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How to Complete a Rapid Pain Assessment in a Busy ED Phyllis Hendry, MD Sophia Sheikh, MD
How to Complete a Rapid Pain Assessmentin a Busy ED
Phyllis Hendry, MDSophia Sheikh, MD
Course DescriptionPain is a component of up to 78% of ED presenting complaints yet most ED physicians
have had minimal training related to pain recognition, assessment and management. Adequate pain assessment is complex and requires time to determine the patient’s past pain and medication history, current pain history, and pain intensity. ED providers are under pressure to recognize and treat pain while also dealing with overcrowding, a vast array of patient complaints, and concerns over opioid addiction and over prescribing. This course will review critical components of a rapid ED pain assessment, the current status of pain scales in the ED, electronic medical record documentation of pain and current literature.
DisclosuresPhyllis Hendry, MD, FACEP, FAAP (Principal Investigator)Sophia Sheikh, MD, FACEP (Sub-Investigator)
Pain Assessment and Management Initiative (PAMI) Funded by Florida Medical Malpractice Joint Underwriting Association, Alvin E. Smith
Safety of Health Care Services Grant: 2014-2018
Learning ObjectivesDescribe various pain assessment tools currently in the literature and pros/cons to using
these tools in the ED setting; Discuss barriers to utilizing pain assessment tools and ways to overcome those barriers; List advantages to implementing a common pain assessment tool in the ED among the
entire ED health care team; andDiscuss evidence and controversy behind pain and patient satisfaction scores.
Pain as of August 2016 Total upheaval in the world of pain management
–New research regarding the neurobiological complexity of pain and long term consequences of untreated acute pain.
Opioid epidemic has everyone pointing fingers and outcry for reducing opioids–CDC, The Joint Commission, Advocacy Groups–“Blame Game” among specialties–“Throwing out the baby with the bath water”
Increase in ED based pain management research
Background, Barriers, and Challenges in the Emergency Department Management of Pain
Pain in the ED: Background and BarriersPain is often the main reason why patients come to the ED
Care in the ED often adds to a patient’s pain
Pain can be a barrier to communication
Overall error prone environment
Pain in the ED: Background and BarriersPatient credibility and provider biases
–Unique population of patients with increased incidence of mental illness, substance abuse and co-morbidities leading to bias
–Limited means or time to verify patient’s history–Drug-seekers vs drug-diverters vs legitimate pain
Pain in the ED: Background and BarriersNeed to balance analgesia and sedation with adverse effects, especially at the extremes
of age and with comorbidities
Pain cannot be treated if it cannot be recognized and assessed1-10 scale not very helpful Limited formal education
Pain in the ED: Background and BarriersPain needs to be addressed within a reasonable period, yet…
–Under pressure to rapidly disposition patients we don’t know–Difficult to differentiate between pain and anxiety–Lack of standardized assessment, reassessment and management tools especially for pediatric,
non-English speaking, nonverbal, elderly or cognitively impaired patients–No RAPID pain evaluation tools for ED or EMS
Trying to Balance Pain Management While…… Dealing with opioid crisis and pressure to
decrease readmissions and triage to discharge times
Working in crowded high risk environment
AssessmentDefinition????
Many Patients Do Not Receive “Adequate” Pain Assessments by EMS or in the ED
Studies:–Only 40-50% of trauma patients received pain assessments and analgesics–34% of elderly patients with hip fracture had no pain assessment documented
How can we appropriately treat pain if we don’t assess it?
Why the Lack of ED Assessment?Numbers don’t reflect the whole story…Acuity and clinical condition may explain lack of assessments- altered/head injured,
intubated, inebriated, unstable –Patients are less likely to be assessed for pain as injury severity increases. –Physiologically unstable patients are least likely to receive a standardized pain assessment and
to receive ED opioids.
Spilman 2016
Why the Lack of ED Assessment?Most EDs use a NRS to assess pain which requires an alert and oriented patient.
Unfamiliarity with other pain scales or lack of time for more complex scales
Patient acuity or condition may not allow for a full assessment
Assessment tools for intoxicated or impaired patients lacking
Patient and Provider Attitudes Influencing Pain Assessment
Hypotheses for Inadequate Assessment or Under-estimation of Pain1. Preference for signs over symptoms- physician ability to detect patient deception poor;
correctly identified actors only 10% of the time.
