High inter-observer agreement of observer-perceived pain assessment in the emergency department

Abstract

BackgroundTriage is used to prioritize the patients in the emergency department. The majority of the triage systems include the patients’ pain score to assess their level of acuity by using a combination of patient reported pain and observer-perceived pain; the latter therefore requires a certain degree of inter-observer agreement.The aim of the present study was to assess the inter-observer agreement of perceived pain among emergency department nurses and to evaluate if it was influenced by predetermined factors like age and gender.MethodA project assistant randomly recruited two nurses, who were not allowed to interact with each other, to assess patient pain intensity on the numeric ranking scale. The project assistant afterwards entered the pain scores in a predesigned electronic questionnaire.We used weighted Fleiss-Cohen (quadratic) kappa statistics, Bland-Altman statistics and logistic regression analysis to assess the inter-observer agreement.ResultsOne hundred and sixty-two patients were included. They had a median age of 38 years and 45% were females. 30% of the patients were acute surgical patients and 70% acute orthopedic patients. The average time between the pain assessments were 1,7 min. The Bland Altman analysis found a mean difference in pain score of 0.2 and 95% limits of agreement of +/− 3 point. When the NRS scores were translated to commonly used pain categories (no, mild, moderate or severe pain) we found a 70% agreement with a mean difference in categories of 0.05 and 95% limits of agreement of +/− 1 category. Patient age, gender, localization of pain, examination room or presence of a significant other did not affect the inter-observer agreement.ConclusionWe found 70% agreement on pain category between the nurses and it is justified that nurse-perceived pain assessment is used for triage in the emergency department.

Multicenter survey on emergency nurses’ perception of Numerical Rating Scale reliability at triage time in adult Emergency Department patients

“…The Authors conclude that their findings justify that nurse-perceived pain assessment is used for triage in the emergency department. 20 One major concern has been driven by the fact that, despite declaring a high NRS score, several patients refuse analgesia delivered by the triage nurse. In an interesting study conducted in France, 38% of patients refused analgesia at triage, mainly (53%) because Pain is bearable without analgesic.…”

Pain at home during childhood cancer treatment: Severity, prevalence, analgesic use, and interference with daily life

“…As Hicks et al (2001) 51 have demonstrated that the Faces Pain Scale Revised (FPS‐R) is an appropriate tool for children's pain intensity in children aged 4 and up, we decided to use this scale rather than the NRS‐11 in the age group 4‐8. Clinically significant pain was defined as a score ≥ 4 on the NRS or the FPS‐R (face number 3 equals a score of 4) on either “worst pain” or “average pain in the last 24 h.” 52,53 …”

“…Since then, it has also been used in children. 47,48 Stinson et al (2015) 49 For the purposes of this study, the Dutch version of the BPI-SF has been slightly changed and adapted to the participants (ie, children equals a score of 4) on either "worst pain" or "average pain in the last 24 h." 52,53 The pain management section of the BPI-SF consists of one openended item in which treatments/medications received for the pain are assessed (ie, "What treatments or medications did you receive for your pain/did your child receive for their pain?"). Afterwards, responses were dichotomized to assess whether any pain treatments/medications were used (yes/no categories).…”

Reducing pain in children with cancer at home: a feasibility study of the KLIK pain monitor app

“…The family version of the app allowed children (aged [8][9][10][11][12][13][14][15][16][17][18] or parents (children aged 0-7) to report pain intensity at the time on an 11-point numeric rating scale (NRS-11) ranging from 0 (no pain) to 10 (worst pain imaginable). When a score ranging between 0 and 3 was reported, families were redirected to interventions suitable to the home setting on the psycho-educational information page of the app.…”

“…Studies on pain management at home reveal parental misconceptions (e.g., pain is unavoidable during cancer) [1] and concerns regarding analgesic use (e.g., pain medication is addictive) [11]. A previous study in children (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) years old) receiving outpatient chemotherapy revealed that in one third of clinically significant pain incidents (score ≥ 4 on scale of 0-10 [12,13]) occurring in the home setting, no analgesic medication was used [5]. It seems that despite the availability of effective pain interventions (either pharmacologic [14,15] or nonpharmacologic [16][17][18][19] in nature) for children with cancer, parents tend to undertreat pain [3].…”