Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures

doi:10.1016/S0196-0644(99)80003-1

Annals of Emergency Medicine

Volume 33, Issue 6, June 1999, Pages 652-658

https://doi.org/10.1016/S0196-0644(99)80003-1 Get rights and content

Study objective: To compare patient and practitioner assessments of pain associated with commonly performed emergency department procedures and use of anesthetics before these procedures.

Methods: This was a prospective, observational, cross-sectional study conducted at a university-based ED with a convenience sample of ED patients. Research assistants recorded the procedure performed and historical and demographic information on standardized data collection instruments. After each procedure, both the patient and practitioner independently recorded assessments of patient pain on a 100-mm visual analog scale (VAS). Use of preprocedure anesthetics and patient preferences regarding their use were also identified. Categorical variables were analyzed by ϰ² tests. Patient and practitioner VAS scores were compared using a paired t test; α was preset at .05. Correlation coefficients were calculated to assess correlation between patient and practitioner pain scores.

Results: A total of 1, 171 procedures were evaluated for the 15 most common procedures performed. The mean patient age was 42.8±18.7 years and 46.1% were male. Overall, the mean patient VAS was 20.8 mm±25.1 mm; the mean practitioner VAS was 23.5 mm±20.3 mm. The mean difference between groups was 3.0 mm (95% confidence interval [Cl], 1.3 to 4.1). Correlation between patient and practitioner pain scores for individual procedures was poor to fair (r=26 to .68). The most painful procedures according to patients in descending order were nasogastric intubation, abscess drainage, fracture reduction, and urethral catheterization. Local anesthetics were administered in 12.8% of procedures yet would be requested before similar future procedures by 17.1% of patients. Patients who would choose local anesthetics in the future gave higher pain scores than those who would not (43.3 mm versus 16.3 mm; mean difference=27.0 mm, 95% Cl, 22.2 to 31.8 mm).

Conclusion: The most painful procedures for ED patients were nasogastric intubation, incision and drainage of abscesses, fracture reduction, and urethral catheterization. Although practitioners also identified these procedures as most painful, the correlation between patient and practitioner pain assessments in individual patients was highly variable. Overall use of anesthetics before these procedures was low. Practitioners should be attentive to their patients' individual anesthetic needs before performing painful procedures.

References (13)

WilsonJE et al.
Oligoanalgesia in the emergency department
Am J Emerg Med
(1989)
ToddKH et al.
Clinical significance of reported changes in pain severity
Ann Emerg Med
(1996)
TerndrupTE
Pediatric pain control
Ann Emerg Med
(1996)
NevinK
Influence of sex on pain assessment and management
Ann Emerg Med
(1996)
ToddKH
Pain assessment and ethnicity
Ann Emerg Med
(1996)
LewisLM et al.
Are emergency physicians too stingy with analgesics
South Med J
(1994)

There are more references available in the full text version of this article.

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The outcomes of pain care are best measured from the perspective of the patient [4]. Ideally, the outcome should not require interpretation by the clinician as significant bias can occur when clinicians evaluate pain severity and response to treatment [9]. Other factors, such as gender may influence factors such as stress and anxiety associated with pain, that in turn influence the outcomes of pain care [10].
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^*: Presented in part at the annual meeting for the Society of Academic Emergency Medicine, Washington DC, May 1997.

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Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures*

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Are emergency physicians too stingy with analgesics

South Med J