Jorien Pierik

Pain Management in the Emergency Chain: The Use and Effectiveness of Pain Management in Patients with Acute Musculoskeletal Pain

OBJECTIVE While acute musculoskeletal pain is a frequent complaint in emergency care, its management is often neglected, placing patients at risk for insufficient pain relief. Our aim is to investigate how often pain management is provided in the prehospital phase and emergency department (ED) and how this affects pain relief. A secondary goal is to identify prognostic factors for clinically relevant pain relief. DESIGN This prospective study (PROTACT) includes 697 patients admitted to ED with musculoskeletal extremity injury. Data regarding pain, injury, and pain management were collected using questionnaires and registries. RESULTS Although 39.9% of the patients used analgesics in the prehospital phase, most patients arrived at the ED with severe pain. Despite the high pain prevalence in the ED, only 35.7% of the patients received analgesics and 12.5% received adequate analgesic pain management. More than two-third of the patients still had moderate to severe pain at discharge. Clinically relevant pain relief was achieved in only 19.7% of the patients. Pain relief in the ED was higher in patients who received analgesics compared with those who did not. Besides analgesics, the type of injury and pain intensity on admission were associated with pain relief. CONCLUSIONS There is still room for improvement of musculoskeletal pain management in the chain of emergency care. A high percentage of patients were discharged with unacceptable pain levels. The use of multimodal pain management or the implementation of a pain management protocol might be useful methods to optimize pain relief. Additional research in these areas is needed.

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury

Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment.

Painful Discrimination in the Emergency Department: Risk Factors for Underassessment of Patients’ Pain by Nurses

Introduction: Unrelieved acute musculoskeletal pain continues to be a reality of major clinical importance, despite advancements in pain management. Accurate pain assessment by nurses is crucial for effective pain management. Yet inaccurate pain assessment is a consistent finding worldwide in various clinical settings, including the emergency department. In this study, pain assessments between nurses and patients with acute musculoskeletal pain after extremity injury will be compared to assess discrepancies. A second aim is to identify patients at high risk for underassessment by emergency nurses. Methods: The prospective PROTACT study included 539 adult patients who were admitted to the emergency department with musculoskeletal pain. Data on pain assessment and characteristics of patients including demographics, pain, and injury, psychosocial, and clinical factors were collected using questionnaires and hospital registry. Results: Nurses significantly underestimated patients’ pain with a mean difference of 2.4 and a 95% confidence interval of 2.2‐2.6 on an 11‐points numerical rating scale. Agreement between nurses’ documented and patients’ self‐reported pain was only 27%, and 63% of the pain was underassessed. Pain was particularly underassessed in women, in persons with a lower educational level, in patients who used prehospital analgesics, in smokers, in patients with injury to the lower extremities, in anxious patients, and in patients with a lower urgency level. Discussion: Underassessment of pain by emergency nurses is still a major problem and might result in undertreatment of pain if the emergency nurses rely on their assessment to provide further pain treatment. Strategies that focus on awareness among nurses of which patients are at high risk of underassessment of pain are needed.

Hartpatiënt moet meer weten over alarmsymptomen

SamenvattingInleiding Patiënten met symptomen van een acuut coronair syndroom (ACS) hebben zo snel mogelijk de juiste behandeling nodig om schade aan het hart te voorkomen of te beperken. Hoewel er veel onderzoek is gedaan naar prehospitale vertraging en de oorzaken daarvan, is er weinig bekend over de motivatie van de patiënt voor het kiezen van een keteningang. Het doel van dit onderzoek is het vinden van factoren die invloed hebben op deze keuze.Methode We deden een explorerend dwarsdoorsnedeonderzoek, waarbij we met een vragenlijst gegevens verzamelden van 67 ACS-patiënten.Resultaten Patiënten kregen toegang tot de acute zorgketen via vier verschillende ingangen: de huisarts (43%), de huisartsenpost (28%), de meldkamer ambulancezorg (112) (21%) of de spoedeisende hulp (7%). De overtuiging van patiënten dat hun huisarts het beste weet wat ze nodig hebben maakte dat ze vaker contact zochten met hun eigen huisarts. Dit deden ook de patiënten die alleen waren toen de symptomen ontstonden. Patiënten met een fast onset van de klachten en acute pijn belden vaker 112, net als patiënten die hun klachten als ernstig inschatten.Conclusie Niet de kennis over alarmsymptomen, maar vooral subjectieve factoren, zoals de interpretatie van de ernst van de klachten, de overtuigingen van de patiënt over wie de juiste zorgverlener is, en de manier (plotseling, pijn) waarop de klachten zich voordoen zijn bepalend voor de keuze van de keteningang bij patiënten met ACS-klachten. Voor het reduceren van prehospitale vertraging kunnen huisartsen een rol spelen door patiënten de juiste voorlichting te geven.