Pain Management in Patients with Acute Musculoskeletal Pain

Pain Medicine 2015; 16: 970–984 Wiley Periodicals, Inc. MUSCULOSKELETAL SECTION Original Research Article Pain Management in the Emergency Chain: The Use and Effectiveness of Pain Management in Patients with Acute Musculoskeletal Pain Jorien G.J. Pierik, MSc,* Maarten J. IJzerman, PhD,* Menno I. Gaakeer, MD,† Sivera A. Berben, PhD,‡,§ Fred L. van Eenennaam, MD,¶,** Arie B. van Vugt, MD, PhD,†† and Carine J.M. Doggen, PhD* *Health Technology & Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede; † Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes; ‡Regional Emergency Healthcare Network, Radboud University Nijmegen, Nijmegen; § Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen; ¶ Ambulance Oost, Hengelo; **Anesthesiology, Ziekenhuisgroep Twente, Almelo; ††Emergency Department and Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands Reprint requests to: Carine J.M. Doggen, PhD, University of Twente, MB-HTSR, Drienerlolaan 5, P.O. Box 217, 7522 NB Enschede, The Netherlands. Tel: 0031 53 438 5410; Fax: 0031 53 489 2159; E-mail: c.j.m.doggen@utwente.nl Conflicts of interest: The authors declare that there is no conflict of interest. Abstract 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. 970 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. Pain Management in Patients with Acute Musculoskeletal Pain

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. Key Words. Acute Musculoskeletal Pain; Chain of Emergency Care; Emergency Department; Clinically Relevant Pain Relief; Analgesics; Ambulance Background Acute pain is a frequent complaint of patients requiring emergency medical care. In many patients, pain is the primary motive for visiting the emergency department (ED). Previous studies have shown that 61 to 91% of patients visiting the ED have a chief complaint related to pain [1–6]. Although pain is acknowledged as a major public health issue, the gap between the increasing knowledge of pain, Acute Pain Management in Musculoskeletal Patients treatment and the effective application of it is large [7]. The term “oligoanalgesia,” introduced in 1989, has been used to describe the phenomenon of poor pain management in the ED through the underuse of analgesics [8]. Acute pain in EDs appears undertreated worldwide which is reflected by the high prevalence of severe pain at discharge and the low percentage of patients receiving analgesics while in pain [1–3,5,6,8–15]. Previous studies have found that the proportion of adults receiving analgesics for painful conditions, such as musculoskeletal trauma, ranged between 11 and 64% [1,8–11,13,14]. Moreover, the percentage of patients discharged with severe pain ranged from 11 to 29% [1,5,6]. Despite substantial advances in pain research over the last decades acute pain management is still often neglected, placing patients at risk for oligoanalgesia [1,13,15]. In the Netherlands, musculoskeletal injury has a high incidence of approximately 20% each year, and more than one-quarter of these patients visits the ED [16]. Patients presenting with acute musculoskeletal pain to the ED are usually triaged to a low triage category which typically results in an extended waiting time for pain relief or oligoanalgesia [17]. A review shows that patient’s pain experience is often underestimated [18]; for example, nurses underestimate the pain intensity of musculoskeletal pain in 95% of the patients [19]. As a result, insufficient pain relief occurs frequently [1,8], especially in patients with fractures [1,9,10,20]. Early and effective pain treatment is important to reduce both short-term and long-term consequences of acute pain. Patients become increasingly more sensitive to painful stimuli if the pain is uncontrolled for a longer period of time [21]. Therefore, treatment of moderate to severe pain should be a priority when a patient came to the ED. Moreover, adequate pain management leads to earlier mobilization, faster rehabilitation and possibly earlier discharge from the hospital [22]. Inadequate pain management is likely to result in decreased productivity and diminished patients’ quality of life [22]. In addition, oligoanalgesia is a risk factor for the development of chronic pain [23,24]. Although the importance of timely pain management is acknowledged, it is also recognized that there are barriers to effective pain relief in emergency patients [25]. The right type of analgesic at an adequate dose at the right moment is necessary to successfully reduce pain. In addition, it is relevant to know if any and which type of pain management was provided in the prehospital phase to provide sufficient pain management in the ED and to optimize pain management in the chain of emergency care. The aims of this study are to investigate how often and which type of pain management is used in patients with musculoskeletal extremity injury presented in emergency care including the prehospital phase and ED. Pain Management in Patients with Acute Musculoskeletal Pain

