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

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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.

Section snippets

Study design and setting

This study is part of a prospective follow-up study; the “PROgnostic factors for the Transition from Acute to Chronic pain in Trauma patients” (PROTACT). The PROTACT study includes adult patients with isolated musculoskeletal extremity injury who attended the emergency department of Medisch Spectrum Twente in Enschede, The Netherlands. This 24/7 emergency service is accessible for 264,000 persons in the Twente region and treats approximately 27,000 patients annually. This study was approved by

Patients’ characteristics

Between September 2011 and July 2013, a total of 803 adult patients with isolated musculoskeletal extremity injury provided written informed consent. Data for 541 patients who filled in both the ED and follow-up questionnaire were used for analyses. For 2 patients, the nurse’s pain score was not registered and therefore those patients were excluded from analyses. The median age of the 539 patients was 45.9 years (interquartile range 33.9-59.2), and 57.9% were women (Table 1). Pain prevalence at

Discussion

Assessment of pain is difficult because pain is a highly subjective and personal experience, which is hardly clinically measurable with objective criteria. In the PROTACT study, nurses significantly underassessed patient’s pain with a mean difference of 2.4 on an 11-points NRS. More important than a statistical significant difference between both assessments is the issue of clinical relevant difference. Earlier findings have demonstrated that a difference of 33% in acute pain scores is

Implications for Emergency Nurses

Knowing which factors can increase risk for discrepancies in pain assessment is a necessary first step toward optimizing pain management and pain relief. Nurses should be aware in which patients they usually underassess the pain. Underestimation of patients’ pain can have negative effects if appropriate treatment is withheld, not only in terms of patient suffering, but unrelieved pain may also lead to adverse physiological effects such as cardiovascular side effects and negative effects on

Acknowledgments

We gratefully acknowledge the nurses and staff, especially A. Christenhusz and M. Poessé- Vennevertloo, in the emergency department of Medisch Spectrum Twente, for their assistance, and we thank patients for participating in the PROTACT-study. Furthermore, we acknowledge the contribution of Ambulance Oost, especially J. Legebeke and F. van Eenennaam, for providing data from the ambulance emergency medical services.

Jorien G.J. Pierik is Researcher, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands, and Policy Advisor, Regional Network for Emergency Care, Acute Zorg Euregio, Enschede, the Netherlands.

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    Jorien G.J. Pierik is Researcher, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands, and Policy Advisor, Regional Network for Emergency Care, Acute Zorg Euregio, Enschede, the Netherlands.

    Maarten J. IJzerman is Professor, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands.

    Menno I. Gaakeer is ED Physician, Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes, the Netherlands.

    Miriam M. R. Vollenbroek-Hutten is Professor, Biomedical Signals and Systems, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands.

    Carine J.M. Doggen is Associate Professor, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands.

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