How to Complete a Rapid Assessment in a Busy ED Phyllis Hendry, MD Sophia Sheikh, MD Course Description .Pain is a component of up to 78% of ED presenting complaints yet most ED physicians have had minimal training related to pain recognition, assessment and management. Adequate pain assessment is complex and requires time to determine the patient’s past pain and medication history, current pain history, and pain intensity. ED providers are under pressure to recognize and treat pain while also dealing with overcrowding, a vast array of patient complaints, and concerns over opioid addiction and over prescribing. This course will review critical components of a rapid ED pain assessment, the current status of pain scales in the ED, electronic medical record documentation of pain and current literature. Disclosures .Phyllis Hendry, MD, FACEP, FAAP (Principal Investigator) .Sophia Sheikh, MD, FACEP (Sub-Investigator)

.Pain Assessment and Management Initiative (PAMI) .Funded by Florida Medical Malpractice Joint Underwriting Association, Alvin E. Smith Safety of Health Care Services Grant: 2014-2018 Learning Objectives .Describe various pain assessment tools currently in the literature and pros/cons to using these tools in the ED setting; .Discuss barriers to utilizing pain assessment tools and ways to overcome those barriers; .List advantages to implementing a common pain assessment tool in the ED among the entire ED health care team; and .Discuss evidence and controversy behind pain and patient satisfaction scores. Pain as of August 2016 .Total upheaval in the world of –New research regarding the neurobiological complexity of pain and long term consequences of untreated acute pain. .Opioid epidemic has everyone pointing fingers and outcry for reducing opioids –CDC, The Joint Commission, Advocacy Groups –“Blame Game” among specialties –“Throwing out the baby with the bath water” .Increase in ED based pain management research Background, Barriers, and Challenges in the Emergency Department Management of Pain Pain in the ED: Background and Barriers .Pain is often the main reason why patients come to the ED

.Care in the ED often adds to a patient’s pain

.Pain can be a barrier to communication

.Overall error prone environment Pain in the ED: Background and Barriers .Patient credibility and provider biases –Unique population of patients with increased incidence of mental illness, substance abuse and co-morbidities leading to bias –Limited means or time to verify patient’s history –Drug-seekers vs drug-diverters vs legitimate pain Pain in the ED: Background and Barriers .Need to balance analgesia and sedation with adverse effects, especially at the extremes of age and with comorbidities

.Pain cannot be treated if it cannot be recognized and assessed .1-10 scale not very helpful .Limited formal education Pain in the ED: Background and Barriers .Pain needs to be addressed within a reasonable period, yet… –Under pressure to rapidly disposition patients we don’t know –Difficult to differentiate between pain and anxiety –Lack of standardized assessment, reassessment and management tools especially for pediatric, non-English speaking, nonverbal, elderly or cognitively impaired patients –No RAPID pain evaluation tools for ED or EMS Trying to Balance Pain Management While…… . Dealing with opioid crisis and pressure to decrease readmissions and triage to discharge times

. Working in crowded high risk environment Definition???? Assessment Many Patients Do Not Receive “Adequate” Pain Assessments by EMS or in the ED

How can we appropriately treat pain if we don’t assess it? .Studies: –Only 40-50% of trauma patients received pain assessments and –34% of elderly patients with hip fracture had no pain assessment documented Why the Lack of ED Assessment? .Numbers don’t reflect the whole story… .Acuity and clinical condition may explain lack of assessments- altered/head injured, intubated, inebriated, unstable –Patients are less likely to be assessed for pain as injury severity increases. –Physiologically unstable patients are least likely to receive a standardized pain assessment and to receive ED opioids.

Spilman 2016 Why the Lack of ED Assessment? .Most EDs use a NRS to assess pain which requires an alert and oriented patient.

.Unfamiliarity with other pain scales or lack of time for more complex scales

.Patient acuity or condition may not allow for a full assessment

.Assessment tools for intoxicated or impaired patients lacking Patient and Provider Attitudes Influencing Pain Assessment Hypotheses for Inadequate Assessment or Under-estimation of Pain 1. Preference for signs over symptoms- physician ability to detect patient deception poor; correctly identified actors only 10% of the time.