The second objective is to explore the effectiveness and adequacy of pain management in the ED with an emphasis on a clinically relevant reduction in pain. Finally, prognostic factors for clinically relevant pain relief will be identified. Knowledge of these prognostic factors may help physicians explore ways to overcome barriers to properly provide analgesia in patients with musculoskeletal extremity injury. Patients and Methods Study Design and Setting This study is part of a 1-year prospective follow-up study; the “PROgnostic factors for the Transition from Acute to Chronic pain in Trauma patients” (PROTACT). Adult patients with musculoskeletal extremity injury attending the ED of the level one trauma centre Medisch Spectrum Twente in Enschede, The Netherlands, were invited to participate. The ED of Medisch Spectrum Twente is a 24 hours a day, 7 days a week ED (24/7 ED). The catchment area for ED is about 264,000 individuals and the ED service treats approximately 27,000 patients annually. Ethical approval for this study was obtained from the regional Medical Research Ethics Committee on Research Involving Human Subjects (CCMO no. NL368.38044.11). All participants provided written informed consent. Study Population Eligible patients were consecutively recruited for the study when admitted to the ED during a 22 month period from September 2011 until July 2013. Inclusion criteria for participation were: i) patients who had musculoskeletal extremity injury caused by blunt trauma; ii) patients who had sufficient communication skills and a basic knowledge of the Dutch language; and iii) patients aged between 18 and 70 years. Exclusion criteria were: i) patients with life or limb threatening conditions; ii) patients with multiple trauma; iii) patients with documented cognitive disability; iv) patients suffering from hallucinations, delusions or suicidal ideation; v) patients with alcohol or drugs intoxication; and vi) patients who were living outside the “catchment area” served by the hospital. For the purpose of this study, we excluded patients who did not provide pain scores both on admission and at discharge. Pain Management in Patients with Acute Musculoskeletal Pain

Procedures and Data Sources Patients admitted to the ED who met the study criteria were informed by a (triage) nurse about the purpose of the study. Those who agreed to participate were asked to provide informed consent and to complete a questionnaire. The questionnaire and informed consent sheet were returned to either a mailbox in the waiting room or sent by ordinary mail. Eligible patients who were not invited by the nurse to participate received an invitation and questionnaire by mail within 1 week of the ED visit. The questionnaire included a validated tool to measure pain intensity and questions about sociodemographic data, pain management, and time between injury and ED admission. In addition to the data obtained from the questionnaire, data from the ED electronic patient registration system were used. The registry is a fully electronic 971 Pierik et al. emergency medical record registry where each entry, order, or activity is automatically time-stamped for prespecified ED events. The registry includes patient demographics (date of birth, sex), referrer, triage urgency level, triage pain score, type of analgesics, medical diagnoses (e.g., injury type and location), type of nonpharmacological pain management, time of providing pain management, and refusal to use analgesics. If patients arrived by ambulance, additional data regarding the use and type of analgesics in the ambulance were retrieved from the registry of the regional emergency medical services (EMS). Measures and Definitions Pain Intensity Pain intensity was measured in the questionnaire using the numerical rating scale (NRS). The NRS of acute pain was validated for use in the ED [26–29] and retrospective 1-week recall of pain intensity was reliable and valid [30,31]. Patients were asked to fill in a number from 0 to 10 to represent their pain severity, where 0 is “no pain” and 10 “the worst pain imaginable” in response to the questions: “How severe was your pain on ED admission?” and “How severe was your pain at ED discharge?”. NRS scores were converted to the categorical groups of i) no pain (NRS 0); ii) minimal pain (NRS 1-2); iii) mild pain (NRS 3-4); iv) moderate pain (NRS 5-6); v) severe pain (NRS 7-8); and vi) very severe pain (NRS 9-10). WHO guidelines and orginally designed for cancer pain management and has been used in other pain studies, including acute pain in patients visiting the ED [15,32–34]. The PMI is considered a valid and reliable measure for pain management [35].

