Pain assessment in ED an evidence-based update


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This presentation delivered at the International Conference on Emergency Medicine in Dublin describes different approaches to assessing pain in emergency department patients. It summarises the evidence supporting the various approaches and makes recommendations for practice.

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Pain assessment in ED an evidence-based update

  1. 1. PAIN ASSESSMENT IN THEEMERGENCY DEPARTMENTAN EVIDENCE-BASEDUPDATEAnne-Maree KellyProfessor and DirectorJoseph Epstein Centre for Emergency MedicineResearch @Western Health , Melbourne, Australia
  2. 2. Permissions This presentation may be reproduced in partor whole for education purposes on thecondition that each reproduced slide containsthe following:‘Re pro duce d with pe rm issio n o f Pro fe sso rAnne -Mare e Ke lly, Jo se ph Epste in Ce ntre fo rEm e rg e ncy Me dicine Re se arch @ We ste rnHe alth, Me lbo urne , Australia’@kellyam_jec
  3. 3. Conflicts of interest None to declareCAVEAT: The focus of this talk is on pain scenarios thatcommonly present to ED. Procedural analgesia and sedationhave not been specifically addressed.
  4. 4. Objectives After this presentation, participants will: Have an understanding of the methods available toassess pain in the emergency department, includingtheir strengths and weaknesses Be aware of the challenges of pain assessment
  5. 5. The truth about pain assessment Pain is a subjective experience….objective measurement isimpossible Pain experience is a complex phenomenon Physical and psychological dimensions In ED, usually measuring intensity/ severity Describing pain only in terms of intensity is like describingmusic only in terms of loudness
  6. 6. Pain assessment in context In ED there are three main variables that impact painassessment Patient characteristics E.g: Age, cognition, conscious state Pain characteristics E.g: Acute vs. chronic The purpose for which we are measuring pain E.g: pain management vs. research `
  7. 7. Purpose Pain management Indication of intensity/ severity Detection of change Identification of pain control/ need for additional pain relief Research Precision regarding intensity/ severity and detection andquantification of change
  8. 8. Methods for pain assessment Vital signs Behavioural features Clinician assessment Patient self-report Numerical methods Categorical methods
  9. 9. Desirable features of a pain scale Valid, reliable Culturally, developmentallyappropriate Easily understood by patientsof varying education Well accepted by patientsand clinicians Quickly and easily explainedto patients Low burden on clinician Low cost Readily available Translated/ adaptable intovarious languagesAdapte d fro m Van Bae ye r, 20 0 6
  10. 10. Poor performing methods Vital sign measurements (eg pulse, blood pressure) havebeen shown repeatedly not to be reliable in pain assessmentof individual patients. Clinicians assessment of pain agrees very poorly with patientself report. Both of these methods should be avoided if othermethods can be used.
  11. 11. Easier said than done Evidence that clinicians continue todemonstrate paternalism regarding painassessment Despite the evidence Despite the wide introduction of pain scoring
  12. 12. Measuring acute pain Self report Preferred if possible to use Observation scales Usually used with young children, the cognitivelyimpaired or those unable to communicate
  13. 13. Self report of pain Verbal categorical scales Numerical rating scales Visual analogue scales Image scales e.g. FACES scales
  14. 14. Verbal categorical scales Example format:‘No ne ’‘Mild’‘Mo de rate ’‘Se ve re ’ Strengths: Simple Valid and reproducible Weaknesses: Poor sensitivity to change in pain Low precision Research suggests temporal variationin correlation with numerical scales Difficult for patients with cognitiveissues
  15. 15. Verbal categorical scales Low precision and sensitivity to change in pain intensitymakes these unsuitable for research use Low sensitivity to change in pain intensity and difficulty ofuse by some patient groups limits utility as pain managementtool May be useful as a screening tool
  16. 16. Numerical rating scales Example format: Usually 0-10 Can be administered verbally or visually Can be vertical or horizontal
  17. 17. Variants of NRS Coloured scales Combine numerical withcolourimetric queues Not been shown to besuperior to NRS
  18. 18. Numerical rating scales Simple, practical Valid and reliable Sensitive to short termchanges in pain Well accepted by patients Flexible administration, phone Can be variation indescription of the anchornumbers ? Lower precision than VAS Debate about whether trulycontinuous for analysis ?Less accepted as aresearch toolStrengths Weaknesses