2. Failure to recognize ED practices that themselves worsen pain by increasing patients’ anxiety and fear.
3. Belief by some practitioners that pain is proportional to tissue damage -don’t appreciate role of individuating factors.
Carter D, et al. Why Is Pain Still Under-Treated In The Emergency Department? Two New Hypotheses. Bioethics Volume 30 Number 3 2016 pp 195–202.
Hypotheses for Inadequate Assessment or Under-estimation of Pain4. Social distances between practitioners and some patient subpopulations can impair
pain assessment and management.
5. Practitioners suspect patients of drug seeking and consequently of fabricating or exaggerating their pain leading to practice of defensive medicine.
Carter D, et al. Why Is Pain Still Under-Treated In The Emergency Department? Two New Hypotheses. Bioethics Volume 30 Number 3 2016 pp 195–202.
Mandated Pain Assessments and Patient Satisfaction Scores
Pain as the 5th Vital Sign “intent of the ‘pain as the fifth vital sign’ campaign was to encourage doctors and
nurses to listen to their patients and assess their pain………. no intent to have everyone take an opioid.”
“In describing pain as the fifth vital sign, the message is that pain assessment is a priority”
-- James N. Campbell 2016
Unintended Consequences of the 5th Vital SignRenewed focus on pain assessment but reliance on uni-dimensional assessment tools
leading to:–Opioid over-prescribing–Adverse events –Over-sedation
• increased from 11 to 24.5 (P < 0.001) per 1,000,000 inpatient hospital days following use of an acute pain treatment algorithm guided by a numerical pain rating
Mandated pain assessments not shown to improve pain management or patient outcomes
Patient Satisfaction Scores71% of ED physicians perceived pressure to prescribe opioids to avoid administrative
and regulatory criticism
98% felt patient satisfaction scores were too highly emphasized by reimbursement entities as a means of performance evaluation
Rising patient volumes and changes in the healthcare climate were reported factors impacting management of patients exhibiting "drug seeking" behavior.
Patient Satisfaction ScoresPress Ganey patient satisfaction scores in the ED not associated with analgesics or opioid
administration in the ED.Very controversial subjectChanges predicted for HCAHPS (the Hospital Consumer Assessment of Healthcare
Providers and Systems) score evaluation and usage
Role of Electronic Medical Record (EMR) in Pain: Has it Improved Pain Assessment?
Incorporation of pain scales into EMRs improved documentation of pain scores
–Mixed results for improved administration of analgesics and reduction in time to administration of analgesics
–Focuses on pain intensity, not pain assessmentPain order sets based on pain severity
–Does not allow for individualization–Risk for adverse events like over-sedation
“Give patients a voice, not a number” -University of Utah
Role of EMR in ED Pain AssessmentKaplan et al. 2008
–Mandatory recording of pediatric pain scores in EMR raised documentation from 7% to 38% but no improvement in administration or decrease in time to treatment
No recent ED studies but Urban et al. 2015 found computerized provider order entry allowed for faster postoperative analgesia, decreased pain scores, and required less medication compared to paper-entry
Pain Assessment and Discharge Planning Pain assessment scores and tools are needed to manage ongoing pain in the ED and to
determine fitness for discharge or need for admission
Appropriate discharge planning:– reduces return visits–expedites return to normal activities and work–helps reduce risk of acute pain progressing to chronic pain
Unidimensional Tools for Pain Assessment: Pain Scales
Pain Assessment Scales Populations
– Adult– Pediatric– Special Situations
No pain scale validated for ED or pre-hospital use Most pediatric scales originally developed to
measure procedural-related pain.
General categories:– Observational-behavioral scales require provider
to assess patient on multiple behaviors and rank them.
– Self-report scales include selection of a face or color or number to represent pain.