The analgesics score was calculated based on the analgesics provided in the ED. No pain medication was scored as “0,” nonopioids as “1,” mild opioids as “2,” and major opioids as “3.” For patients who received more than one type of analgesic, the most potent analgesic as per PMI definition was used. The pain intensity score for PMI was calculated using NRS on ED admission as reported by the patient. A pain intensity score of “0” was defined as no pain (NRS 0), “1” minimal and mild pain (NRS 1–4), “2” moderate pain (NRS 5-6) and “3” severe and very severe pain (NRS 7–10). The PMI was calculated by substracting the pain intensity score from the analgesic score. Possible scores ranged from 23 to 13. Patients with negative PMI scores were classified as receiving inadequate analgesics management. Duration of ED Stay The duration patients were in the ED was obtained from the ED patient registry.

Time in the ED represents the time recorded from ED admission to ED discharge and was reported in minutes. Nonpharmacological Treatment in ED Analgesics Administered or Self-Initiated Intake in Prehospital Phase Data regarding the use and type of analgesics in prehospital phase were collected by questionnaires and retrieved from the registry of the regional EMS. In the questionnaire, the patient could indicate if any type of analgesics was taken on his or her own initiative or was given by a health professional such as a general practitioner (GP), before attending the ED. Analgesics Administered in the ED The type of analgesic administered in the ED was obtained directly from the ED patient registry. Analgesics administered (if any) were categorized as follows: i) no analgesics; ii) nonopioids such as paracetamol (acetaminophen) or nonsteriodal antiinflammatory drug (NSAID); iii) mild opioids such as codeine and tramadol; and iv) major opioids such as morphine and fentanyl.

Adequate Analgesic Pain Management in ED The pain management index (PMI) combines an analgesics score and a pain intensity score to determine adequacy of pain management. The PMI is based on the 972 Data regarding type of nonpharmacological treatment were obtained from the ED patient registry and were categorized as follows: i) no pain treatment; ii) immobilization; iii) reposition; iv) compression; v) coldpack; and vi) others. Clinically Relevant Pain Relief Clinically relevant pain relief for acute pain was defined as 33% or more decrease in pain intensity [36]. The relation between demographic factors (sex and age), pain characteristics (pain intensity on admission), pain management characteristics (analgesics or nonpharmacological pain management in the ED, analgesic use in prehospital phase and the duration of ED stay) and injury related characteristics (type of injury, urgency level), were investigated to identify their association with clinically relevant pain relief. Data Analysis Descriptive data are presented as means with standard deviations (SD) or 95% confidence intervals (CIs) for differences in continuous variables as medians with interquartile ranges (IQR, 25th–75th percentile) for time variables and as frequencies for categorical variables. Pain intensity differences were calculated by subtracting the pain score at discharge from the pain score on admission. In addition, to determine the percentage of reduction this pain intensity Acute Pain Management in Musculoskeletal Patients Table 1 Characteristics of 697 patients with acute musculoskeletal trauma Age, median (IQR) Gender, women, N (%) Time in ED, median (IQR) Pain on admission, N (%) Pain intensity score on admission, mean (SD) Pain at discharge, N (%) Pain intensity score at discharge, mean (SD) Documented pain intensity score at triage, mean (SD) Injury type, N (%) Fracture Dislocation Sprains & strains Contusion Muscle rupture 47.2 (30.7–58.1) 391 (56.1%) 100 min (72–143) 689 (98.9%) 6.5 (2.4) 682 (97.7%) 5.6 (2.5) 4.0 (1.4)* 489 (70.2%) 33 (4.7%) 89 (12.8%) 69 (9.9%) 17 (2.4%) *5 9 missings difference was divided by the pain score on admission.