2. Failure to recognize ED practices that themselves worsen pain by increasing patients’ anxiety and fear.

3. Belief by some practitioners that pain is proportional to tissue damage -don’t appreciate role of individuating factors.

Carter D, et al. Why Is Pain Still Under-Treated In The Emergency Department? Two New Hypotheses. Bioethics Volume 30 Number 3 2016 pp 195–202. Hypotheses for Inadequate Assessment or Under-estimation of Pain 4. Social distances between practitioners and some patient subpopulations can impair pain assessment and management.

5. Practitioners suspect patients of drug seeking and consequently of fabricating or exaggerating their pain leading to practice of defensive medicine.

Carter D, et al. Why Is Pain Still Under-Treated In The Emergency Department? Two New Hypotheses. Bioethics Volume 30 Number 3 2016 pp 195–202. Mandated Pain Assessments and Patient Satisfaction Scores Pain as the 5th Vital Sign .“intent of the ‘pain as the fifth vital sign’ campaign was to encourage doctors and nurses to listen to their patients and assess their pain………. no intent to have everyone take an opioid.”

.“In describing pain as the fifth vital sign, the message is that pain assessment is a priority”

-- James N. Campbell 2016 Unintended Consequences of the 5th Vital Sign .Renewed focus on pain assessment but reliance on uni-dimensional assessment tools leading to: –Opioid over-prescribing –Adverse events –Over-sedation • increased from 11 to 24.5 (P < 0.001) per 1,000,000 inpatient hospital days following use of an acute pain treatment algorithm guided by a numerical pain rating .Mandated pain assessments not shown to improve pain management or patient outcomes Patient Satisfaction Scores .71% of ED physicians perceived pressure to prescribe opioids to avoid administrative and regulatory criticism

.98% felt patient satisfaction scores were too highly emphasized by reimbursement entities as a means of performance evaluation

.Rising patient volumes and changes in the healthcare climate were reported factors impacting management of patients exhibiting "drug seeking" behavior. Patient Satisfaction Scores .Press Ganey patient satisfaction scores in the ED not associated with analgesics or opioid administration in the ED. .Very controversial subject .Changes predicted for HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) score evaluation and usage Role of Electronic Medical Record (EMR) in Pain: Has it Improved Pain Assessment?

.Incorporation of pain scales into EMRs improved documentation of pain scores –Mixed results for improved administration of analgesics and reduction in time to administration of analgesics –Focuses on pain intensity, not pain assessment .Pain order sets based on pain severity –Does not allow for individualization –Risk for adverse events like over-sedation “Give patients a voice, not a number” -University of Utah Role of EMR in ED Pain Assessment .Kaplan et al. 2008 –Mandatory recording of pediatric pain scores in EMR raised documentation from 7% to 38% but no improvement in administration or decrease in time to treatment

.No recent ED studies but Urban et al. 2015 found computerized provider order entry allowed for faster postoperative analgesia, decreased pain scores, and required less medication compared to paper-entry Pain Assessment and Discharge Planning .Pain assessment scores and tools are needed to manage ongoing pain in the ED and to determine fitness for discharge or need for admission

.Appropriate discharge planning: –reduces return visits –expedites return to normal activities and work –helps reduce risk of acute pain progressing to Unidimensional Tools for Pain Assessment: Pain Scales Pain Assessment Scales . Populations . General categories: – Adult – Observational-behavioral scales require provider – Pediatric to assess patient on multiple behaviors and rank them. – Special Situations . – Self-report scales include selection of a face or No validated for ED or pre-hospital color or number to represent pain. use . Most pediatric scales originally developed to measure procedural-related pain. Examples of Pain Scales Pain Scales* Verbal, Alert and Oriented Non-verbal, GCS <15 or Cognitive Impairment Adult 1. Verbal Numeric Scale (VNS)/ 1. Adult Non-Verbal Pain Scale (NVPS) Numeric Rating Scale (NRS) 2. Assessment of Discomfort in Dementia (ADD) 2. (VAS) 3. Behavioral Pain Scale (BPS) 3. Defense and Veterans Pain 4. Critical-Care Observation Tool (CPOT) Rating Scale (DVPRS) Pediatric 3 yo and older Birth – 6 mos 1. Wong Baker Faces 1. Neonatal Infant Pain Scale (NIPS) 2. Oucher (3-12yrs) 2. Neonatal Pain Assessment and Sedation Scale (N-PASS) 3. Numerical Rating Scale (NRS) 3. Neonatal Facial Coding System (NFCS) (7-11yrs) 4. CRIES 8 yo and older Infant and older 1. Revised Faces, Legs, Activity, Cry, and Consolability 1. Visual Analogue Scale (VAS) (r-FLACC) 2. Verbal Numeric Scale (VNS)/ 2. Non Communicating Children’s Pain Checklist (NCCPC-R) Numeric Rating Scale (NRS) 3. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) (ages 1-7) What do the numbers mean?

