Pain and Pain-Related functional interference among discharged emergency department patients

Study objectives: We assess pain and pain-related functional interference in patients discharged from the emergency department (ED). Methods: After written informed consent, patients underwent structured interviews conducted by research assistants at ED discharge and were contacted as early as 3 days after discharge for telephone interviews. Medical records were abstracted. Study measures included pain severity (10-point numeric rating scale [NRS]), satisfaction with various pain-related features of ED care (6-point ordinal scales), the prevalence of chronic pain syndromes, previous reported ED utilization, and pain-related interference with function (10-point scales) assessed using the Brief Pain Inventory (BPI). This was a multicenter, prospective, observational study conducted in 4 academic EDs and 1 community ED in the United States and Canada. ED patients 8 years and older with complaints of moderate to severe pain (NRS>3) who were discharged home were eligible for inclusion. Exclusion criteria included inadequate contact information to allow for telephone follow-up, altered mental status, angina, or privacy concerns. Results: Two hundred forty subjects entered the study. A majority were women (57%), and their median age was 32 years (range 9 to 91 years). On ED arrival, patient-reported pain ratings were high (mean 7.4, median 8, range 4 to 10, interquartile ratio [IQR] 6 to 9), and on discharge, these ratings remained moderately high (mean 5.6, median 6, range 0 to 10, IQR 4 to 8). Initial pain assessments were recorded in the medical record in 81% of cases. Documented follow-up pain assessments during the ED stay were rare. At discharge, 49 (21%) of 231 patients reported being less than satisfied with their pain management. Only 60% of patients indicated that the ED staff informed them to report their pain, and 23% of patients reported being given no instructions about management of their pain after discharge. Follow-up was successful for 159 (66%) of 240 patients. These patients were contacted by a mean period of 6 days after their ED visit. By this time, 31 (20%) patients were pain free, 37 (23%) patients had mild pain (NRS 1 to 3), 53 (34%) patients had moderate pain (NRS 4 to 6), and 37 (18%) patients reported severe pain (NRS 7 to 10). Mean pain-related functional interference scores were highest for the General Activity (5.0), Normal Work (4.4), and Sleep (4.2) categories of the BPI). The prevalence of chronic pain syndromes in this sample was 44% (69 of 158 patients). Patients with chronic pain syndromes reported a mean of 3.6 ED visits within the preceding year versus 1.1 visits for those without chronic pain (median 3 versus 0). For patients with chronic pain, the median and mean durations for their symptoms were 24 months and 52 months, respectively. Conclusion: Pain severity among patient presenting to EDs with pain is high, and documented pain assessments beyond triage are rare. Pain levels remain high during the first week after discharge, and pain-related functional impairment is common. A large proportion of ED patients presenting with pain have chronic pain syndromes and report high levels of ED utilization. Previous studies of pain-related outcomes after ED discharge are few. Pain-related functional interference measures represent promising tools in our efforts to understand the impact of untreated pain on our patients. The high prevalence of chronic pain syndromes among our patients represents a challenge to our specialty.