and musculoskeletal discomfort, among others. Patients who reported a pain level >4 after 1hour were seen by a physician, who determined if IV analgesics were indicated. Overall length of stay in the ED remained unchanged, but patient satisfaction increased. The use of triage nurses helped to reduce wait times and length of stay in the ED, but little is known about how pain affected the acuity rating that patients were given by staff during triage procedures (Cheung et al., 2002). There is a paucity of data on nurse-initiated analgesia in EDs in the United States or elsewhere. The literature suggested that triage nurse acuity rating and the triage system itself had a greater impact on patient wait times in the ED than did patient self-reports of pain scores. This evidence would seem to support the findings of the present study. Age Age, in the present study, was found to influence whether or not patients received pain medication. This is consistent with evidence that has indicated that age was a factor in analgesia administration provided in the ED. One research group conducted a retrospective review of 540 charts of patients with acute trauma who were admitted to the hospital from the ED (Neighbor, Honner, & Kohn, 2004). Fewer than one-half of the patients received opioid analgesia via the IV route within 3hours (median 95minutes) of their arrival in the ED. The findings indicated that patients who were older than 65 or younger than 10 years, intubated, had a lower trauma score, or did not require fracture manipulation were less likely to receive opioid pain medication. Another study, which included over 800 patients treated in the ED, indicated that patients who were <50 years old or who suffered pain as a result of trauma were more likely to receive discharge prescriptions for opioids (Heins et al., 2006). A study that included both pediatric and adult patients compared pain management in three different ED settings (Petrack, Christopher, & Kriwinsky, 1997). The researchers reported that 63% of patients received analgesia during their ED visit. However, pediatric patients were significantly less likely to receive analgesia than adults. One report focused on the effect of ED crowding on the management of pain in older adults with hip fractures (Hwang, Richardson, Sonuyi, & Morrison, 2006). The mean age of the sample was 83 years (range 52-101 years). Although >80% of the patients reported significant pain, 35% received no analgesia. Of the 57% who received opioids for their pain, almost one-third were given meperidine, even though this medication is not recommended for use in older adults. The researchers concluded that older patients were at increased risk for inadequate pain assessment and treatment with inappropriate pain medication. A comparison of ED analgesia for children and adults with fracture pain was reported using data from the NHAMCS (Brown, Klein, Lewis, Johnston, & Cummings, 2003). The researchers examined data for 2,828 patients ranging in age from <1 year to >70 years, who had closed fractures of the clavicle or extremity. Results indicated that pediatric patients and patients >70 years old were less likely to receive any analgesic or opioid analgesia. Children had fewer documented pain severity scores, and, even when pain severity scores were recorded, there was no difference in likelihood of receiving analgesics. Only 73% of all patients with documented moderate or severe pain received analgesics, with 54% receiving opioids. Surprisingly, children who were <16 years old and treated in pediatric EDs were less likely to have documented pain scores than children of the same age who were treated in general EDs. Race African Americans, in general, experienced longer wait times in the ED in the present study. The effect of race might be related to health disparities or could be a hospital-level (e.g., major teaching, nonteaching) effect which was not examined within this model. Thus, it is possible that hospitals serving the African-American communities in the present sample could take longer to provide service, which therefore does not necessarily reflect the effect of race. There is conflicting evidence of the effect of race/ethnicity on analgesic administration in the ED. A retrospective review of medical records of 127 African-American and 90 White patients with isolated long-bone fractures was conducted to determine if analgesic administration differed by race (Todd, Deaton, D'Adamo, & Goe, 2000). Before review by an emergency physician and a nurse, all information related to patient ethnicity was removed from patient charts. Multiple logistic regression analysis was conducted to control for potential confounding variables (e.g., ethnicity, total time in the ED, payer status). The researchers found that the presence of pain was reported by 54% of African-American patients and 59% of White patients. However, only 57% of the African-American patients received analgesics for their pain compared with 74% of the White patients. An earlier study by Todd, Samaroo, and