Summary Table 2Studies on the timing and frequency of pain assessment, and timing of treatment (KQ1)

Author, YearStudy Design, settingSample sizeClinical condition/ baseline painIntervention/exposure of interestOutcomes measuredResults
Arendts, 20065Retrospective cohort study in an Australian ED857Thoracic, including cardiac 12.9%, abdominal 30.6%, urological 11.4%, gynecological 4%, trauma 31%, neurological 35%, and misc. 6.6%. 15% were admitted to critical care, 49% admitted to general ward, and 19% admitted to ED observationMorphine was the drug used in 94% of cases.Time from arrival to first dose of opiate. Patients were grouped in 2: time <60 minutes, and time >=60 minutes.Median time to first dose of opiate = 53 min. 73.5% received no alternative analgesia prior to opiate. Patients with 60+ minute delay were more likely to be female, older, of lower triage acuity, seen by junior medical staff, suffering from nontrauma-related illness, and admitted to hospital rather than discharged. These predictors were significant in multivariate analysis.
Grant, 20066Retrospective review of patient records4730r 473 pain patients, 213 (45%) had severe pain and 105 (22%) had moderate pain. By type of pain: Chest pain: 14–17% Abdominal pain: 19–21% Headache/neuropathi c: 8–11% Muscular: 29–32% Skeletal: 11–15% Ears, nose throat: 2–3% NOS 6–12%Any form of analgesiaTime intervals between patient arrival, assessment, and delivery of analgesia.For patients with moderate pain v. severe pain, mean time interval (min):Arrival to doctor assessment: 142 v 42 Arrival to prescription of analg: 168 v 58 Arrvial and receipt of analg: 236 v 72 Delay btw prescription and administration of analgesia: 68 v 14.% of patients who received analgesia within time frame meeting BAEM guidelines: 24% in severe pain, 18% in moderate pain. 32% of patients were re-evaluated in terms of analgesia requirements.
Hwang, 20067Retrospective review of medical records from a prospective cohort study158Patients reporting complaint of pain: 81%Transfer administrative data (ADT) on time of registration and discharge was used to determine ED crowding risk factors: ED census and mean ED length of stay (LOS) during the hour the index hip fracture patient arrived.4 quality measures: 1) time to pain assessment by a physician; 2) documentation of administration of pain medication 3) type of analgesic (opioid v nonopioid (NSAID, acetaminophen) if given; 4) time to pain treatmentMinutes to first documented pain assessment, mean (range): 40 (0–600)Minutes to first documented pain treatment: 141 (10–525)Delay in treatment, minutes: 122 (0–526)64.1% received analgesia for pain (57% opioids, 7% nonopioids).32.8% of patients for whom opioid was prescribed received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment and longer times to pain assessment, in a multivariate analysis that adjusted for age, gender, RAND score, dementia, and mean ED LOS >100% annual.
Ranji, 20068Systematic Review of RCTs of opiate analgesia v placebo in acute abdomen9 studies in 1062 adults, and 3 studies in 291 children.3 studies enrolled only patients with right lower quadrant pain; all others enrolled patients with undifferentiated acute abdominal pain.use of opiate analgesia in acute abdomenEffect of opiates on patient history (potential to minimize previously concerning symptoms v. increasing its accuracy by calming the patient); on the physical examination; and on potential management errors11 comparisons from 9 studies in adults showed a trend toward changes in the physical examination with opiate administration, with a summary RR of 1.51 (95%CI 0.85 – 2.69). There was significant heterogeneity among the studies; in 3 comparisons, pain relief reported by the opiate group did not significantly differ from placebo. Studies did not generally distinguish between potentially beneficial changes such as improved localization of tenderness and potentially harmful changes such as changes in peritoneal signs. In 2 studies, loss of periotneal signs after analgesia occurred in 5.6% to 18.7% of patients with opiates, compared with 2.6% to 7.7% of those in the control group. Diagnostic accuracy: a meta-analysis of 4 adult studies indicated no significant change in the rate of incorrect management decisions with opiates vs. placebo. Analgesia was adequate in all these studies, and no significant heterogeneity was found. The frequency of possible unnecessary surgeries was similar between opiate and control groups (7.6% v 7.9%). Meta-analysis showed a non-significant trend toward fewer unnecessary surgeries among patients with opiates.
Shabbir, 20049Prospective study in a direct access A&E department where patients were immediately assessed by the surgical on-call service.100Acute abdominal pain. Clinical diagnoses included non-specific abdominal pain, PID, peptic ulcer disease, pancreatitis, appendicitis, renal, cholecystitis.Most common drugs used: diclofenac 37% pethidine 26% Most common routes used: 80% intramuscular route 0% received intravenous analgesia.Waiting time for analgesia and its relationship to subjective visual analogue pain scores and clinical diagnosesMean waiting time for analgesia was 1.4 hours (range 2 min to 14 hr).Female patients had a longer mean wait time than males (129 min v. 69 min, p=0.09). Patients admittted at nighttime received analgesia quicker (mean 76 min) than during the day time (mean 114 min). 77% were satisfied with the adequacy of analgesia once given; 23% thought the pain relief was not sufficient. Neither clinical diagnosis nor age influenced the timing of analgesia.
Vila, 200510Retrospective chart review, single hospital: H.Lee Moffitt Cancer Center and Research InstitutePre-intervention: 79 opioid ADRs for 117,672 inpatient hospital days, Post-intervention: 67 opioid ADRs for 65,388 inpatient hospital daysCancer patientsAll nursing staff and support personnel were required beginning January 2001 to document each patient’s rating of their pain intensity using a numerical scale, along with other vital signs with every routine patient assessment.Change in patient satisfaction and opioid-related ADRs, including oversedation or respiratory depression requiring discontinuation of theopioid or reversal with naloxone, in the 4 years before and 2 years after implementation of new pain management standards.Pre-intervention: 79 opioid ADRs for 117,672 inpatient hospital days, of these 13 involved oversedation. Post-intervention: 67 opioid ADRs for 65,388 inpatient hospital days; of these there were 16 oversedation events. There was a significant increase in the incidence of both events (opioid ADRs and cases of oversedation) post-NPTA (p=0.01 and p=0.03 respectively). The overall rate of ADRs increased by 49%, with a rate ratio of 1.49 (95%CI 1.08–2.07)67% of patients received analgesia within 1 hour after presentation; approximately 25% waited over 2 hrs. Patient satisfaction ratings increased significantly before and after the NPTA period. (p<0.00001)

From: APPENDIX E, Evidence Summary Tables

Cover of Assessment and Management of Acute Pain in Adult Medical Inpatients
Assessment and Management of Acute Pain in Adult Medical Inpatients: A Systematic Review [Internet].
Helfand M, Freeman M.
Washington (DC): Department of Veterans Affairs (US); 2008 Apr.

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