Summary
Pain is a presenting symptom in 70% of visits to an emergency department. Severe pain can lead to
deterioration of physiological symptoms and considerable anxiety and stress when left untreated.
However, inadequate management of pain (oligoanalgesia) is a well-recognised phenomenon within
the emergency department. Despite a number of suggested reasons for oligoanalgesia, there is a lack
of empirical research investigating the factors are associated with good pain management and
reasons for differences in pain management between emergency departments. This research
proposes to address this research gap using a mixed methods approach.
A systematic review of interventions to improve pain management and evidence synthesis of factors
affecting pain management within the emergency department will be undertaken to identify effective
interventions and examine the context in which these interventions work. Case studies of emergency
departments will be undertaken to identify factors affecting pain management and to understand how
pain is managed differently between departments and with different patient groups, providing
empirical evidence to complement existing literature.
Evidence from the synthesis and case studies will be used to identify factors associated with good
pain management and a national survey of emergency departments will be undertaken to identify the
prevalence of these factors and seek information around the willingness to implement changes.
Background
Pain is the most common reason for seeking healthcare and is a presenting complaint in around 70%
of visits to an emergency department 1, 2, 3. The emergency department is responsible for treating
patients with trauma-related pain, other acute pain (e.g. abdominal pain, headache) and also has a
role in the treatment of patients with pain due to chronic disease and terminal illness. Although pain
may be viewed as a temporary experience, acute pain can trigger a number of physiological
responses and have a significant negative impact on patients. Examples of responses include
pressure upon the cardiovascular and respiratory systems (e.g. increased breathing and heart rates),
temporarily impaired gastrointestinal function and depression of the immune system, as well as
negative psychological and cognitive effects 4. Untreated episodes of acute pain can lead to further
episodes of pain or debilitating chronic pain syndromes and aggressive behaviour 5,6..
Management of pain is therefore an essential part of the duty of care within an emergency department
and recognition and treatment of pain should be a priority7. Pain management is seen as an important
quality indicator and has been shown to correlate with patient satisfaction with the emergency
department 8, 9. However, inadequate pain management (oligoanalgesia) resulting from inadequate
prescribing or delay in prescribing analgesia in the emergency department has long been recognised
as a significant problem globally 10, 11. Studies from emergency departments in Europe, America and
Canada suggest that over 50% of patients leave the department in significant or severe pain12, 13. In
the UK, a Healthcare Commission (HCC) survey recently criticised pain management in UK
emergency departments14.
There are many potential explanations for the degree of oligoanalgesia within the emergency
department. Culturally, pain management in the emergency department has historically not been a
priority. There is an inherent conflict between the goal of speedy diagnosis and subsequent treatment
required and the relatively time-consuming process of assessing, treating and monitoring patient pain
levels whilst in the department, particularly if pain is considered a symptom rather than a physiology in
itself 6, 10. The lack of relationship between the doctor and patient within the emergency department
has also been suggested as problematic, particularly as the nature of emergency care work
necessitates a level of detachment and tolerance for suffering that may be higher than in other
disciplines 6.
Pain is a subjective concept which can only be assessed using patient-reported measures and is also
open to subjective judgements from the clinician interpreting these measures. Clinical judgement can
be affected by many factors such as inadequate knowledge of pain relief, requirement of tangible
proof of pain and a lack of belief of the patient’s assessment of pain 10. As a result, the assessment of
patients with cognitive impairment or communication problems is particularly difficult and potentially
worse within the emergency department as trauma or stress can impact upon an individual’s ability to
communicate6. The subjectivity of assessment of pain may be reflected in evidence that patient
factors such as triage category, gender, ethnic origin and age can have an impact upon levels of
analgesia prescribing within the emergency department 15, 16, 17.
Despite oligoanalgesia being a well known phenomenon, few solutions have been proposed, although
more studies looking at improving pain management in the emergency departments have appeared in
recent years18, 12, 7. There have been a number of studies and reviews discussing potential barriers to
pain management, focussing mainly on physician and cultural barriers. However, much of this work is
speculative or has involved applying general learning around pain management from other contexts to
the emergency department, rather than studying pain management within the emergency department
to understand theories and practice specific to the emergency department. The lack of empirical
research on facilitators or obstacles to pain management in the emergency department has been
recognised 6. There is a particular lack of qualitative research around barriers and facilitators to pain
management, and any existing research has been based upon factors identified outside the
emergency department 20. Studies based specifically within the emergency department have focussed
upon patient factors that are associated with poor provision of pain relief 3, 20.
