Understanding the High Frequency Use of the Emergency Department for Patients With Chronic Pain: A Mixed-Methods Study

Abstract

Introduction: Chronic pain (CP) is a common driver of emergency department (ED) visits despite the ED not being the ideal setting for CP because of increased risk of adverse events and high costs. Purpose: The purpose of this study is to understand factors contributing to CP-related ED visits, patients' care experiences, and patients' perspectives on alternatives to the ED. Methods: We used a mixed-methods design combining semi-structured interviews and questionnaires with 12 patients with CP who had 12 or more ED visits over 1 year. We analyzed test scores using descriptive statistics and interviews using applied thematic analysis. Results: Four themes emerged. Factors contributing to ED visits included the following: fear (e.g., pain and its impact); inability to cope with pain; family suggestions to go to the ED; and access to other services and resources. Patients had validating and invalidating experiences in the ED: needs were met or not met; and feeling acknowledged or unacknowledged. Patients' experiences with their family physician included feeling supported or unsupported. Alternatives to the ED included working with an interdisciplinary team, developing personalized care plans, and increased community-based resources. Conclusions: Patients with CP and frequent ED use present with complex pain and care experiences, requiring careful attention to management strategies and the patient–provider relationship.

A systematic mixed studies review of patient experiences in the ED

“…In turn, this influenced the behaviour patients exhibited toward their care providers with some becoming frustrated and angry. Other patients changed their behaviour so they could be viewed as the "best patient possible", [45] "compliant", [41] and avoid "adding to staff stress". [46] Further, some patients welcomed the "passive" [46] patient role because of their presenting condition (e.g.…”

“…Respect was demonstrated on a spectrum, ranging from a lack of respect to a high level of respect. Positive experiences were associated with being listened to carefully and attentively, [35-37, 40, 46, 47, 50-60] having the opportunity to talk uninterrupted, [47,50] being taken seriously, [36,45,49,51,61,62] and feeling as though care providers had the time for them. [51,53,55,59,60,63,64] Similarly, care providers that were on the same level as patients (i.e.…”

“…However, when relational respect was minimal or absent, patients reported more negative experiences. This occurred when ED care providers talked in front of patients as if they were not there, [37,58,68,70,71] when patients felt they were not taken seriously, [45,63,65,66,72] were disregarded, [45,73] treated with judgement or discrimination, [41,42,45,68,72,74] or humiliated. [41,45,62,74]…”

“…[60] • "I felt like I was being taken seriously…" [36,62] • "… the worst time of my life, is the time walking in the emergency door and [being] told I sought medication." [45] • "… [the nurses said] things like how it [being transgender] was against God and just wasn't right." [74] Communicating with patients to keep them informed…”

“…confusion and fear [39,40,. 43,63,72] Patients described being uninformed as not being provided with sufficient verbal or written information about matters such as how long they might have to wait and what to do following discharge,[36,39,41,46,52,56,58,60,61,63,65,72,[81][82][83] receiving information they could not understand,[46,63,68] when information was delivered abruptly,[68,81,82] when information from multiple care providers was inconsistent or contradictory,[36,42,58,60,78] and when they were asked to repeat themselves numerous times [42,45,61,66]. Caring for patientsBeing cared for encompassed both routine/ functional aspects of care (e.g.…”