Hoffman (1993) compared analgesia administration in 31 Hispanic and 108 non-Hispanic Whites seen in an ED for the treatment of isolated long-bone fractures. The results indicated that Hispanics were twice as likely to not receive analgesics. This finding was contradicted in a 2002 study that compared analgesic administration for long-bone fractures in 181 White, 58 African-American, 46 Hispanic, and 38 Asian patients between the ages of 18 and 55 years (Fuentes, Kohn, & Neighbor, 2002). Over 70% of the White, African-American, and Hispanic subjects in the study were men. Asian subjects were almost equally divided by gender. The researchers reported that the overall risk for not receiving analgesics ranged between 16% (Asians) and 22% (Hispanics). Overall risk of not receiving analgesia was 20% and did not differ by race/ethnicity. However, Hispanic men were more likely not to receive parenteral analgesia compared with other racial/ethnic groups. The researchers also found that men were at increased risk for receiving no analgesia, compared with women in the sample. Another study included 345 patients with long-bone fractures, who were seen in two urban emergency departments (Bijur et al., 2008). Of these patients, 20% were White, 28% were African American, and 51% were Hispanic. Results indicated that the administration of pain medications was not associated with race or ethnic background. Tamayo Sarver, Dawson, et al. (2003) developed three clinical vignettes designed to determine if race/ethnicity and socially desirable information influenced the prescription of opioid analgesics by ED physicians. Over 2,800 practicing ED physicians participated in the study. Results indicated that prescription of opioids by the study participants was not affected by race or ethnicity (Hispanic, African American, White). Another report, by Tamayo Sarver, Hinze, Cydulka, and Baker (2003), which analyzed a national sample of ED patients, also indicated that there was no association between race and prescription of opioids. Conclusions and Nursing Implications This study explored the impact of reported (perceived) pain and other variables which were thought to affect wait times in the ED setting. Interestingly, but perhaps not unexpectedly, triage assessment explained the largest proportion of variance in the model tested. Overall, the patients' perceived pain level had very little impact on wait time. Despite the limited importance of race in explaining wait time, the results suggested longer wait times for African Americans. Although this difference may be an artifact of regional difference (rural vs. urban) in wait time, it merits further exploration. Limitations This study was a secondary analysis of the 2005 NHAMCS survey and, as such, additional data that could have enhanced this research were not available. For example, the NHAMCS data set did not differentiate between chronic and acute pain nor specify socioeconomic status. Therefore, these factors could not be included in the data analysis. Only data from EDs in the U.S. and OPD clinics of nonfederal short-stay and general hospitals were included in this study. Results cannot be generalized to EDs outside the U.S. or to EDs in specialty hospitals. Recommendations Based on the findings in the present study, the following suggestions are put forth. First, pain assessment tools that include both patient perceptions of pain and triage ratings of immediacy should be developed for use in the ED. Another recommendation is the use of reliable and valid tools to assess pain in the ED for the various populations that are served (e.g., adult, pediatric, cognitively impaired). The education of caregivers should be ongoing and include information on pain management in diverse populations. Myths associated with pain and pain management (e.g., the elderly have less pain) should be reviewed when educating health care providers. Finally, pain assessment should be performed by an ED nurse, and, when appropriate, patients should be treated for their pain before seeing a physician. The benefits of nurse autonomy in the administration of pain medication in the ED include reducing median pain scores and wait times (Fry & Holdgate, 2002; Fry et al., 2004). An additional benefit associated with nurse autonomy when giving analgesia was increased patient satisfaction with the ED experience (Campbell et al., 2004). Further research is needed to pinpoint factors which allow disparities to exist and why individuals with more pain are not treated sooner. References Beel et al., 2000. 1.Beel TL, Mitchiner JC, Frederiksen SM, McCormick J. 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Department of Nursing, University of Delaware, Newark, Delaware  Address correspondence to Dr. Erlinda C. Wheeler, DNS, RN, Department of Nursing, Room 311, McDowell Hall, University of Delaware, Newark, DE 19716.
PII: S1524-9042(09)00070-8 doi:10.1016/j.pmn.2009.06.005 © 2010 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved. | |
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