This presentation delivered at the International Conference on Emergency Medicine in Dublin describes different approaches to assessing pain in emergency department patients. It summarises the evidence supporting the various approaches and makes recommendations for practice.

1. PAIN ASSESSMENT IN THE
EMERGENCY DEPARTMENT
AN EVIDENCE-BASEDUPDATE
Anne-Maree Kelly
Professor and Director
Joseph Epstein Centre for Emergency Medicine
Research @Western Health , Melbourne, Australia

2. Permissions
 This presentation may be reproduced in part
or whole for education purposes on the
condition that each reproduced slide contains
the following:
‘Re pro duce d with pe rm issio n o f Pro fe sso r
Anne -Mare e Ke lly, Jo se ph Epste in Ce ntre fo r
Em e rg e ncy Me dicine Re se arch @ We ste rn
He alth, Me lbo urne , Australia’
@kellyam_jec

3. Conflicts of interest
 None to declare
CAVEAT: The focus of this talk is on pain scenarios that
commonly present to ED. Procedural analgesia and sedation
have not been specifically addressed.

4. Objectives
 After this presentation, participants will:
 Have an understanding of the methods available to
assess pain in the emergency department, including
their strengths and weaknesses
 Be aware of the challenges of pain assessment

5. The truth about pain assessment
 Pain is a subjective experience….objective measurement is
impossible
 Pain experience is a complex phenomenon
 Physical and psychological dimensions
 In ED, usually measuring intensity/ severity
 Describing pain only in terms of intensity is like describing
music only in terms of loudness

6. Pain assessment in context
 In ED there are three main variables that impact pain
assessment
 Patient characteristics
 E.g: Age, cognition, conscious state
 Pain characteristics
 E.g: Acute vs. chronic
 The purpose for which we are measuring pain
 E.g: pain management vs. research
 `

7. Purpose
 Pain management
 Indication of intensity/ severity
 Detection of change
 Identification of pain control/ need for additional pain relief
 Research
 Precision regarding intensity/ severity and detection and
quantification of change

8. Methods for pain assessment
 Vital signs
 Behavioural features
 Clinician assessment
 Patient self-report
 Numerical methods
 Categorical methods

9. Desirable features of a pain scale
 Valid, reliable
 Culturally, developmentally
appropriate
 Easily understood by patients
of varying education
 Well accepted by patients
and clinicians
 Quickly and easily explained
to patients
 Low burden on clinician
 Low cost
 Readily available
 Translated/ adaptable into
various languages
Adapte d fro m Van Bae ye r, 20 0 6

10. Poor performing methods
 Vital sign measurements (eg pulse, blood pressure) have
been shown repeatedly not to be reliable in pain assessment
of individual patients.
 Clinicians assessment of pain agrees very poorly with patient
self report.
 Both of these methods should be avoided if other
methods can be used.

11. Easier said than done
 Evidence that clinicians continue to
demonstrate paternalism regarding pain
assessment
 Despite the evidence
 Despite the wide introduction of pain scoring

12. Measuring acute pain
 Self report
 Preferred if possible to use
 Observation scales
 Usually used with young children, the cognitively
impaired or those unable to communicate

13. Self report of pain
 Verbal categorical scales
 Numerical rating scales
 Visual analogue scales
 Image scales e.g. FACES scales

14. Verbal categorical scales
 Example format:
‘No ne ’
‘Mild’
‘Mo de rate ’
‘Se ve re ’
 Strengths:
 Simple
 Valid and reproducible
 Weaknesses:
 Poor sensitivity to change in pain
 Low precision
 Research suggests temporal variation
in correlation with numerical scales
 Difficult for patients with cognitive
issues

15. Verbal categorical scales
 Low precision and sensitivity to change in pain intensity
makes these unsuitable for research use
 Low sensitivity to change in pain intensity and difficulty of
use by some patient groups limits utility as pain management
tool
 May be useful as a screening tool

16. Numerical rating scales
 Example format:
 Usually 0-10
 Can be administered verbally or visually
 Can be vertical or horizontal

17. Variants of NRS
 Coloured scales
 Combine numerical with
colourimetric queues
 Not been shown to be
superior to NRS

18. Numerical rating scales
 Simple, practical
 Valid and reliable
 Sensitive to short term
changes in pain
 Well accepted by patients
 Flexible administration, e.g.
by phone
 Can be variation in
description of the anchor
numbers
 ? Lower precision than VAS
 Debate about whether truly
continuous for analysis
 ?Less accepted as a
research tool
Strengths Weaknesses

