The Effect of Emergency Department Crowding on Analgesia in Patients with Back Pain in Two Hospitals

Abstract

Objectives: The authors assessed the association between measures of emergency department (ED) crowding and treatment with analgesia and delays to analgesia in ED patients with back pain.Methods: This was a retrospective cohort study of nonpregnant patients who presented to two EDs (an academic ED and a community ED in the same health system) from July 1, 2003, to February 28, 2007, with a chief complaint of ''back pain.'' Each patient had four validated crowding measures assigned at triage. Main outcomes were the use of analgesia and delays in time to receiving analgesia. Delays were defined as greater than 1 hour to receive any analgesia from the triage time and from the room placement time. The Cochrane-Armitage test for trend, the Cuzick test for trend, and relative risk (RR) regression were used to test the effects of crowding on outcomes.Results: A total of 5,616 patients with back pain presented to the two EDs over the study period (mean ± SD age = 44 ± 17 years, 57% female, 62% black or African American). Of those, 4,425 (79%) received any analgesia while in the ED. A total of 3,589 (81%) experienced a delay greater than 1 hour from triage to analgesia, and 2,985 (67%) experienced a delay more than 1 hour from room placement to analgesia. When hospitals were analyzed separately, a higher proportion of patients experienced delays at the academic site compared with the community site for triage to analgesia (87% vs. 74%) and room to analgesia (71% vs. 63%; both p < 0.001). All ED crowding measures were associated with a higher likelihood for delays in both outcomes. At the academic site, patients were more likely to receive analgesia at the highest waiting room numbers. There were no other differences in ED crowding and likelihood of receiving medications in the ED at the two sites. These associations persisted in the adjusted analysis after controlling for potential confounders of analgesia administration.Conclusions: As ED crowding increases, there is a higher likelihood of delays in administration of pain medication in patients with back pain. Analgesia administration was not related to three measures of ED crowding; however, patients were actually more likely to receive analgesics when the waiting room was at peak levels in the academic ED.ACADEMIC EMERGENCY MEDICINE 2010; 17:276-283 ª

Vital Signs Are Not Associated with Self-Reported Acute Pain Intensity in the Emergency Department

“…[1][2][3] Optimal pain management is lacking in most EDs, as many patients do not receive analgesia [3][4][5][6][7][8][9][10][11][12] and time to analgesic administration is often too long. 3,[5][6][7][8][10][11][12][13][14][15][16][17][18][19] Most health care professionals underestimate pain intensity. 20,21 In the absence of tachycardia or hypertension, we observed that ED staff tend to discredit self-assessments of severe pain when patients do not appear to be suffering.…”

An Ethnography of the Culture of Pain in a Non-Pediatric Emergency Department

“…Researchers have studied the social context of the ED environment and the potential effect on the management of pain with a recent emphasis on effect of ED overcrowding (Bernstein et al, 2009;Duignan & Dunn, 2009;Hwang, Richardson, Sonuyi, & Morrison, 2006;Hwang et al, 2008;Pines, Shofer, Isserman, Abbuhl, & Mills, 2010;Russo, 2010;Tanabe, 1996;Tanabe & Buschmann, 1999). Of those studies located, three quantitative studies measured ED nurses' perceived barriers to general pain management (Duignan & Dunn, 2009;Tanabe, 1996;Tanabe & Buschmann, 1999), four studies examined the effect of ED crowding on quality of pain care, analgesia in patients with back pain, the management of pain in older adults with hip fracture, and patients who presented at triage with severe pain (Hwang et al, 2006;Hwang et al, 2008;Pines & Hollander, 2008;Pines et al, 2010).…”

“…Of those studies located, three quantitative studies measured ED nurses' perceived barriers to general pain management (Duignan & Dunn, 2009;Tanabe, 1996;Tanabe & Buschmann, 1999), four studies examined the effect of ED crowding on quality of pain care, analgesia in patients with back pain, the management of pain in older adults with hip fracture, and patients who presented at triage with severe pain (Hwang et al, 2006;Hwang et al, 2008;Pines & Hollander, 2008;Pines et al, 2010). One qualitative study was located that identified the theme things that hinder decision-making for pediatric pain (Russo, 2010).…”

“…Respondents rated the frequency of barriers 56% perceived inability to offer analgesia until a diagnosis was made, 52% identified a lack of time to assess and control pain adequately, 51% perceived the responsibility of caring for other acutely ill patients in addition to patients with pain, 45% identified the inability to monitor side effects when patients left the ED for diagnostic procedures, 35 % identified doctors' reluctance to prescribe analgesia, and 23% perceived overcrowding in the department as barriers to pain management. Hwang, Richardson, Sonuyi, and Morrison (2006) that demonstrated during periods of higher crowding, higher census and high number of boarders (number of admitted patients waiting for inpatient beds) were associated with delays in pain treatment and fewer patients received any form of analgesic medication (Hwang et al, 2008;Pines et al, 2010). Investigation of the extant literature revealed no examples of empiric research validating the effect of ED overcrowding on the treatment of pediatric procedural pain.…”

The relationship between emergency department crowding and outcome of referred critical patients from other hospitals

“…11 In Pines et al study, 57.0% were men with the mean ± SD age of 44 ± 17 years. 12 In Nasr-Esfahani et al study, 484 patients were admitted to the ED with the mean ± SD age of 53.8 ± 20.3 which 55.8% were men. 13 In Cha et al study, 46.3% were women and 53.7% were men and the mean age was 47 years.…”