Pain intensity differences between the different approaches to pain management were analysed using two-tailed Student’s t test and mean differences with corresponding 95% CIs were calculated. A P value <0.05 is considered statistically significant. Boxplots were used to give a graphical representation of the association between the type of pain management and the type of analgesics, and the pain intensity difference between admission and discharge. Univariate and multivariate analyses were performed to identify prognostic factors for the dichotomous outcome variable clinically relevant pain relief. Associations between categorical variables and the outcome variable were investigated using chi-squared tests. Odds ratios (ORs) and corresponding 95% CIs were calculated and interpreted as the relative risk of the presence of a potential risk prognostic factor for clinical relevant pain relief compared with the absence of risk prognostic factor (reference group). Because preselection of prognostic factor based on P values estimated from univariate analyses may result in unstable prediction models [37], all candidate prognostic factors were considered in the multivariate analysis. Backward stepwise selection of all candidate variables was applied using the likelihood ratio test with a P value of 0.157 according to Akaike’s Information Criterion. Adjusted Odds Ratios (ORadj) and corresponding 95% CIs were calculated. All data were analysed using SPSS version 21.0 (IBM Corporation, Armonk, NY). Results Patient Characteristics and Pain Intensity Overall, 1994 adult patients with musculoskeletal extremity injury caused by blunt trauma met the inclusion criteria. Written informed consent and questionnaires were obtained from 803 patients of whom 697 patients filled in both pain scores on admission and at discharge. Distribution of age and sex among the nonresponders was not significantly different from the participating patients. Median age of the 697 patients was 47.2 years (IQR 30.7– 58.1) and 56.1% were women (Table 1). A fracture was the most common reason for admission (70.2%). Patients reported a high frequency of pain, both on admission (98.9%) and at discharge (97.7%). Overall, the mean selfreported pain intensity score changed from 6.50 on admission to 5.64 at discharge (difference 0.86; 95% CI 0.71– 0.99). Figure 1 shows the percentage of patients with pain Figure 1 The percentages of patients with reported pain levels at discharge by pain intensity on admission. 973 Pierik et al.

Figure 2 Percentage of patients with type of pain management provided in the ED by pain intensity on admission. levels at discharge within pain intensity categories on admission. Overall, 560 out of 697 (80.3%) patients had moderate to severe pain on admission and, more than two-third of the patients (67.6%) had moderate to severe pain at discharge. they received analgesics. Yet, the patients who used analgesics in prehospital phase (n 5 278) had a higher mean pain score of 7.00 on admission compared with 6.17 for those patients not taking analgesics (difference of 0.82; 95%CI 0.47–1.18). Type of Pain Management in ED Overall, 609 out of the 697 patients (87.4%) received pain management in ED. Most patients (n 5 360) received nonpharmacological treatment only, 59 patients received analgesics only, and 190 patients a combination of both nonpharmacological treatment and analgesics.

Figure 2 shows the percentage and type of pain management that was provided to patients in the ED according to their pain intensity on admission. The percentage of patients who received analgesics, with or without nonpharmacological treatment, increased when pain was more severe from 0% (no pain) to 72% (very severe pain). Analgesics Use in the Chain of Emergency Care Figure 3 gives an overview of the analgesic use in the chain of emergency care. Patients came to the ED by four different routes. Overall, 278 out of the 697 patients (39.9%) used one or more analgesics in the prehospital phase. A high percentage of patients (41.6%) was self-referred and 20.7% of these self-referrals did use analgesics before attending the ED. This percentage is somewhat lower than the overall of 25.1% of patients who self-initiated the intake of analgesics, mostly the nonopioid paracetamol. Of the 337 patients who visited a GP or other health professional before attending the ED, 58 patients (17.2%) received analgesics, mostly the nonopioid paracetamol. Out of the 279 patients who did not receive analgesics, 102 patients (32.6%) had already taken analgesics themselves. For 50 out of the 337 patients (14.8%) the GP was the first link in the chain where they … Pain Management in Patients with Acute Musculoskeletal Pain