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The Pain and Emergency Medicine Initiative Supported by The Mayday Fund through a grant to The Emergency Medicine Foundation Knox H. Todd, MD, MPH.

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Presentation on theme: "The Pain and Emergency Medicine Initiative Supported by The Mayday Fund through a grant to The Emergency Medicine Foundation Knox H. Todd, MD, MPH."— Presentation transcript:

1 The Pain and Emergency Medicine Initiative Supported by The Mayday Fund through a grant to The Emergency Medicine Foundation Knox H. Todd, MD, MPH

2 PEMI Co-investigators Manon Choiniere Cameron Crandall James Ducharme Celeste Johnston Kathleen Puntillo

3 Background Pain is the most common reason for ED visits Pain is the most common reason for ED visits Little data on the impact of pain after discharge Little data on the impact of pain after discharge Objectives: Objectives: Assess pain characteristics and pain-related functional interference Assess pain characteristics and pain-related functional interference Develop research network of US and Canadian EDs Develop research network of US and Canadian EDs Develop cadre of physicians and nurses interested in ED pain management and research Develop cadre of physicians and nurses interested in ED pain management and research

4 Methods Design Design Multicenter, prospective, observational study Multicenter, prospective, observational study Setting Setting 13 academic and community emergency departments in the US and Canada 13 academic and community emergency departments in the US and Canada Participants Participants age 8 and older, moderate/severe pain (NRS>3), discharged home age 8 and older, moderate/severe pain (NRS>3), discharged home

5 Methods Exclusion Criteria Exclusion Criteria inadequate contact information (address, phone, contact at separate address) inadequate contact information (address, phone, contact at separate address) ischemic heart disease ischemic heart disease mental status abnormality mental status abnormality inability to speak English or Spanish inability to speak English or Spanish sexual assault sexual assault domestic violence domestic violence muteness/deafness muteness/deafness prior enrollment prior enrollment

6 Methods Structured ED interviews, chart abstraction, follow-up telephone interviews Structured ED interviews, chart abstraction, follow-up telephone interviews Study Measures: Study Measures: Demographics Pain severity CommunicationED analgesic use Discharge instructionsED utilization Prevalence of chronic pain Satisfaction Pain-related interference with function Regular source of care

7 Results Subjects subjects from 13 EDs Subjects subjects from 13 EDs Age - median: 32 years Age - median: 32 years Sex - 57% female Sex - 57% female Phone interviews median 6 days after d/c Phone interviews median 6 days after d/c 82% contacted within 14 days 82% contacted within 14 days

8 ED Pain Intensity

9 Time to Analgesic Total ED time (triage to discharge): Mean192 minutes Median159 minutes Time to first analgesic (triage to analgesic): Mean 110 minutes Median 88 minutes

10 Assessment Proportion receiving initial ED pain assessment:79% Proportion receiving >1 ED pain assessment: 17%

11 ED Communication QuestionsYes Did we make it clear that we consider txmt of pain important?58% Did we make it clear that you should tell us when you have pain?58% Did you receive pain medication while in the ED?65% Did you ask for pain medication while in the ED?26% Did you feel that you needed pain medication while in the ED?72% % of patients receiving analgesics if they felt they were needed:63% % of patients asking for analgesics when they felt they needed analgesics but did not receive them: 45%

12 Discharge Instructions No or Unclear Did you receive instructions from your physician or nurse for managing pain at home? 28% How clear were the instructions about how to change the amount and timing of any pain medications if the current schedule does not relieve pain? 55% How clear were the instructions about how to change the amount and timing of the pain medication if the current schedule produces side effects? 57% How clear were the instructions about whom to call about your pain if you have any questions? 33%

13 Chronic Pain and the ED 134 subjects (44%) with chronic pain Median duration of symptoms - 2 years % reporting at least 1 ED visit within the past year: Chronic Pain: 79% No Chronic Pain: 40% Mean # ED visits per person within past year Chronic Pain: 4.3 No Chronic Pain: 1.3

14 Healthcare Utilization

15 Follow-up Pain Intensity

16 Pain Intensity

17 Pain-related Functional Interference

18 Conclusions Pain intensity is high in ED and after discharge Pain intensity is high in ED and after discharge Analgesics are delayed Analgesics are delayed Follow-up pain assessments uncommon Follow-up pain assessments uncommon IM routes used in a high proportion of cases IM routes used in a high proportion of cases Deficiencies in communication and d/c Deficiencies in communication and d/c Many have chronic pain - high rates of ED use Many have chronic pain - high rates of ED use Significant proportions with pain experience persistent pain-related functional interference Significant proportions with pain experience persistent pain-related functional interference Much remains to be done Much remains to be done

