The Pain and Emergency
Medicine Initiative
Supported by The Mayday Fund
through a grant to
The Emergency Medicine Foundation
Knox H. Todd, MD, MPH
PEMI Co-investigators
Manon Choiniere
Cameron Crandall
James Ducharme
Celeste Johnston
Kathleen Puntillo
Background
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Pain is the most common reason for ED visits
Little data on the impact of pain after discharge
Objectives:
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Assess pain characteristics and pain-related
functional interference
Develop research network of US and Canadian EDs
Develop cadre of physicians and nurses interested in
ED pain management and research
Methods

Design
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
Setting
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Multicenter, prospective, observational study
13 academic and community emergency
departments in the US and Canada
Participants
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age 8 and older, moderate/severe pain
(NRS>3), discharged home
Methods
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Exclusion Criteria
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inadequate contact information
(address, phone, contact at separate address)
ischemic heart disease
mental status abnormality
inability to speak English or Spanish
sexual assault
domestic violence
muteness/deafness
prior enrollment
Methods
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
Structured ED interviews, chart abstraction,
follow-up telephone interviews
Study Measures:
Demographics
Pain severity
Communication
ED analgesic use
Discharge instructions
ED utilization
Prevalence of chronic pain
Satisfaction
Pain-related interference with function
Regular source of care
Results
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Subjects - 304 subjects from 13 EDs
Age - median: 32 years
Sex - 57% female
Phone interviews median 6 days after d/c
82% contacted within 14 days
ED Pain Intensity
Pain Intensity at ED Arrival and Discharge
60
ED arrival
Frequency
40
ED discharge
20
0
0*
1*
2*
3*
4
5
6
7
8
9
Pain Intensity (NRS)
* subjects with ED arrival pain scores 0-3 excluded from study
10
Time to Analgesic

Total ED time (triage to discharge):
Mean
192 minutes
Median 159 minutes

Time to first analgesic (triage to analgesic):
Mean
110 minutes
Median
88 minutes
Assessment


Proportion receiving
initial ED pain assessment:
79%
Proportion receiving
>1 ED pain assessment:
17%
ED Communication
Questions
Yes
Did we make it clear that we consider txmt of pain important?
58%
Did we make it clear that you should tell us when you have pain?
58%
Did you receive pain medication while in the ED?
65%
Did you ask for pain medication while in the ED?
26%
Did you feel that you needed pain medication while in the ED?
72%
% of patients receiving analgesics if they felt they were needed:
63%
% of patients asking for analgesics when they felt they needed
analgesics but did not receive them:
45%
Discharge Instructions
No or
Unclear
Did you receive instructions from your physician or nurse for
managing pain at home?
How clear were the instructions about how to change the
amount and timing of any pain medications if the current
schedule does not relieve pain?
How clear were the instructions about how to change the
amount and timing of the pain medication if the current
schedule produces side effects?
How clear were the instructions about whom to call about your
pain if you have any questions?
28%
55%
57%
33%
Chronic Pain and the ED
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
134 subjects (44%) with chronic pain
Median duration of symptoms - 2 years

% reporting at least 1 ED visit within the past year:
Chronic Pain:
79%
No Chronic Pain:
40%

Mean # ED visits per person within past year
Chronic Pain:
4.3
No Chronic Pain:
1.3
Healthcare Utilization
ED Utilization for Patients Reporting At Least One ED Visit in
Previous 12 Months
35
30
With Chronic Pain
Frequency
25
Without Chronic Pain
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
more
than
Number of ED Visits in Previous 12 Months
10
* ED visits reported by 40% of those without chronic pain and 79% with
chronic pain
Follow-up Pain Intensity
Pain Intensity for 196 Subjects with Pain at Follow-up
(median 6 days after ED discharge)
Note: an additional 108 subjects (36% ) were pain-free
40
Frequency
30
20
10
0
1
2
3
4
5
6
Pain Intensity (NRS)
7
8
9
10
Pain Intensity
80%
70%
ED arrival
60%
ED discharge
50%
Follow-up
40%
30%
20%
10%
0%
Pain-free
Mild 1-3
Mod. 4-6
Severe 7-10
Pain-related Functional Interference
Pain-related Interference with Function among 196 Subjects
with Pain at Time of First Follow-up
(median 6 days after ED discharge)
80%
60%
40%
20%
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Conclusions
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Pain intensity is high in ED and after discharge
Analgesics are delayed
Follow-up pain assessments uncommon
IM routes used in a high proportion of cases
Deficiencies in communication and d/c
Many have chronic pain - high rates of ED use
Significant proportions with pain experience
persistent pain-related functional interference
Much remains to be done
PEMI Site Investigators
Timothy Mader, Baystate Medical Center; Robert Cox, Spalding
Medical Center; James Ducharme, Atlantic Health Sciences
Corporation; Jacques Lee, Sunnybrook and Women’s Hospital; Joel
Bartfield, Albany Medical Center; Dave Fosnocht, U. of Utah;
Cameron Crandall, U. of New Mexico; Christian Vaillancourt,
Ottawa General Hospital; Basmah Safdar, Yale Medical Center;
Martha Neighbor, San Francisco General Hospital; Paula Tanabe,
Northwestern University; Leslie Zun, Mt. Sinai Medical Center;
Barbara Lock, Columbia Presbyterian Medical Center; Alan Heins,
U. of South Alabama Medical Center; Thomas Terndrup, U. of
Alabama at Birmingham; Andrew Chang, Montefiore Medical
Center; Edward Panacek, U. California at Davis; Edward Sloan, U.
of Illinois at Chicago; James Miner, Hennepin County Medical
Center; Eric Larson, Medical U. South Carolina; Ken Iserson, U. of
Arizona; Bradford Walters, William Beaumont Hospital
ACEP Pain Policy - 2004

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ED patients should receive expeditious pain management,
avoiding delays such as those related to diagnostic testing or
consultation.
Hospitals should develop unique strategies that will optimize ED
patient pain management using both narcotic and nonnarcotic
medications.
ED policies and procedures should support the safe utilization
and prescription writing of pain medications in the ED.
Effective physician and patient educational strategies should be
developed regarding pain management, including the use of pain
therapy adjuncts and how to minimize pain after disposition
from the ED.
Ongoing research in the area of ED patient pain management
should be conducted.
Ann Emerg Med. 2004;44:198.
ED Analgesia Use: 1997 & 2001
National Hospital Ambulatory Care Survey Data – ED Summary. NCHS 2001.
EM Pain Literature
45
40
*
35
30
25
20
15
10
5
0
90
91
92
93
94
95
96
97
98
99
00
01
02
03
Medline Search by Year of Publication: Pain and Emergency Medicine
APS EM Scholars
2003
Cameron S. Crandall
David Fosnocht
Sam McLean
Martha Neighbor
Basmah Safdar
2004
Mary Ann Cooper
Matt Lewin
Barbara Lock
John McManus
Gerard Rebegliati
Scott Rohrbeck
Sachin Shah
Leslie Zun