Gregory Garra

Validation of the Wong‐Baker FACES Pain Rating Scale in Pediatric Emergency Department Patients

OBJECTIVES The Wong-Baker FACES Pain Rating Scale (WBS), used in children to rate pain severity, has been validated outside the emergency department (ED), mostly for chronic pain. The authors validated the WBS in children presenting to the ED with pain by identifying a corresponding mean value of the visual analog scale (VAS) for each face of the WBS and determined the relationship between the WBS and VAS. The hypothesis was that the pain severity ratings on the WBS would be highly correlated (Spearmans rho > 0.80) with those on a VAS. METHODS This was a prospective, observational study of children ages 8-17 years with pain presenting to a suburban, academic pediatric ED. Children rated their pain severity on a six-item ordinal faces scale (WBS) from none to worst and a 100-mm VAS from least to most. Analysis of variance (ANOVA) was used to compare mean VAS scores across the six ordinal categories. Spearmans correlation (rho) was used to measure agreement between the continuous and ordinal scales. RESULTS A total of 120 patients were assessed: the median age was 13 years (interquartile range [IQR] = 10-15 years), 50% were female, 78% were white, and six patients (5%) used a language other than English at home. The most commonly specified locations of pain were extremity (37%), abdomen (19%), and back/neck (11%). The mean VAS increased uniformly across WBS categories in increments of about 17 mm. ANOVA demonstrated significant differences in mean VAS across face groups. Post hoc testing demonstrated that each mean VAS was significantly different from every other mean VAS. Agreement between the WBS and VAS was excellent (rho = 0.90; 95% confidence interval [CI] = 0.86 to 0.93). There was no association between age, sex, or pain location with either pain score. CONCLUSIONS The VAS was found to have an excellent correlation in older children with acute pain in the ED and had a uniformly increasing relationship with WBS. This finding has implications for research on pain management using the WBS as an assessment tool.

Triage Pain Scores and the Desire for and Use of Analgesics

STUDY OBJECTIVE Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them. METHODS We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics. RESULTS We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics. CONCLUSION Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.

The Wong-Baker pain FACES scale measures pain, not fear.

Objective The Wong-Baker FACES Pain Rating Scale (WBS) is preferred by parents and patients for reporting pain severity. However, it is speculated that the “no hurt” and “hurts worst” anchors confound pain measurement with nonnociceptive states. The objective of our study was to determine if fear confounds reporting of pain severity on the WBS. We hypothesized that the WBS would correlate with a psychometrically different pain severity scale (the visual analog scale [VAS]) and not correlate with a fear measure, the Child Medical Fear Scale (CMFS). Methods This was a prospective observational study of children 7 to 12 years presenting to a university-based suburban pediatric ED with acute pain. Patients rated pain severity on the WBS ordinal scale and a 100-mm unhatched VAS with marked end points of “no pain” and “worse pain ever.” Patients also completed a 26-item CMFS. Correlations between the WBS and VAS with the CMFS total score were assessed with Spearman correlation and exploratory factor analysis. Results All 3 scales were completed in 197 children. Correlation between the severity scales (WBS-VAS) was moderate: 0.63 (95% confidence interval [CI], 0.54–0.71). However, correlations between the WBS-CMFS and VAS-CMFS were poor: −0.02 (95% CI, −0.16 to −0.12) and 0.01 (95% CI, −0.13 to 0.15), respectively. Correlations did not differ by sex, grade, pain location, or cause of pain (traumatic vs atraumatic). Exploratory factor analysis demonstrated excellent loadings within 2 factors: pain and fear. Conclusions The WBS demonstrates moderate correlation with another measure of pain (VAS) and is not mistaken for fear among school-aged patients presenting to the ED with pain.