Pain Scales* Verbal, Alert and Oriented Non-verbal, GCS <15 or Cognitive Impairment
Adult 1. Verbal Numeric Scale (VNS)/ Numeric Rating Scale (NRS)
2. Visual Analogue Scale (VAS)3. Defense and Veterans Pain
Rating Scale (DVPRS)
1. Adult Non-Verbal Pain Scale (NVPS)2. Assessment of Discomfort in Dementia (ADD)3. Behavioral Pain Scale (BPS)4. Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1. Wong Baker Faces 2. Oucher (3-12yrs)3. Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1. Visual Analogue Scale (VAS)2. Verbal Numeric Scale (VNS)/
Numeric Rating Scale (NRS)
Birth – 6 mos1. Neonatal Infant Pain Scale (NIPS)2. Neonatal Pain Assessment and Sedation Scale (N-PASS)3. Neonatal Facial Coding System (NFCS) 4. CRIES
Infant and older1. Revised Faces, Legs, Activity, Cry, and Consolability
(r-FLACC)2. Non Communicating Children’s Pain Checklist (NCCPC-R)3. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
What do the numbers mean?Pain = 3 Pain = 10
The Nature of PainPain - complex, multifactorial, emotional, and subjective sensationPain Scales- unidimensional, single digit tool, representing a snapshot of the magnitude
of pain at a specific time
Factors Affecting Assessment-Personalized Approach
• Age, gender, ethnicity• Socioeconomic and psychiatric factors• Culture and religion• Genetics• Previous experiences • Patient perceptions Patient expectations and perceived care
by the treating provider(s)
Pain Assessment ScalesValidity? ‘‘Does this instrument measure what it is supposed to measure?’’
• Picture scales good in populations with limited literacy (peds), males uncomfortable with scales depicting severe pain with tears
• Verbal rating scales showed limited precision in low literacy and cognitively impaired pts.• Lack of supporting ED data
Todd KH. Pain assessment instruments for use in the emergency department. Emerg Med Clin North Am. 2005 May;23(2):285-95
Visual Analog Scale (VAS) Limitations Fosnocht et al. Am J Emer Med, 2005
–N= 1999, prospective observational study–Change in VAS did not correlate with change in pain intensity, as measured by verbal descriptor
scale (VDS)–Change in VAS may not be a valid indicator of pain relief
Visual Analog Scale (VAS) Limitations Blumstein and Moore. Acad Emerg Med, 2003
–No single cutoff on the pain scale could reliably predict a patient’s desire for medication
Lee et al. Acad Emerg Med 2003–A change of 30 (0-100) on the VAS is the minimal clinically important difference, based on
adequate pain control as specified by the patient
Numeric Rating Scale (NRS) Limitations and Issues
NRS pain scale validated research tool to assess change in pain in cancer patients The NRS is sensitive to the short-term changes in pain intensity associated with
emergent care• NRS preferred by patients, higher completion rates than VAS
Numeric Rating Scale (NRS) Limitations and Issues
Patients and staff often have different subjective definitions of the 0-10 scale.–Leads to inaccurate measurement of pain
If the reporting of pain is inaccurate, it can only be expected that the treatment will be equally ineffective.
FLACC Scale Limitations and Issues
Cannot be generalized to older children, adolescents, or adult patients
Limited utility in cognitively impaired pediatric patients
Scale with Color, Numerical, Descriptive and Visual Components- Old Version
Defense and Veterans Pain Rating Scale (DVPRS) v 2.0
• Excellent correlation to Brief Pain Inventory-Short Form
• New pain faces- excellent interrater agreement
Defense and Veterans Pain Rating Scale (DVPRS) v 2.0 Assesses subjective + objective (functionality) pain experience
Color coding system (green, yellow, red) has specific implications for prioritizing patients in need of prompt and effective pain care
Pain intensity scale has utility for identifying injured service members most at risk for early central sensitization from severe unrelieved pain
Promising for the ED population but……
Defense and Veterans Pain Rating Scale (DVPRS) v 2.0Study population- military
–81.4% male, 62.9% Caucasian, 60.3% married, 42% associate’s degree or higher–72% active duty military–36% Acute post-op pain–32% chronic non-cancer pain–29% neuropathic pain
–Demographics not reflective of most ED populations
Factors Associated with Higher Pain ScoresYounger age Female genderAfrican American raceMedicaid insuranceMultiple ED visits in the past year ED diagnoses of sickle cell pain, back/neck/shoulder pain, and headache
Pain Score 8, Now What?What should we do with a pain score?
–How do we compare studies using different pain scores?–Treat if the number is high? And with what ?–Not treat if the number is low? –What number is unacceptable for discharge?–Do we believe the score?
Pain score 8, Now What?What change in the pain score means a patient can go home?
–Decision point: admit or discharge home
What changes indicate “successful” treatment?
Pain Reduction Clinical OutcomesMinimal clinically significant difference (MCSD) in pain severity- 1.5 on 11 point NRS or
a proportional change of 25%.
