Study: Pain Underdiagnosed and Undertreated in the Emergency Department

A Norwegian study in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine suggests that pain is inadequately treated in emergency departments (ED) for a variety of reasons, including a lack of provider knowledge about pain protocols and treatment. While the results are not surprising, they mirror challenges in the United States and elsewhere, and the findings are important because so many patients report to EDs due to acute or chronic pain.

Pain management is a fundamental aspect of care in emergency departments (EDs) worldwide, and yet inadequate treatment of pain remains a pervasive problem. In Norway, the problem persists despite multiple protocols for pain assessment and treatment in the ED. Previous studies have shown that even when nurses have local pain protocols, an unacceptable proportion of patients receive an inadequate assessment and pain treatment.

In the current study, prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation at St. Olav’s Hospital in Trondheim, Norway. The patients’ perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10. The most common chief complaints in both groups were abdominal pain, chest pain, breathing difficulties, and neurological and infectious conditions.

Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58%), only a dismal 14% received pain relief.

“This study reveals a known phenomenon; specifically, patients do not receive optimal assessment and treatment of pain in the ED,” the researchers observed. “...Although pain management is a fundamental aspect of emergency care, there are several attitudinal and structural barriers to efficient and adequate pain management in the ED.”

Among those barriers are problems also present in US ED departments, including communication barriers and language problems, intoxicated patients, patients with altered mental status, including dementia, and patient difficulty in describing or categorizing their pain. While some of these challenges can be compounded in elderly patient, the study found no significant difference in the proportion of patients over 64 years of age who were and were not asked about pain.

“Pain is one of the most common reasons for seeking emergency medical care; thus, it is important for healthcare professionals to focus on effectively assessing and treating pain,” the authors concluded. “Pain management is accepted as a quality indicator of care, and additional focus on strategies to improve pain management in the ED is necessary to ensure that all patients receive optimal pain assessment and treatment.”