  19. 19. Visual analogue scale Example format: Patient asked to mark the line Usually an un-hatched 100mm line Pain score is the number of mm from ‘0’ end of the line
  20. 20. Variants of VAS Coloured scales Often coloured on oneside and numerical onthe other Reliable and wellaccepted in children andcognitively impaired
  21. 21. Visual analogue scales Valid and reliable Sensitive to changes in pain Well validated as a researchtool Reliant on vision and writtenresponse Harder to comprehend byelderly and cognitivelyimpaired Patients find harder to usethan NRSStrengths Weaknesses
  22. 22. NRS or VAS? Research suggests psychometric properties arevery similar NRS better accepted by patients VAS better accepted by researchers
  23. 23. Recent change in opinion Because of: Ease of use Fit with clinical pain management Patient preference Higher completion rate NRS increasingly accepted as both clinicaland research tool
  24. 24. Image scales Patient presented with a setof images and asked tochoose the one that bestrepresents their pain The image chosencorresponds with a numberfor analysis Variety of similar tools
  25. 25. Image scales Valid and reliable Simple to use Correlate with numericalmethods e.g. VAS Able to be used by childrenand some patients withcognitive impairment Limited experience withdisease-related pain most validated on proceduralpain Questions regardinginterpretation and analysis Continuous vs. categorical Some scales show bias atupper or lower endStrengths Weaknesses
  26. 26. A bit more about analysis Demonstratedcorrelation with VAS VAS bands are notdiscrete VAS bands are not thesame size Tendency to analyze asif continuous-? justified
  27. 27. The balance of evidence In conscious, cognitively sound adolescents andadults: The numerical rating scale is best accepted andvalidated for pain management and has growingacceptance as a research tool VAS is best validated as a research tool but is harderto use and less accepted by patients
  28. 28. My opinion Numerical rating scale isbest all-round painassessment tool
  29. 29. Children Most children aged 5 or over can provide self report ofpain intensity - if an age-appropriate tool is used By 9 or 10 years, numerical rating scales or VAS arewell accepted and reliable
  30. 30. Pain scales by age Two major reviews Substantially inagreement Apply to both painmanagement andresearch Acknowledge limitedevidence for some toolsAge group Preferredscale3-6(Preschool)Pieces ofHurt4-12 Faces painScale-Revised5-17 Colouredanaloguescale9+ Numericalrating scale
  31. 31. Observation scales FLACC Faces, legs, activity,cry, consolability Validated for post-operative pain inchildren 2 months to 7years AlderHay TriagePain Score Cry/ voice, facialexpression,movement, colour,posture Reliability and validityin early studies
  32. 32. Observational scales: The evidence Solid evidence that observational pain scales under-estimate pain in children aged 3 and older Not a surprising result Should not be used in preference to an age-appropriateself report tool
  33. 33. Cognitively impaired adults Includes patients with dementia Self report of pain is possible by many patients in thisgroup Lack of evidence regarding performance of various toolsfor different levels of cognitive impairment
  34. 34. The evidence There is some evidence that with increasing cognitiveimpairment, VAS and numerical rating scales are harderto use Faces pain scale-revised Well accepted Low failure rate, even in moderate-severe impairment
  35. 35. Observation scales Most not developed for use with acute pain FLACC and PAINAD scores have been used Limited data on validity and reliability
  36. 36. PAINAD score
  37. 37. Interesting new area of research Pain assessment in the unconscious /intubated patient A number of tools in development Include behavioural assessments +/-physiological parameters Varying psychometric properties Clinical utility to be established
  38. 38. Examples Critical care pain observation tool (B) Behavioural pain scale (B) Non verbal adult pain assessment scale (B) Pain assessment and intervention notationalgorithm (B + P)
  39. 39. Some areas for further research Reliability, validity and clinical utility of selfreport tools across different levels of cognitiveimpairment and cultural and education groups Pain assessment in children under 6 years Pain assessment in sedated/ unconsciouspatients
  40. 40. Take home messages When feasible, patient self-report of pain usingan appropriate tool is the most valid andreliable approach across all age and cognitivegroups Observational scales are a poor alternative
  41. 41. Measuring pain is not enough All of the science of pain measurement meansnothing if it does not result in action to relievepain Pain measurement may be the fifth ‘vital sign’but unless a response to address it istriggered we are wasting our time
  42. 42. Questions?Questions?Questions?@kellyam_jec