Pain is one of the most common symptoms of patients presenting to the emergency department (ED). Nevertheless, the assessment of pain severity was not required in most Korean EDs until the introduction of the Korean Triage Acuity Scale by the amendment of the Enforcement Regulations of the Emergency Medical Care Act of 2016. There are few studies on pain control for patients who presented to the ED, and there has been little research on pain control pain for ED trauma patients [1,2]. Trauma patients have reported low satisfaction with their pain management [3]. In several studies, the authors reported that only 21% to 68% of patients with moderate acute pain received analgesics, and 50% to 74% of patients still had moderate pain at discharge [4,5]. Inappropriate pain control after trauma can result in poor treatment results and can slow wound healing and recovery. Additionally, rapid and effective pain control can increase patient satisfaction with care [6,7].

Because of the low awareness of the medical staff for pain assessment and congestion in the emergency room, pain management was not adequately addressed in many emergency rooms in Korea before the introduction of the Korean Triage Acuity Scale. Aggressive intervention activities including various methods have been proposed, but these are difficult for many EDs that lack resources.

The purpose of this study was to investigate the effectiveness of simple quality improvement (QI) activities for early pain management of patients with extremity injury in the ED.

In this study, an ED-based QI activity for pain management in acute extremity injuries was effective in increasing the rate of analgesic prescriptions. The time to prescription was also shortened significantly after the simple intervention.

To increase the prescription rate of analgesics, it is important to evaluate the pain; this is the first stage of pain management. Unfortunately, the prevalence of pain evaluation in the nursing records before the intervention was low, less than 1.4%. Thus, the purpose of the study was to increase the rate of pain scoring documentation in EMRs. After the simple intervention, the pain scoring increased, up to 50%, and the time to prescription decreased by more than 50 minutes. Interestingly, the prescription rate of analgesics was more significantly increased in patients with minor injuries, and the time to prescription was significantly improved in patients with moderate-to-severe injuries, after the intervention. Previous studies have reported that younger and chronic pain patients received more opioids and other drug prescriptions at the time of discharge, and fewer analgesic medications were prescribed in compromised patients and elderly patients [8]. The rates of prescription of pain medication were higher in elderly patients, in men, in moderate and severe injuries, in fractures, in upper extremity long-bone injuries, and in subsequently hospitalized patients in this study. In addition, patients in the intervention group were twice as likely to be prescribed pain medication compared to patients in the non-intervention group. These results are readily understandable in comparison with the results of a recent multicenter study on pain management according to the type of fracture, which suggested that analgesics are prescribed at a higher rate because long-bone fractures are more common in elderly patients [9].

Pain management is of interest in many areas of medicine, and many studies are underway to develop guidelines for pain control, to assess the adequacy of analgesics, and to manage them in particular patient groups [10-13]. Problems with oligoanalgesia in the ED have been reported in previous studies. Berben et al. reported that the average number of patients complaining of pain in the ED was 88.5%, and that two-thirds of the trauma patients also complained of moderate-to-severe pain [2]. Pain relief at discharge was effective in approximately 37% of patients, 46% reported no change, and 17% reported increased pain. Paul et al. determined the efficacy of pain scores in ED trauma patients; 53% of patients were treated with analgesics, and 60% of them had pain scores [4]. Their study showed that through pain assessments, pain medications were administered to people with severe pain [4]. In a prospective blinded observational study, pain assessment and control was even worse than in prior retrospective studies [14]. Additionally, opioids are often recommended for moderate-to-severe pain, and the rate of administration is high; our study also showed a high rate of opioid use in fractures and patients with moderate-to-severe pain [15]. In a study analyzing the use of analgesics in extremity or clavicle fractures, 64% of all patients received analgesics and 42% received narcotic analgesics. Moreover, 73% of patients with moderate or severe pain received an analgesic and 54% received narcotic analgesics [16]. In this study, the prescription rate of analgesics for the fracture group was not increased to the same extent as the increased documentation of pain score. There are many reasons why the prescription rate might not have risen sufficiently: First, some ED staff could not attend the QI education and group meeting due to work schedules, and the education was not an essential program for all staff. Second, any feedback or monitoring of QI activity was performed during the intervention. Because pain documentation by the triage nurse was not obligatory during the QI activity, the rate of pain score documentation was only approximately 50%. Considering that the prescription rate of pain medication in the group with a pain recording was 34.9%, which is higher than that for all subjects, the prescription rate is expected to rise as the pain rate increases.