Pain = 3 Pain = 10 The Nature of Pain .Pain - complex, multifactorial, emotional, and subjective sensation .Pain Scales- unidimensional, single digit tool, representing a snapshot of the magnitude of pain at a specific time Factors Affecting Assessment-Personalized Approach

• Age, gender, ethnicity • Socioeconomic and psychiatric factors • Culture and religion • Genetics • Previous experiences • Patient perceptions . Patient expectations and perceived care by the treating provider(s) Pain Assessment Scales .Validity? .‘‘Does this instrument measure what it is supposed to measure?’’ • Picture scales good in populations with limited literacy (peds), males uncomfortable with scales depicting severe pain with tears • Verbal rating scales showed limited precision in low literacy and cognitively impaired pts. • Lack of supporting ED data

Todd KH. Pain assessment instruments for use in the emergency department. Emerg Med Clin North Am. 2005 May;23(2):285-95 Visual Analog Scale (VAS) Limitations .Fosnocht et al. Am J Emer Med, 2005 –N= 1999, prospective observational study –Change in VAS did not correlate with change in pain intensity, as measured by verbal descriptor scale (VDS) –Change in VAS may not be a valid indicator of pain relief Visual Analog Scale (VAS) Limitations .Blumstein and Moore. Acad Emerg Med, 2003 –No single cutoff on the pain scale could reliably predict a patient’s desire for medication

.Lee et al. Acad Emerg Med 2003 –A change of 30 (0-100) on the VAS is the minimal clinically important difference, based on adequate pain control as specified by the patient Numeric Rating Scale (NRS) Limitations and Issues

.NRS pain scale validated research tool to assess change in pain in cancer patients .The NRS is sensitive to the short-term changes in pain intensity associated with emergent care • NRS preferred by patients, higher completion rates than VAS Numeric Rating Scale (NRS) Limitations and Issues .Patients and staff often have different subjective definitions of the 0-10 scale. –Leads to inaccurate measurement of pain .If the reporting of pain is inaccurate, it can only be expected that the treatment will be equally ineffective. FLACC Scale Limitations and Issues

.Cannot be generalized to older children, adolescents, or adult patients

.Limited utility in cognitively impaired pediatric patients Scale with Color, Numerical, Descriptive and Visual Components- Old Version Defense and Veterans Pain Rating Scale (DVPRS) v 2.0

• New pain faces- excellent interrater • Excellent correlation to -Short agreement Form Defense and Veterans Pain Rating Scale (DVPRS) v 2.0 . Assesses subjective + objective (functionality) pain experience

. Color coding system (green, yellow, red) has specific implications for prioritizing patients in need of prompt and effective pain care

. Pain intensity scale has utility for identifying injured service members most at risk for early central sensitization from severe unrelieved pain

. Promising for the ED population but…… Defense and Veterans Pain Rating Scale (DVPRS) v 2.0 .Study population- military –81.4% male, 62.9% Caucasian, 60.3% married, 42% associate’s degree or higher –72% active duty military –36% Acute post-op pain –32% chronic non- –29% neuropathic pain

–Demographics not reflective of most ED populations Factors Associated with Higher Pain Scores .Younger age .Female gender .African American race .Medicaid insurance .Multiple ED visits in the past year .ED diagnoses of sickle cell pain, back/neck/shoulder pain, and Pain Score 8, Now What? .What should we do with a pain score? –How do we compare studies using different pain scores? –Treat if the number is high? And with what ? –Not treat if the number is low? –What number is unacceptable for discharge? –Do we believe the score? Pain score 8, Now What? .What change in the pain score means a patient can go home? –Decision point: admit or discharge home

.What changes indicate “successful” treatment? Pain Reduction Clinical Outcomes .Minimal clinically significant difference (MCSD) in pain severity- 1.5 on 11 point NRS or a proportional change of 25%.

