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Pain relief crucial to patient satisfaction in emergency depts: Study

15 Jul 2021

By Ruwan Laknath Jayakody The importance of improving patients’ satisfaction regarding pain relief needs to be emphasised among emergency department healthcare staff members, as it affects patients’ perceptions and their overall evaluation of the care provided to them, the first-ever study done in Sri Lanka in the setting of an emergency department to assess pain management practices and patients satisfaction concerning pain relief noted. These observations were made in an original research titled “Self-perceived pain characteristics, pain management practices, and patient satisfaction in the Emergency Department of the Kalutara District General Hospital” authored by P.D. Kawiratne and C.M.A.D. Chandrasekara and published in the Sri Lanka Journal of Medicine’s 30th Volume’s First Issue on 1 July 2021. Pain, as noted in “Prospective study on the prevalence, intensity, type, and therapy of acute pain: A second-level urban emergency department” by P. Mura and S. Elisabetta; “Acute pain in the emergency department: The challenges” by L. Keating and S. Smith; “Pain prevalence and patient preferences concerning pain management in the emergency department” by J.S. Martin and R. Spring; and “Pain management in the emergency department: A review article on options and methods” by A. Ali and M. Banaie, is the presenting complaint (acute injuries, headache, chest, abdominal, back and musculoskeletal pain, etc., as per “Prospective analysis of pain and pain management in an emergency department” by M. Leigheb and M. Sabbatini) in a range of diseases for which patients seek treatment from emergency departments and is a common symptom that leads to a majority of visits to emergency departments and thereby causes considerable burden to such busy settings. Emergency department-related events are taking place with a higher incidence, as per “Emergency medical service systems in Sri Lanka: Problems of the past, challenges of the future” by K. Wimalaratne, J.I. Lee, K.H. Lee, H.Y. Lee, J.H. Lee, and I.H. Kang; the Ministry of Health’s “Knowledge, attitudes, and skills among primary healthcare workers in Sri Lanka on first aid safety for poisoning” by W.D.A.S. De Silva, R. Fernando, and S.M. Samarage; and “The National Poisons Information Centre in Sri Lanka: The first 10 years” by R. Fernando. However, K.H. Todd and J. Ducharme note in “Pain in the emergency department: Results of the pain and emergency medicine initiative multi-centre study” that in the majority of the emergency departments, pain assessment, and management is subpar and not up to the expected standards. Among the interventions implemented to address the issue is, Kawiratne and Chandrasekara note the application of the validated Numerical Rating Scale (NRS) tool (zero to 10) to assess pain and with guidelines along with time frames to treat the pain as per the severity. In this regard, Wimalaratne et al. cite the best practices guidelines on pain management put forward by the Royal College of Emergency Medicine, which state that the assessment of pain should take place within 20 minutes of arrival, followed by the reassessment of the pain condition in one hour. Using this tool is particularly important in the context of V. Guru and I. Dubinsky pointing out in “The Patient vs. caregiver perception of acute pain in the emergency department” that the assumption of the intensity of pain being made by healthcare workers instead of using a validated scale to identify the intensity was inaccurate on 50% of the occasions. Moreover, Kawiratne and Chandrasekara emphasise that the undertreatment or inadequate treatment of pain through the underuse of analgesics (painkillers) in the face of valid indication (oligoanalgesia) is a common occurrence in emergency department settings. Pertaining to the same, Todd and Ducharme found that while 42% of the patients who had not received analgesics, desired pain relief, only 31% had expressed concern, while 74% had been discharged with moderate to severe pain. Therefore, Kawiratne and Chandrasekara explain that irrespective of the nature and the severity of the illness, patients expect adequate and prompt pain relief, noting also that adequate pain relief contributes to better outcomes and patient satisfaction (effective pain management is, as per S.J. Welch’s “20 years of patient satisfaction research applied to the emergency department: A qualitative review” and H.C. Bhakata and C.A. Marco’s “Pain management: Association with patient satisfaction among emergency department patients”, a major element that has a correlation with patient satisfaction). Kawiratne and Chandrasekara also add that optimum pain management practices in emergency department settings would have beneficial outcomes such as the improved quality of life (the level of pain significantly influences the quality of life), compliance, and client satisfaction regarding the healthcare system. An observational descriptive cross-sectional study was conducted by Kawiratne and Chandrasekara at the Emergency Department of the Kalutara District General Hospital. The data were collected from the patients admitted from June 2020 to August 2020. Consecutive sampling was done. Patients presenting with a score of over 13 on the Glasgow Coma Scale (GCS) were included. The sample size that was recruited was 408 participants. The male to female ratio was 3:2. The age of both genders was with overlapping interquartile ranges, in turn reflecting fair similarity. Comorbidities were present more among the females (41.7% compared to 27.8% of males). Nearly one-seventh of the sample was on long-term medications. One-tenth were suffering from chronic pain. An interviewer-administered questionnaire and a data extraction sheet were used. The intensity of the pain was assessed using the NRS. The patients were assessed two hours upon admittance or at the discharge/disposition, whichever was the earliest. At the time of admission, approximately two-fifths of the sample (42.2%) responded as having no pain, while two-thirds experienced some level of pain and 12% were experiencing the highest level of severe pain (a score of nine or 10). From more than three-fourths of the sample, the first contact doctor had asked as to whether they were in pain, and approximately 60% of them were told that they were being given medications for pain relief (approximately 40% were not told that they would be given pain relief medications). Nearly half (48.7%) of those who had pain on admission had asked for pain relief medication. With regard to the satisfaction concerning pain management and the overall care, it was found that in general, while the majority were having favourable evaluations on the “information provided by the staff concerning the pain”, “the medications given for the pain” (an aspect which as pointed out by the researchers should be promoted by giving the relevant details on the medications to the patients), and “overall care of the emergency department”, there were, however, relatively higher proportions of unfavourable responses among most of the patients concerning the “information provided on the modes of analgesics available for the patient’s condition” and on the “information given on the side effects of analgesics”, denoting dissatisfaction regarding these aspects. The commonest cause of painful presentation was chest pain followed by fractures due to trauma and soft tissue injuries. There were no significant differences of the pain satisfaction score between characteristics such as gender and the presence of comorbidities. However, a higher, increased level of satisfaction was seen in the patient group that was told by the first contact doctor that pain medication would be given. Furthermore, satisfaction was more in the group that had asked for pain medication. Since patients being told that pain relief medication would be provided led to favourable results including satisfaction regarding pain management and care, this suggests that a health staff member sparing a few seconds to inform the clients that pain medication will be given is, as recommended by Kawiratne and Chandrasekara, an aspect of care that should be emphasised in staff capacity development and evaluation sessions. With regard to patients who requested for medication experiencing a higher level of satisfaction, Kawiratne and Chandrasekara observed that while there could be a subjective component in self-quantification on the part of the patients with regard to the level of pain experienced by them, it is also important to ascertain whether health staff tend to prescribe medications with higher potency for this group of patients that requests for pain relief medications as the level of satisfaction could be influenced by the potency of the analgesics given. Age did not show a significant association with the score for satisfaction over pain management, but the latter score was correlated significantly and positively with the total satisfaction score concerning the overall care provided by the emergency department. Simply put, when the patients’ perception of the quality of pain management is favourable, it in turn increases the overall satisfaction of the care provided by the emergency department. Addressing clinicians, administrators, and policy planners in conclusion, Kawiratne and Chandrasekara reiterated that since patient satisfaction concerning the health system is important in evaluation, there is a necessity of attending to and providing quality pain management care for clients at clinics in emergency department settings.


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