19 Timothy Mader, Baystate Medical CenterRobert Cox, Spalding Medical Center James Ducharme, Atlantic Health Sciences CorporationJacques Lee, Sunnybrook and Women’s Hospital Joel Bartfield, Albany Medical CenterDave Fosnocht, University of Utah Cameron Crandall, University of New MexicoChristian Vaillancourt, Ottawa General Hospital Basmah Safdar, Yale Medical CenterMartha Neighbor, San Francisco General Hospital Paula Tanabe, Northwestern UniversityLeslie Zun, Mt. Sinai Medical Center Barbara Lock, Columbia Presbyterian Medical Center Alan Heins, U. of South Alabama Medical Center Thomas Terndrup, U. of Alabama at Birmingham Andrew Chang, Montefiore Medical Center Edward Panacek, University of California at DavisEdward Sloan, University of Illinois at Chicago James Miner, Hennepin County Medical CenterEric Larson, Medical University of South Carolina Ken Iserson, University of Arizona Bradford Walters, William Beaumont Hospital Timothy Mader, Baystate Medical CenterRobert Cox, Spalding Medical Center James Ducharme, Atlantic Health Sciences CorporationJacques Lee, Sunnybrook and Women’s Hospital Joel Bartfield, Albany Medical CenterDave Fosnocht, University of Utah Cameron Crandall, University of New MexicoChristian Vaillancourt, Ottawa General Hospital Basmah Safdar, Yale Medical CenterMartha Neighbor, San Francisco General Hospital Paula Tanabe, Northwestern UniversityLeslie Zun, Mt. Sinai Medical Center Barbara Lock, Columbia Presbyterian Medical Center Alan Heins, U. of South Alabama Medical Center Thomas Terndrup, U. of Alabama at Birmingham Andrew Chang, Montefiore Medical Center Edward Panacek, University of California at DavisEdward Sloan, University of Illinois at Chicago James Miner, Hennepin County Medical CenterEric Larson, Medical University of South Carolina Ken Iserson, University of Arizona Bradford Walters, William Beaumont Hospital PEMI Site Investigators Timothy Mader, Baystate Medical Center; Robert Cox, Spalding Medical Center; James Ducharme, Atlantic Health Sciences Corporation; Jacques Lee, Sunnybrook and Women’s Hospital; Joel Bartfield, Albany Medical Center; Dave Fosnocht, U. of Utah; Cameron Crandall, U. of New Mexico; Christian Vaillancourt, Ottawa General Hospital; Basmah Safdar, Yale Medical Center; Martha Neighbor, San Francisco General Hospital; Paula Tanabe, Northwestern University; Leslie Zun, Mt. Sinai Medical Center; Barbara Lock, Columbia Presbyterian Medical Center; Alan Heins, U. of South Alabama Medical Center; Thomas Terndrup, U. of Alabama at Birmingham; Andrew Chang, Montefiore Medical Center; Edward Panacek, U. California at Davis; Edward Sloan, U. of Illinois at Chicago; James Miner, Hennepin County Medical Center; Eric Larson, Medical U. South Carolina; Ken Iserson, U. of Arizona; Bradford Walters, William Beaumont Hospital

20 ACEP Pain Policy ED patients should receive expeditious pain management, avoiding delays such as those related to diagnostic testing or consultation. Hospitals should develop unique strategies that will optimize ED patient pain management using both narcotic and nonnarcotic medications. ED policies and procedures should support the safe utilization and prescription writing of pain medications in the ED. Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED. Ongoing research in the area of ED patient pain management should be conducted. Ann Emerg Med. 2004;44:198.

21 ED Analgesia Use: 1997 & 2001 National Hospital Ambulatory Care Survey Data – ED Summary. NCHS 2001.

22 EM Pain Literature Medline Search by Year of Publication: Pain and Emergency Medicine *

23 APS EM Scholars 2003 Cameron S. Crandall David Fosnocht Sam McLean Martha Neighbor Basmah Safdar 2004 Mary Ann Cooper Matt Lewin Barbara Lock John McManus Gerard Rebegliati Scott Rohrbeck Sachin Shah Leslie Zun


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