19. Visual analogue scale
 Example format:
 Patient asked to mark the line
 Usually an un-hatched 100mm line
 Pain score is the number of mm from ‘0’ end of the line

20. Variants of VAS
 Coloured scales
 Often coloured on one
side and numerical on
the other
 Reliable and well
accepted in children and
cognitively impaired

21. Visual analogue scales
 Valid and reliable
 Sensitive to changes in pain
 Well validated as a research
tool
 Reliant on vision and written
response
 Harder to comprehend by
elderly and cognitively
impaired
 Patients find harder to use
than NRS
Strengths Weaknesses

22. NRS or VAS?
 Research suggests psychometric properties are
very similar
 NRS better accepted by patients
 VAS better accepted by researchers

23. Recent change in opinion
 Because of:
 Ease of use
 Fit with clinical pain management
 Patient preference
 Higher completion rate
 NRS increasingly accepted as both clinical
and research tool

24. Image scales
 Patient presented with a set
of images and asked to
choose the one that best
represents their pain
 The image chosen
corresponds with a number
for analysis
 Variety of similar tools

25. Image scales
 Valid and reliable
 Simple to use
 Correlate with numerical
methods e.g. VAS
 Able to be used by children
and some patients with
cognitive impairment
 Limited experience with
disease-related pain
 most validated on procedural
pain
 Questions regarding
interpretation and analysis
 Continuous vs. categorical
 Some scales show bias at
upper or lower end
Strengths Weaknesses

26. A bit more about analysis
 Demonstrated
correlation with VAS
 VAS bands are not
discrete
 VAS bands are not the
same size
 Tendency to analyze as
if continuous-? justified

27. The balance of evidence
 In conscious, cognitively sound adolescents and
adults:
 The numerical rating scale is best accepted and
validated for pain management and has growing
acceptance as a research tool
 VAS is best validated as a research tool but is harder
to use and less accepted by patients

28. My opinion
 Numerical rating scale is
best all-round pain
assessment tool

29. Children
 Most children aged 5 or over can provide self report of
pain intensity - if an age-appropriate tool is used
 By 9 or 10 years, numerical rating scales or VAS are
well accepted and reliable

30. Pain scales by age
 Two major reviews
 Substantially in
agreement
 Apply to both pain
management and
research
 Acknowledge limited
evidence for some tools
Age group Preferred
scale
3-6
(Preschool)
Pieces of
Hurt
4-12 Faces pain
Scale-
Revised
5-17 Coloured
analogue
scale
9+ Numerical
rating scale

31. Observation scales
 FLACC
 Faces, legs, activity,
cry, consolability
 Validated for post-
operative pain in
children 2 months to 7
years
 AlderHay Triage
Pain Score
 Cry/ voice, facial
expression,
movement, colour,
posture
 Reliability and validity
in early studies

32. Observational scales: The evidence
 Solid evidence that observational pain scales under-
estimate pain in children aged 3 and older
 Not a surprising result
 Should not be used in preference to an age-appropriate
self report tool

33. Cognitively impaired adults
 Includes patients with dementia
 Self report of pain is possible by many patients in this
group
 Lack of evidence regarding performance of various tools
for different levels of cognitive impairment

34. The evidence
 There is some evidence that with increasing cognitive
impairment, VAS and numerical rating scales are harder
to use
 Faces pain scale-revised
 Well accepted
 Low failure rate, even in moderate-severe impairment

35. Observation scales
 Most not developed for use with acute pain
 FLACC and PAINAD scores have been used
 Limited data on validity and reliability

36. PAINAD score

37. Interesting new area of research
 Pain assessment in the unconscious /
intubated patient
 A number of tools in development
 Include behavioural assessments +/-
physiological parameters
 Varying psychometric properties
 Clinical utility to be established

38. Examples
 Critical care pain observation tool (B)
 Behavioural pain scale (B)
 Non verbal adult pain assessment scale (B)
 Pain assessment and intervention notation
algorithm (B + P)

39. Some areas for further research
 Reliability, validity and clinical utility of self
report tools across different levels of cognitive
impairment and cultural and education groups
 Pain assessment in children under 6 years
 Pain assessment in sedated/ unconscious
patients

40. Take home messages
 When feasible, patient self-report of pain using
an appropriate tool is the most valid and
reliable approach across all age and cognitive
groups
 Observational scales are a poor alternative

41. Measuring pain is not enough
 All of the science of pain measurement means
nothing if it does not result in action to relieve
pain
 Pain measurement may be the fifth ‘vital sign’
but unless a response to address it is
triggered we are wasting our time

42. Questions?
Questions?
Questions?
@kellyam_jec