Recently, there have been a number of studies looking at interventions to improve pain management
within the emergency department, such as the use of pain scales to improve the assessment of pain,
protocols for administration of pain relief or patient or nurse-administered opioids18, 19, 21. These largely
address subsets of patients (e.g. long bone fractures, chronic pain) and guidance on pain
management may be specific to these patient groups. Various guidelines around pain management in
emergency departments exist 7, 22 but modification of behaviour in response to these has been
inadequate and the evidence base for creating effective policy guidance is still considered to be weak
23.
Despite some level of improvement in pain management in emergency departments in recent years
24, there are still many unanswered questions regarding why so many patients leave the emergency
department with unresolved pain and why such a significant proportion of patients feel that their
requests for pain control have not been managed adequately. In the UK there is considerable
variation in patient-reported levels of pain management between providers. In 2008 a national survey
of emergency department patients found that 59% of patients felt that the staff had definitely done
everything they could to help control their pain, with the proportion ranging from 41%-74% between
emergency departments 24. In this same survey, 14% of people felt that staff did not even try to
control their pain (range 4-26%). Although some of this variation may be due to differences in
populations (older age, female gender and lower urgency triage codes have been associated with
delay to analgesia), these figures were adjusted for age, sex and ethnicity which suggests that there
are significant differences in the way pain is managed between departments. It is likely that these
differences are due to a complex combination of organisational, professional and patient factors.
Given that pain management is an acknowledged problem and that this is a significant issue in the
quality of care within emergency departments, it is essential to understand which factors are
associated with adequate pain management in order to improve the levels of pain management and
decrease the variance in performance between departments. Interventions to improve pain
management are more likely to be successful if they are based on a good theoretical understanding of
the factors that influence pain management. The current lack of research in this area may contribute
to the lack of effect from existing interventions to improve pain management.
Aim:
To explore ways of improving pain management within adult emergency departments in England and
Wales and identify factors affecting pain management.
More specifically this will involve:

Reviewing existing literature around interventions for improving pain management and factors
associated with pain management in emergency department.

Investigating facilitators and barriers to improving pain management within emergency
departments and reasons for differences between departments. In particular, identifying
factors that can be modified within the constraints of different types of departments and for
different groups of patients.

Investigating the feasibility of introducing interventions to improve pain management within
emergency departments
Plan of investigation and timescales
In order to address how to improve pain management in the adult emergency department, it is
important to understand how pain is currently managed, what factors are associated with good pain
management and whether those factors can be modified in poorly performing departments in order to
improve pain management.
This is a mixed methods study. Qualitative methods will be used to identify factors that may be
associated with the quality of pain management, and potential barriers and facilitators to good pain
management. This will enable the development of a quantitative survey that will be used to identify
the prevalence of these factors and barriers. The research has three sequential phases:
Phase 1: Systematic review and evidence synthesis (months 1-12)
The first phase of the research will involve expanding a systematic review of interventions to improve
pain management and the provision of pain relief within the emergency department and undertaking
evidence synthesis of factors affecting pain management. A systematic review was undertaken within
ScHARR of interventions to improve pain management in 2009 25. This will be updated and then
extended to examine contexts in which any effective interventions work (e.g. patient condition,
emergency department type). The evidence synthesis will identify patient, professional and
organisational factors that affect pain management. A preliminary literature search identified a limited
body of literature focussing mainly on patient factors. A systematic approach to synthesising existing
literature will be taken 26. The systematic review and evidence synthesis will be updated throughout
the course of the fellowship to ensure all recent evidence is included.
The aim of this phase of the research is to provide an up-to-date understanding of the existing
evidence so that the empirical research phases 2 and 3 can build upon the current knowledge base.
Phase 2: Case studies (months 13-36)
The second phase of the research is a multiple case study design of three emergency departments
with different levels of pain management 27. This will involve a stepped approach, first understanding
case studies in one emergency department with good pain management and an emergency
department with recently improved pain management to identify patient, professional and
organisational factors affecting pain management. Then a further case study of one emergency
department with poorer levels of pain management will be undertaken to identify barriers and examine
the feasibility of introducing successful interventions and facilitators identified within the evidence
synthesis and earlier case studies.