.Change of at least 2 on a 0–10 pain intensity scale, or 33% pain intensity difference reported to represent patient-determined clinically important relief.

.Change of 30 (0-100) on VAS is minimal clinically important difference, based on adequate pain control per patient. What Existing Pain Scales are Missing .None designed specifically for ED setting .Scales used by majority of EDs are not designed for chronic pain .Lack of context (what does 8 out of 10 really mean?) .Most scales used in the ED don’t assess functionality PMPs Functionality and Quality of Life Substance Abuse, Opioid Risk Tools Mental Health Assessment Other Assessment Tools: Moving away from Numbers Prescription Monitoring Programs-- Theoretically a Helpful Assessment Tool

.No integration with EMR; .Doesn’t provide interpretation—how many MME pt .Difficult to find; takes? .Invalid password; .How many overlapping rx?; .Site maintenance; .Doesn’t list type of dr. writing rx or their .Too many clicks; office/location/contact info; . .Delay in time rx filled to when it shows up in system; Doesn’t take into account non-medical use; . .If pharmacy inputs data wrong then nothing will show- Doesn’t tell you abuse hx; missing rx; .Doesn’t tell you if pt has pain contract

.Multiple records for same pt; So Why Don’t We Always Use Them? PMPs and Opioid Overdose Risks- Assessment .Predictors for opioid overdose: .Number of days receiving more than 100 MME .Number of ‘trinity’ days (opioid, benzodiazepines, muscle relaxer) .Number of prescriptions .Multiple drug days .Early refills PDMPs and Opioid Overdose Risks- Assessment .Predictors for high-risk behaviors: .>/= 4 opioid prescriptions AND .>/= 4 providers for schedule II-V medications in the past 12 months Physical Functionality & Quality of Life Scales .Brief Pain Inventory .Physical Functional Ability Questionnaire .Palliative Performance Scale . (Karnofsky Scale) .Oswestry Low Back Disability Index .American Pain Foundation Scale .EQ5D-5L Physical Functionality & Quality of Life Scales .These scales are difficult to administer in ED setting due to length and time but provide important assessment components. .Most ED physicians are not familiar with these scales. .What about re-assessments? Substance Abuse Tools .Webster's Opioid Risk Tool (ORT) .Screener and Opioid Assessment for Patients in Pain (SOAPP®) .Current Opioid Misuse Measure (COMMTM) .Prescription Drug Use Questionnaire (PDUQ) .Screening Tool for Addiction Risk (STAR) .Screening Instrument for Substance Abuse Potential (SISAP) .Pain Medicine Questionnaire (PMQ) Substance Abuse Screening in the ED .Weiner et al. 2016 –32.9% of ED patients considered for discharge with an opioid scored “at-risk” on Screener and Opioid Assessment for Patients with Pain (SOAPP-R)

.Broderick et al 2015 –Patients were asked if used street drugs or marijuana in the past 3 months –40% sensitivity- missed 60% of individuals testing positive on the Alcohol, Smoking, and Substance Involvement Screening Tool (ASSIST) –72% sensitivity for marijuana use Mental Health Tools .SIGECAPS .Beck Depression Inventory-Fast Screen (BDI-FS) .The Mental Health Triage Scale (MHTS) .Patient Health Questionnaire Catastrophizing and Anxiety scales Kapoor et al 2016 .100 patients presenting to ED with acute pain

.Pain Catastrophizing Scale (PCS), and the State-Trait Anxiety Inventory-State Subscale (STAI-S).

.Pain intensity was significantly and positively associated with pain catastrophizing and anxiety Catastrophizing and Anxiety scales Kapoor et al 2016 .Need to consider the psychological distress from anxiety and pain catastrophizing of patients presenting to EDs with acute pain.