Improved pain management in this study was achieved by a survey about pain management in the ED, ED staff education, and changing the practice of the triage nurse’s documentation of pain scores in the EMRs. According to the results of the survey, the perception of ED pain management by physicians and nurses was inconsistent with the low analgesic prescription rate during the study period. Although the healthcare providers evaluated a middle level of appropriateness, the prescription rate of analgesics was only approximately 20% before the QI activity. This mismatch in the results may reflect a low perception for the need of pain control. For this reason, the ED-based QI activity included education about pain management for healthcare providers: the current status of pain control in the ED, the importance of pain management, and methods of pain assessment. An important component of the QI activity was to change the default value from ‘no’ to ‘yes’ for pain scoring. Because the emergency room operates 24 hours/day, 365 days/year, and includes a staff of various occupations, it is important to use objective pain scores to share the patient’s condition among healthcare providers. The benefits of pain assessment have been demonstrated in several studies [17,18]. Studies have shown significant pain reduction at the hospital level after pain medication was prescribed through a pre-hospital pain assessment. A study also showed an increase in prescription rates for pain medications in post-operative pain patients after a QI activity for post-operative pain control [17,18]. The incidence of pain assessment, reevaluation, and pain score recording was found to be generally associated with reduced pain time, as in our study [19,20]. The reduction in analgesics administration time through these pain medication improvement activities has also been shown in pediatric studies [21].

This study has several limitations. First, because it was a retrospective single-center study, it could not reflect the variable groups of patients among different EDs. However, the study included more than 1,700 isolated patients with extremity injury in the ED, and the characteristics of participants did not differ between periods. Second, the threshold for pain control was not defined as the patients’ subjective pain score, but a researcher’s decision based on injury severity using ICD-10 codes. Because only 1.4% before the intervention and approximately half of the patients after the intervention had pain scoring by the triage nurse, it was difficult to compare appropriate pain control by the patients’ pain during the two periods. For this reason, we used the ICD-10 diagnosis to compare the two groups. The distribution of diagnoses was similar in both periods. Third, the time to prescription was used instead of the time to analgesic injection. It was not possible to determine accurate analgesic injection times. The time to injection is affected by various factors, such as the transfer time for the medication, time to intravenous access, and ED crowding. We focused on the time to prescription by a doctor after the QI activity. The mean time to a prescription was approximately 60 minutes, which could be considered a long time for early pain control. The time to prescription was defined as the time from ED registration to prescription of an analgesic by a doctor. The time from ED registration to triage was approximately 10 to 20 minutes, and the time from triage to doctor examination was 20 to 30 minutes in this hospital. Therefore, it can be assumed that the time from examination to prescription was improved to within 30 minutes. Fourth, this study did not exert adequate effort, such as creating posters, inviting personal feedback, or requiring an essential education program, to ensure that all ED staff received the intervention. The authors intentionally wanted to achieve appropriate pain management with a simple intervention. Therefore, modifying the EMR pain score recording method and employing a simple intervention activity of monthly meetings is meaningful and can lead to pain relief and decreased times to prescription. Considering that the analgesics prescription rate was not sufficiently improved in the present study, an increased number of and more diverse intervention activities are required to meet a future goal of increased analgesic prescriptions.

In summary, ED-based QI activities, including a change in pain score documentation in the EMR, can improve the rate of analgesic prescription and time to prescription for patients with extremity injuries in the ED.