Much of the current literature around factors affecting pain management within the emergency
department is based around research from contexts other than the emergency department. The indepth qualitative approach used in phase 2 is important because it will lead to a knowledge base
grounded in the emergency department. Preliminary literature searches identified gaps in research in
this area and it is hoped that data from the case studies will expand upon existing literature and fill
some of the knowledge gaps in the area.
Identification and recruitment of sites (months 1-12):
The scores relating to pain management for every major adult emergency department in England and
Wales from the Healthcare Commission Emergency Department survey 2004 and 2008 24 will be
obtained from the Care Quality Commission (CQC), either directly from the Picker Institute who ran
the survey or from individual Trust reports that are available on the website. This score was calculated
for patients who were in pain upon their visit to emergency department and is based upon the
responses to questions around time to analgesia and whether patients felt that staff had done
everything they could to control their pain. These will be analysed to create a shortlist of emergency
departments that performed consistently well, consistently poorly and sites that improved significantly
in score over the period 2004-2008.
Sites from each of these groups will be selected and invited to participate in the research, until 3
relevant emergency departments have agreed to participate.
Undertaking case studies
The case studies will involve collecting data from multiple sources: documentation, interviews, focus
groups and direct observation 27. Qualitative interviews and focus groups are essential to
understanding attitudes and processes of pain management from different perspectives.
Observational work will help in understanding the roles of different staff and interactions between staff
and patients, and will complement accounts given by interviewees 28.
Documentation and records pertaining to pain management (e.g. pain management protocols, pain
audits, use of pain measurement tools within notes) will be examined. Each site visit will involve an
initial half-day of general observation to look at how pain is managed, processes and personnel
involved, assessment of the layout of the department and understanding the patient journey for
patients presenting with pain as a key symptom. Any direct observations of staff-staff and patient-staff
interactions relating to pain management within the emergency department will be undertaken with as
little intrusion as possible in order to minimise the impact of observer effect upon the interactions
being observed.
Semi-structured interviews will be carried out with a purposive sample of 8-12 staff at each site,
including senior and junior clinical staff, nursing staff, managers and receptionists. Interviews will
invite respondents to offer their own insights on how pain is managed and prioritised, including
strategies used, barriers and facilitators, and differences between patient groups (e.g. pain due to
fracture, chronic pain). Interviews with a maximum diversity sample of 10-15 patients per site will be
carried out, either within the department directly following their discharge from the emergency
department or by telephone at a later date. Criteria for patient selection will be driven by the findings
of the literature review. These interviews will focus upon the patient’s experience of pain management
and identify barriers or facilitators to pain management perceived by the patient.
Following the interviews further focused observation will be undertaken. Findings about the pain
management within the department will be fed back to a focus group of staff and patient
representatives who will be asked to think about how to improve pain management within their
department. Where interventions felt to be successful are in place (or identified as successful within
the literature), the focus group will be asked to consider what makes these a success and whether the
intervention could be applied to other contexts. In emergency departments where interventions are
not used, or considered not to be working, the focus groups will be asked to consider the feasibility of
implementing or improving interventions identified in the literature and perceived barriers to doing so.
The aim is to conduct case studies first in a department which appears to have good pain
management and those with improved pain scores in order to develop an understanding of what
factors facilitate pain management and factors that have contributed to any improvement. These
ideas will then be explored within focus groups in the site with poorer pain management. Although this
research plans to identify “good” and “poor” departments, it is possible that these labels could turn out
to be inappropriate. The HCC survey may not properly represent pain management, it may be
confounded by other factors such as patient case mix, or it may not reflect the experiences of specific
patient groups. These issues will be explored within interviews.
Data collection will be undertaken over a period of around 6-7 days in each site in total, over 3-4 visits
and will aim to cover a variety of time periods including in-and out of hours and weekends. Qualitative
data will be analysed using framework analysis, including the stages of familiarisation, identification of
a thematic framework, indexing, charting and mapping and interpretation of the data 29. Yin’s
approach to multiple case study analysis will be used 27.
