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The Pain and Emergency Medicine Initiative

The Pain and Emergency Medicine Initiative. Supported by The Mayday Fund through a grant to The Emergency Medicine Foundation Knox H. Todd, MD, MPH. PEMI Co-investigators. Manon Choiniere Cameron Crandall James Ducharme Celeste Johnston Kathleen Puntillo. Background.

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The Pain and Emergency Medicine Initiative

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  1. The Pain and Emergency Medicine Initiative Supported by The Mayday Fund through a grant to The Emergency Medicine Foundation Knox H. Todd, MD, MPH

  2. PEMI Co-investigators Manon Choiniere Cameron Crandall James Ducharme Celeste Johnston Kathleen Puntillo

  3. Background • Pain is the most common reason for ED visits • Little data on the impact of pain after discharge • Objectives: • Assess pain characteristics and pain-related functional interference • Develop research network of US and Canadian EDs • Develop cadre of physicians and nurses interested in ED pain management and research

  4. Methods • Design • Multicenter, prospective, observational study • Setting • 13 academic and community emergency departments in the US and Canada • Participants • age 8 and older, moderate/severe pain (NRS>3), discharged home

  5. Methods • Exclusion Criteria • inadequate contact information (address, phone, contact at separate address) • ischemic heart disease • mental status abnormality • inability to speak English or Spanish • sexual assault • domestic violence • muteness/deafness • prior enrollment

  6. Methods • Structured ED interviews, chart abstraction, follow-up telephone interviews • Study Measures: Demographics Pain severity Communication ED analgesic use Discharge instructions ED utilization Prevalence of chronic pain Satisfaction Pain-related interference with function Regular source of care

  7. Results • Subjects - 304 subjects from 13 EDs • Age - median: 32 years • Sex - 57% female • Phone interviews median 6 days after d/c • 82% contacted within 14 days

  8. ED Pain Intensity

  9. Time to Analgesic • Total ED time (triage to discharge): Mean 192 minutes Median 159 minutes • Time to first analgesic (triage to analgesic): Mean 110 minutes Median 88 minutes

  10. Assessment • Proportion receiving initial ED pain assessment: 79% • Proportion receiving >1 ED pain assessment: 17%

  11. ED Communication

  12. Discharge Instructions

  13. Chronic Pain and the ED • 134 subjects (44%) with chronic pain • Median duration of symptoms - 2 years • % reporting at least 1 ED visit within the past year: Chronic Pain: 79% No Chronic Pain: 40% • Mean # ED visits per person within past year Chronic Pain: 4.3 No Chronic Pain: 1.3

  14. Healthcare Utilization

  15. Follow-up Pain Intensity

  16. Pain Intensity

  17. Pain-related Functional Interference

  18. Conclusions • Pain intensity is high in ED and after discharge • Analgesics are delayed • Follow-up pain assessments uncommon • IM routes used in a high proportion of cases • Deficiencies in communication and d/c • Many have chronic pain - high rates of ED use • Significant proportions with pain experience persistent pain-related functional interference • Much remains to be done

  19. Timothy Mader, Baystate Medical Center; Robert Cox, Spalding Medical Center; James Ducharme, Atlantic Health Sciences Corporation; Jacques Lee, Sunnybrook and Women’s Hospital; Joel Bartfield, Albany Medical Center; Dave Fosnocht, U. of Utah; Cameron Crandall, U. of New Mexico; Christian Vaillancourt, Ottawa General Hospital; Basmah Safdar, Yale Medical Center; Martha Neighbor, San Francisco General Hospital; Paula Tanabe, Northwestern University; Leslie Zun, Mt. Sinai Medical Center; Barbara Lock, Columbia Presbyterian Medical Center; Alan Heins, U. of South Alabama Medical Center; Thomas Terndrup, U. of Alabama at Birmingham; Andrew Chang, Montefiore Medical Center; Edward Panacek, U. California at Davis; Edward Sloan, U. of Illinois at Chicago; James Miner, Hennepin County Medical Center; Eric Larson, Medical U. South Carolina; Ken Iserson, U. of Arizona; Bradford Walters, William Beaumont Hospital PEMI Site Investigators Timothy Mader, Baystate Medical Center Robert Cox, Spalding Medical Center James Ducharme, Atlantic Health Sciences Corporation Jacques Lee, Sunnybrook and Women’s Hospital Joel Bartfield, Albany Medical Center Dave Fosnocht, University of Utah Cameron Crandall, University of New Mexico Christian Vaillancourt, Ottawa General Hospital Basmah Safdar, Yale Medical Center Martha Neighbor, San Francisco General Hospital Paula Tanabe, Northwestern University Leslie Zun, Mt. Sinai Medical Center Barbara Lock, Columbia Presbyterian Medical Center Alan Heins, U. of South Alabama Medical Center Thomas Terndrup, U. of Alabama at Birmingham Andrew Chang, Montefiore Medical Center Edward Panacek, University of California at Davis Edward Sloan, University of Illinois at Chicago James Miner, Hennepin County Medical Center Eric Larson, Medical University of South Carolina Ken Iserson, University of Arizona Bradford Walters, William Beaumont Hospital Timothy Mader, Baystate Medical Center Robert Cox, Spalding Medical Center James Ducharme, Atlantic Health Sciences Corporation Jacques Lee, Sunnybrook and Women’s Hospital Joel Bartfield, Albany Medical Center Dave Fosnocht, University of Utah Cameron Crandall, University of New Mexico Christian Vaillancourt, Ottawa General Hospital Basmah Safdar, Yale Medical Center Martha Neighbor, San Francisco General Hospital Paula Tanabe, Northwestern University Leslie Zun, Mt. Sinai Medical Center Barbara Lock, Columbia Presbyterian Medical Center Alan Heins, U. of South Alabama Medical Center Thomas Terndrup, U. of Alabama at Birmingham Andrew Chang, Montefiore Medical Center Edward Panacek, University of California at Davis Edward Sloan, University of Illinois at Chicago James Miner, Hennepin County Medical Center Eric Larson, Medical University of South Carolina Ken Iserson, University of Arizona Bradford Walters, William Beaumont Hospital

  20. ACEP Pain Policy - 2004 • ED patients should receive expeditious pain management, avoiding delays such as those related to diagnostic testing or consultation. • Hospitals should develop unique strategies that will optimize ED patient pain management using both narcotic and nonnarcotic medications. • ED policies and procedures should support the safe utilization and prescription writing of pain medications in the ED. • Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED. • Ongoing research in the area of ED patient pain management should be conducted. Ann Emerg Med. 2004;44:198.

  21. ED Analgesia Use: 1997 & 2001 National Hospital Ambulatory Care Survey Data – ED Summary. NCHS 2001.

  22. EM Pain Literature * Medline Search by Year of Publication: Pain and Emergency Medicine

  23. 2003 Cameron S. Crandall David Fosnocht Sam McLean Martha Neighbor Basmah Safdar 2004 Mary Ann Cooper Matt Lewin Barbara Lock John McManus Gerard Rebegliati Scott Rohrbeck Sachin Shah Leslie Zun APS EM Scholars

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