Change of at least 2 on a 0–10 pain intensity scale, or 33% pain intensity difference reported to represent patient-determined clinically important relief.
Change of 30 (0-100) on VAS is minimal clinically important difference, based on adequate pain control per patient.
What Existing Pain Scales are MissingNone designed specifically for ED setting Scales used by majority of EDs are not designed for chronic pain Lack of context (what does 8 out of 10 really mean?)Most scales used in the ED don’t assess functionality
Other Assessment Tools: Moving away from Numbers
PMPsFunctionality and Quality of LifeSubstance Abuse, Opioid Risk ToolsMental Health Assessment
Prescription Monitoring Programs--Theoretically a Helpful Assessment Tool
No integration with EMR; Difficult to find; Invalid password; Site maintenance; Too many clicks; Delay in time rx filled to when it shows up in system; If pharmacy inputs data wrong then nothing will show-
missing rx;Multiple records for same pt;
Doesn’t provide interpretation—how many MME pt takes? How many overlapping rx?; Doesn’t list type of dr. writing rx or their
office/location/contact info;Doesn’t take into account non-medical use; Doesn’t tell you abuse hx; Doesn’t tell you if pt has pain contract
So Why Don’t We Always Use Them?
PMPs and Opioid Overdose Risks- AssessmentPredictors for opioid overdose:Number of days receiving more than 100 MMENumber of ‘trinity’ days (opioid, benzodiazepines, muscle relaxer)Number of prescriptionsMultiple drug days Early refills
PDMPs and Opioid Overdose Risks- AssessmentPredictors for high-risk behaviors:>/= 4 opioid prescriptions AND>/= 4 providers for schedule II-V medications in the past 12 months
Physical Functionality & Quality of Life ScalesBrief Pain InventoryPhysical Functional Ability QuestionnairePalliative Performance Scale (Karnofsky Scale)Oswestry Low Back Disability IndexAmerican Pain Foundation Scale EQ5D-5L
Physical Functionality & Quality of Life Scales These scales are difficult to administer in ED setting due to length and time but provide
important assessment components.Most ED physicians are not familiar with these scales.What about re-assessments?
Substance Abuse ToolsWebster's Opioid Risk Tool (ORT)Screener and Opioid Assessment for Patients in Pain (SOAPP®)Current Opioid Misuse Measure (COMMTM)Prescription Drug Use Questionnaire (PDUQ)Screening Tool for Addiction Risk (STAR) Screening Instrument for Substance Abuse Potential (SISAP) Pain Medicine Questionnaire (PMQ)
Substance Abuse Screening in the EDWeiner et al. 2016
–32.9% of ED patients considered for discharge with an opioid scored “at-risk” on Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
Broderick et al 2015–Patients were asked if used street drugs or marijuana in the past 3 months–40% sensitivity- missed 60% of individuals testing positive on the Alcohol, Smoking, and
Substance Involvement Screening Tool (ASSIST)–72% sensitivity for marijuana use
Mental Health ToolsSIGECAPSBeck Depression Inventory-Fast Screen (BDI-FS) The Mental Health Triage Scale (MHTS)Patient Health Questionnaire
Catastrophizing and Anxiety scalesKapoor et al 2016100 patients presenting to ED with acute pain
Pain Catastrophizing Scale (PCS), and the State-Trait Anxiety Inventory-State Subscale (STAI-S).
Pain intensity was significantly and positively associated with pain catastrophizing and anxiety
Catastrophizing and Anxiety scalesKapoor et al 2016Need to consider the psychological distress from anxiety and pain catastrophizing of
patients presenting to EDs with acute pain.
“Brief behavioral interventions in conjunction with pharmacological interventions could improve outcomes”.
Does One Perfect ED Assessment Tool Exist?
Does one perfect assessment tool exist? An ideal pain assessment should include:
–patient’s subjective experience + – functionality assessment + –pain catastrophizing and anxiety + – substance abuse and opioid-addiction risks + –PDMPs+ –psychiatric conditions and comorbidities RAPID???
And we still have to complete a history and physical exam!