Phase 3: Survey of emergency departments (months 37-48)
A national survey of emergency departments will be undertaken to identify pain management
interventions and strategies in use, the prevalence of factors affecting pain management identified
within phases 1 and 2, the willingness to implement changes shown to be effective, and the barriers
to effecting change.
As well as offering an in-depth understanding of pain management in emergency departments, the
data from the qualitative work will be analysed to generate hypotheses about factors associated with
good pain management and barriers to improving pain management. These data, alongside
information identified from the literature, will be used to develop a questionnaire for use in a survey
testing the prevalence of these issues nationally. This postal survey will be sent out to the clinical lead
in all major emergency departments in England and Wales (n=~200). The survey should achieve a
high response rate (around 70%) with 2 reminder letters and telephone calls to non-responders 30 31.
The department in which this fellowship will be based often undertakes surveys of emergency
departments so the infrastructure required to send out surveys (i.e. database of contact details) is
already in place.
The questionnaire will consist of two parts. The first will ask about the existence of various factors
relevant to pain management. This is likely to include questions around staff and organisational
issues that arise (e.g. education and training in pain management), any interventions used or tested
(e.g. use of pain monitoring tools, protocols) and use and perceptions of facilitators and barriers to
good practice. The survey will seek information on how different subsets of patients are managed in
order to identify areas where there is a need for further specific guidance and where pain
management strategies are lacking. The second part of the survey will seek information on the
willingness to implement changes or interventions identified within phases 1 and 2 and further details
of any barriers to doing this.
This survey will facilitate a greater understanding of factors associated with good pain management
and will provide information as to the variation in how pain is managed between departments. Where
possible, information will be obtained from routine data sources in order to minimise the length of the
questionnaire (e.g. data around factors such as patient casemix, staffing levels etc).
Development of pain management toolkit and proposed outputs (months 49-60)
The findings of the study will be summarised and used to develop a pain management toolkit that will
be distributed to emergency departments to promote good pain management. The main output of the
study will be the impact upon practice and benefit for patients as a result of: identifying methods for
improving pain management that are likely to be feasible and effective; identifying barriers to
improved pain management and ways of overcoming these barriers; an improvement in pain
management and patient experience.
In addition to completing the PhD thesis, the research will also be presented at national and
international conferences and seminars. Further potential publications include:
 updated literature review and evidence synthesis
 qualitative research from the case study sites
 the national survey; the current picture of pain management in emergency department
 a mixed methods publication bringing together the results of all three phases and providing
recommendations for improving practice 32.
It is hoped that the research will identify areas of further research needed in the area of pain
management in the emergency department and provide the basis to apply for funding for developing
and testing an intervention to improve pain management in emergency departments.
Ethical approval (months 1-12)
Ethical approval for undertaking the case studies and survey will be sought from a multicentre
research ethics committee (MREC) at the start of the project. Upon approval from MREC, local
research ethics approval and research governance approval will be sought from sites identified. Due
to the timescales involved in seeking ethical and research governance approval, this will be
undertaken concurrently with the evidence synthesis.
Justification of importance of this research and its relevance to the NHS
This research will provide information on how pain management can be improved within emergency
departments in the NHS and will provide recommendations for overcoming common barriers to
change. Pain management is an important quality indicator and is likely to play a part in performance
indicators for emergency care. This research willl provide important information on the causes of
oligoanalgesia and identify modifiable factors within the NHS and enable emergency departments to
improve their quality of care. The research should generate good practice guidance for emergency
departments and the qualitative case studies may enable emergency departments involved to
improve the priority of pain management within their departments and help to improve their
performance
References
1. Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ 2002: The high prevalence of
pain in emergency medical care. Am J Emerg Med 20:165-169,
2. Todd KH, Ducharme J, Choiniere M et al. Pain in the Emergency Department: results of the Pain
and Emergency Medicine Initiative (PEMI) Multicenter Study. Journal of Pain 2007; 8 (6): 460-466
3. Tanabe P, Buschmann M. A prospective study of ED pain management practices and the patients
perspective. J Emerg Nurs 1999; 25(3): 171-7
4. Middleton C. Understanding the physiological effects of unrelieved pain. Nurs Times 2003; 99(37):
28-31
5Johnson SH. Pain management in the Emergency Department: current landscape and agenda for
research. J Law Med Ethics, 2005; 33(4):739-40
6. Johnson SH. The Social, Professional and Legal Framework for the Problem of Pain Management
in Emergency Medicine. J Law Med Ethics, 2005; 33(4)
7. British Association for Emergency Medicine. Clinical Effectiveness Committee Guideline for the
Management of Pain in Adults. London, 2007.