Heat or Cold Packs for Neck and Back Strain: A Randomized Controlled Trial of Efficacy

OBJECTIVES Acute back and neck strains are very common. In addition to administering analgesics, these strains are often treated with either heat or cold packs. The objective of this study was to compare the analgesic efficacy of heat and cold in relieving pain from back and neck strains. The authors hypothesized that pain relief would not differ between hot and cold packs. METHODS This was a randomized, controlled trial conducted at a university-based emergency department (ED) with an annual census of 90,000 visits. ED patients >18 years old with acute back or neck strains were eligible for inclusion. All patients received 400 mg of ibuprofen orally and then were randomized to 30 minutes of heating pad or cold pack applied to the strained area. Outcomes of interest were pain severity before and after pack application on a validated 100-mm visual analog scale (VAS) from 0 (no pain) to 100 (worst pain), percentage of patients requiring rescue analgesia, subjective report of pain relief on a verbal rating scale (VRS), and future desire for similar packs. Outcomes were compared with t-tests and chi-square tests. A sample of 60 patients had 80% power to detect a 15-mm difference in pain scores. RESULTS Sixty patients were randomized to heat (n = 31) or cold (n = 29) therapy. Mean (+/-standard deviation [SD]) age was 37.8 (+/-14.7) years, 51.6% were female, and 66.7% were white. Groups were similar in baseline patient and pain characteristics. There were no differences between the heat and cold groups in the severity of pain before (75 mm [95% CI = 66 to 83] vs. 72 mm [95% CI = 65 to 78]; p = 0.56) or after (66 mm [95% CI = 57 to 75] vs. 64 mm [95% CI = 56 to 73]; p = 0.75) therapy. Pain was rated better or much better in 16/31 (51.6%) and 18/29 (62.1%) patients in the heat and cold groups, respectively (p = 0.27). There were no between-group differences in the desire for and administration of additional analgesia. Twenty-five of 31 (80.6%) patients in the heat group and 22 of 29 (75.9%) patients in the cold group would use the same therapy if injured in the future (p = 0.65). CONCLUSIONS The addition of a 30-minute topical application of a heating pad or cold pack to ibuprofen therapy for the treatment of acute neck or back strain results in a mild yet similar improvement in the pain severity. However, it is possible that pain relief is mainly the result of ibuprofen therapy. Choice of heat or cold therapy should be based on patient and practitioner preferences and availability.

Patients overwhelmingly prefer inpatient boarding to emergency department boarding.

BACKGROUND Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow. OBJECTIVE Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways. METHODS We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data. RESULTS Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED. CONCLUSIONS Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.

Feasibility and reliability of a multisource feedback tool for emergency medicine residents.

BACKGROUND While the Accreditation Council for Graduate Medical Education recommends multisource feedback (MSF) of resident performance, there is no uniformly accepted MSF tool for emergency medicine (EM) trainees, and the process of obtaining MSF in EM residencies is untested. OBJECTIVE To determine the feasibility of an MSF program and evaluate the intraclass and interclass correlation of a previously reported resident professionalism evaluation, the Humanism Scale (HS). METHODS To assess 10 third-year EM residents, we distributed an anonymous 9-item modified HS (EM-HS) to emergency department nursing staff, faculty physicians, and patients. The evaluators rated resident performance on a 1 to 9 scale (needs improvement to outstanding). Residents were asked to complete a self-evaluation of performance, using the same scale. ANALYSIS Generalizability coefficients (Eρ(2)) were used to assess the reliability within evaluator classes. The mean score for each of the 9 questions provided by each evaluator class was calculated for each resident. Correlation coefficients were used to evaluate correlation between rater classes for each question on the EM-HS. Eρ(2) and correlation values greater than 0.70 were deemed acceptable. RESULTS EM-HSs were obtained from 44 nurses and 12 faculty physicians. The residents had an average of 13 evaluations by emergency department patients. Reliability within faculty and nurses was acceptable, with Eρ(2) of 0.79 and 0.83, respectively. Interclass reliability was good between faculty and nurses. CONCLUSIONS An MSF program for EM residents is feasible. Intraclass reliability was acceptable for faculty and nurses. However, reliable feedback from patients requires a larger number of patient evaluations.