Tools for Obtaining a Pain History and Completing an “Assessment”: OPQRST, SOCRATES and QISS TAPED
Numerous questions Time constrainingBeyond scope of this presentation Portions could be incorporated into model rapid pain assessment
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O: Onset (when did it start) P: Provocation or Palliation (what makes it better or worse) Q: Quality (sharp, dull, crushing) R: Region and Radiation
S: Severity (pain score)
T: Timing (type of onset, intermittent, constant)AS: Associated Symptoms
PN: Pertinent Negatives
Site - Where is the pain? Or the maximal site of the pain.
Onset - When did the pain start, and was it sudden or gradual? Include also whether if it is progressive or regressive.
Character - What is the pain like? An ache? Stabbing?
Radiation - Does the pain radiate anywhere?
Associations - Any other signs or symptoms associated with the pain?
Time course - Does the pain follow any pattern?
Exacerbating/Relieving factors - Does anything change the pain?
Severity - How bad is the pain?
• Quality
• Impact
• Site
• Severity
• Temporal
• Aggravating and alleviating
• Past response and preferences
• Expectations and goals
• Diagnostics and physical exam
How would components of your assessment differ for the following cases?80 YO with hip fracture after a mechanical fall4 YO with lip laceration 35 YO with sickle cell disease and pain19 YO with femur fracture after MVC45 YO with chronic low back pain on a pain contract55 YO with depression and fibromyalgia
Pain Assessment Toolbox:Proposed Components
1. Pain history and exam2. Subjective- pain scales or scores3. Functionality/disability4. Chronic pain scales5. Substance abuse tools 6. Opioid risk/abuse tools7. PMPs8. Catastrophizing scales9. Anxiety scales10. Mental health screening tools
Chronic Pain Grade Questionnaire
PMPs ORT, CAGE-AID, SBIRT, DAST-10,
PMPS
Perform pain history and examSubjective pain assessmentFunctional pain assessment
Is pain chronic?
No
Yes
At risk for substance abuse? Opioid abuse?
No Yes
Signs of Pain Catastrophizing? Anxiety?
Yes
NoPCS
STAI-SRisk for depression?
YesNo SIGECAPSInstitute appropriate treatment;
Monitor and reassess
Pain Assessment Algorithm in an
Ideal World
Pain Assessment Toolbox Components1. Pain history and exam2. Subjective- pain scales3. Functionality/Disability4. Chronic pain scales5. Substance abuse tools6. Opioids risk/abuse tools7. PMPs8. Catastrophizing scales9. Anxiety scales10.Mental health screening
Developing a Rapid Pain Assessment for the ED Consider the patient’s subjective pain assessment then adjust based on exam or patient
behavior
Better approach is to ask how pain is affecting function?
Assign value to a number- contextualize the score and change in score. (10/10 hang nail pain vs 10/10 fracture pain)
Combine a qualitative scale + physician interpretation of the NRS along with other factors (allergies, PDMD, frequent visits, presenting injury/hx, level of tolerance, etc.)
Conclusions
What is Needed? Pain scales that are validated in the ED setting
– Study of Defense and Veterans Pain Rating Scale (DVPRS) v 2.0 in ED– Need more than a number!
Determine ways to assess a patient’s subjective and objective pain experience along with substance/opioid abuse risks
Research and collaboration – CDS (clinical decision support) algorithm development: acute vs chronic, critical vs noncritical, risk factors and
comorbidities, etc.– Screening tools
Communicate with the ED patient!Patients getting adequate pain relief may not want to report.
–Fear provider may decrease pain medications or efforts to identify source of pain (Carter 2016)–49% did not want analgesics (pain score 6.4) and 19% of these patients received them anyway
(Singer 2008)
Talk to patients and find out if pain is tolerable or intolerable, identify a common goal
Education on need for accurate pain scores to assess treatment–Discuss reality of pain relief- pain scores of 0 are unrealistic
The Bottom Line Pain is multifactorial thus assessment should reflect this
Tailor assessment to the patient– How you assess the 4 yo with a laceration will differ from the 45 yo with chronic back pain on a pain
contract
Recognize the role psychosocial factors play in pain assessment
Don’t forget about reassessments– Assess functional status with each re-evaluation
The Bottom Line Finally…..
– Know your limitations and those of your work environment– Consider patient acuity and reasonable goals of care
QuestionsThank you! Please share your ideas on how to perform a rapid ED pain assessment.
Email: [email protected] or [email protected]: 904-244-4986 Website: http://pami.emergency.med.jax.ufl.edu
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