8. Welch SJ Twenty years of patient satisfaction research applied to the emergency department: a
qualitative review. Am J Med Qual 2010; 25 (1): 64-72
9. Muntlin A, Carlsson M, Gunningberg L. Barriers to change hindering quality improvement: the
reality of emergency care. J Emerg Nurs 2010; 36: 317-23
10. Rupp T, Delaney KA. Inadequate analgesia in Emergency Medicine. Ann Emerg Med 2004; 43:
494-503
11. Fosnocht DE, Swanson ER, Barton ED. Changing attitudes about pain and pain control in
emergency medicine. Emerg Med Clin North Am. 2005;23:297-306.
12. Decosterd I, Hugli O, Tamches E et al. Oligoanalgesia in the Emergency Department: Short-Term
Beneficial Effects of an Education Program on Acute Pain. Ann Emerg Med 2007; 50(4): 463-71
13. Todd KH, Sloan EP, Chen C et al. Survey of pain etiology, pain management practices and
patient satisfaction in two urban emergency departments. Can J Emerg Med 2002; 4(4): 252-6
14. Pocock N, Healthcare Commission 2008 Emergency Survey. NELM news service.
http://www.nelm.nhs.uk/en/NeLM-Area/News/2009---January/14/Healthcare-Commission-2008emergency-department-survey
15. Arendts G, Fry M. Factors associated with delay to opiate analgesia in Emergency Departments.
Journal of Pain 2006; 7(9): 682-686
16. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department
analgesia. Am J Emerg Med 1996; 14:157-60.
17. Rafferty KA, Smith-Coggins R, Chen AHM. Gender-associated differences in emergency
department pain management. Ann Emerg Med 1995; 26:414-21
18. Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency department: Efficacy,
rate of adverse events and impact on time to analgesia. Emerg Med 2002; 14:249-254
19. Kelly A-M. A process approach to improving pain management in the emergency department:
development and evaluation. J Accid Emerg Med 2000: 17:185-187
20. Wilsey BL, Fishman SM, Crandall M et al. A qualitative study of the barriers to chronic pain
management in the ED. Am J Emerg Med 2008; 26:255-63
21. Evans E, Turley N, Robinson N et al. Randomised controlled trial of patient controlled analgesia
compared with nurse delivered analgesia in the emergency department. EMJ 2005; 22:25-29
22. Joint Commission on the Accreditation of Healthcare Organizations, “Standards, Intents,
Examples and Scoring Questions for Pain Assessment and Management”. In: Comprehensive
Accreditation Manual for Hospitals. JCAHO Department of Standards, 1999 Oakbrook terrace, Illinois.
23. Ducharme J. Clinical Guidelines and Policies: Can they improve Emergency Department pain
management? J Law Med Ethics. 2005
24. Healthcare Commission National NHS Patient Survey. Emergency Department 2008. Available at:
http://www.cqc.org.uk/_db/_documents/Full_national_results_with_historical_comparisons.pdf
25. Hew, R. Personal communication 2010.
26. Pope C, Mays N, Popay J. Synthesizing qualitative and quantitative health evidence. 2007,
Maidenhead, England. Open University Press, McGraw-Hill Education.
27. Yin RK. Case study research design and methods. (3rd ed.). 2003. Thousand Oaks, CA: Sage.
28. Pope C, Mays N. Qualitative research in health care. (3rd Ed). 2006. Oxford: Blackwell publishing
group.
29. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman, Burgess,
editors. Analysing qualitative data. London: Routledge, 1994: 173-194
30. Jones LA and Goodacre S. Magnesium sulphate in the treatment of acute asthma: evaluation of
current practice in adult emergency departments. EMJ J 2009; 26(11):783-5
31. Sampson F, Goodacre S, Kelly A-M, Kerr D. How is DVT diagnosed and managed in UK and
Australian emergency departments? EMJ 2005; 22:780-782
32.O’Cathain A, Murphy E, Nicholl J. Three techniques for integrating data in mixed methods studies.
BMJ 2010; 341: 1147-1150