Pretreatment of Patients Requiring Oral Contrast Abdominal Computed Tomography With Antiemetics: A Randomized Controlled Trial of Efficacy

STUDY OBJECTIVE Ingestion of diatrizoate meglumine before abdominal computed tomography (CT) is time consuming. We hypothesized that pretreatment with metoclopramide or ondansetron would result in faster ingestion of diatrizoate meglumine than placebo. METHODS The study was a double-blind, randomized controlled trial on adults requiring oral contrast abdominal CT. Patients were randomized to placebo, metoclopramide 10 mg, or ondansetron 4 mg intravenously 15 minutes before ingesting 2 L of diatrizoate meglumine. The primary outcome was time to complete diatrizoate meglumine ingestion. Secondary outcome measures included volume of diatrizoate meglumine ingested, 100-mm visual analog scale for nausea at 15-minute intervals, time to CT, vomiting, and use of rescue antiemetics. The study was powered to detect a 60-minute difference in diatrizoate meglumine ingestion time between saline and medication groups. RESULTS One hundred six patients were randomized; placebo (36), metoclopramide (35), and ondansetron (35). Groups were similar in baseline characteristics. Median (interquartile range) times for diatrizoate meglumine ingestion were placebo 109 minutes (82 to 135 minutes); metoclopramide 105 minutes (75 to 135 minutes); and ondansetron 110 minutes (79 to 140 minutes) (P=.67). Vomiting was less frequent with metoclopramide (3%) than placebo (18%) or ondansetron (9%) (P=.11). The visual analog scale for nausea at each point was not significantly different between groups (P=.11). The need for rescue antiemetics was lowest for metoclopramide (3%) compared with placebo (27%) and ondansetron (12%) (P=.02). CONCLUSION Pretreatment with ondansetron or metoclopramide does not reduce oral contrast solution ingestion time.

Changes in practice patterns with the opening of a dedicated pediatric emergency department.

ObjectivesDedicated pediatric emergency departments (ED) staffed by pediatric emergency medicine physicians are becoming more common. We compared processes of care and outcomes before and after opening a dedicated pediatric ED. MethodsA before and after trial design was used to estimate whether there were any changes in ordering of laboratory tests, radiographic imaging, admission rates, ED length of stay (LOS), rates of left without being seen (LWBS) and patient satisfaction scores after opening a dedicated pediatric ED staffed by pediatric emergency medicine physicians. ResultsThere were 34,961 pediatric patients; 16,311 (47%) presented before and 18,650 (53%) after opening the pediatric ED. Overall radiologic imaging decreased (42.5% vs. 39.3%; difference, 3.2%; 95% confidence interval [95% CI], 2.1%–4.2%) as did computed tomography (8.9% vs. 7.6%; difference, 1.2%; 95% CI, 0.7%–1.8%) but not magnetic resonance imaging. Laboratory testing decreased from 33.1% to 30.1% (difference, 3%; 95% CI, 2.1%–4.0%) of patients. Mean [SD] ED LOS (3.1 [2.5] vs. 2.8 [2.2] hours; difference, 0.36; 95% CI, 0.31–0.41) as well as the rate of LWBS (1.0% vs. 0.6%; difference, 0.4%; 95% CI, 0.2%–0.5%) also decreased. Admission rates (9.4% vs. 9.4%) and unscheduled return visits within 72 hours (3.2% vs. 3.5%) were unchanged. Mean (SD) monthly satisfaction scores increased from 81.3 (2.2) to 86.3 (2.2) (difference, 5; 95% CI, 3%–7%). ConclusionsOpening of a pediatric ED with pediatric emergency physicians was associated with decreases in ED LOS, rates of LWBS, general radiographic, and computed tomography imaging as well as laboratory testing, and increases in patient satisfaction scores. The clinical significance of these changes is unclear.