.“Brief behavioral interventions in conjunction with pharmacological interventions could improve outcomes”. Does One Perfect ED Assessment Tool Exist? Does one perfect assessment tool exist? .An ideal pain assessment should include: –patient’s subjective experience + –functionality assessment + –pain catastrophizing and anxiety + –substance abuse and opioid-addiction risks + –PDMPs+ –psychiatric conditions and comorbidities RAPID??? And we still have to complete a history and physical exam! Tools for Obtaining a Pain History and OPQRST,Completing SOCRATES an “Assessment”: and QISS TAPED .Numerous questions .Time constraining .Beyond scope of this presentation .Portions could be incorporated into model rapid pain assessment O: Onset (when did it Site - Where is the pain? Or the start) maximal site of the pain. • Quality P: Provocation or Palliation Onset - When did the pain start, and was mpact (what makes it better or • I it sudden or gradual? Include also whether if it is progressive or regressive. worse) • Site • Severity Character - What is the pain like? An Q: Quality (sharp, dull, ache? Stabbing? crushing) • Temporal Radiation - Does the pain radiate R: Region and Radiation • Aggravating and alleviating anywhere? S: Severity (pain score) • Past response and preferences Associations - Any other signs or T: Timing (type of onset, • Expectations and goals symptoms associated with the pain? intermittent, constant) • Diagnostics and physical exam Time course - Does the pain follow any pattern? AS: Associated Symptoms Exacerbating/Relieving factors - Does PN: Pertinent Negatives anything change the pain? everity - How bad is the pain? S 62 How would components of your assessment differ for the following cases? .80 YO with hip fracture after a mechanical fall .4 YO with lip laceration .35 YO with sickle cell disease and pain .19 YO with femur fracture after MVC .45 YO with chronic low on a pain contract .55 YO with depression and fibromyalgia Pain Assessment Toolbox: Proposed Components

1. Pain history and exam 2. Subjective- pain scales or scores 3. Functionality/disability 4. Chronic pain scales 5. Substance abuse tools 6. Opioid risk/abuse tools 7. PMPs 8. Catastrophizing scales 9. Anxiety scales 10. Mental health screening tools Pain Assessment Perform pain history and exam Subjective pain assessment Algorithm in an Functional pain assessment Ideal World Yes Is pain chronic? Chronic Pain Grade Questionnaire No At risk for substance PMPs ORT, CAGE- abuse? Opioid abuse? AID, SBIRT, Pain Assessment Toolbox No Yes DAST-10, Components PMPS 1. Pain history and exam Signs of Pain 2. Subjective- pain scales Catastrophizing? Anxiety? 3. Functionality/Disability PCS Yes 4. Chronic pain scales No 5. Substance abuse tools STAI-S 6. Opioids risk/abuse tools Risk for depression? 7. PMPs Yes 8. Catastrophizing scales No SIGECAPS 9. Anxiety scales Institute appropriate treatment; 10.Mental health screening Monitor and reassess Developing a Rapid Pain Assessment for the ED . Consider the patient’s subjective pain assessment then adjust based on exam or patient behavior

. Better approach is to ask how pain is affecting function?

. Assign value to a number- contextualize the score and change in score. (10/10 hang nail pain vs 10/10 fracture pain)

. Combine a qualitative scale + physician interpretation of the NRS along with other factors (allergies, PDMD, frequent visits, presenting injury/hx, level of tolerance, etc.) Conclusions What is Needed? . Pain scales that are validated in the ED setting – Study of Defense and Veterans Pain Rating Scale (DVPRS) v 2.0 in ED – Need more than a number!

. Determine ways to assess a patient’s subjective and objective pain experience along with substance/opioid abuse risks

. Research and collaboration – CDS (clinical decision support) algorithm development: acute vs chronic, critical vs noncritical, risk factors and comorbidities, etc. – Screening tools

Communicate with the ED patient! .Patients getting adequate pain relief may not want to report. –Fear provider may decrease pain medications or efforts to identify source of pain (Carter 2016) –49% did not want analgesics (pain score 6.4) and 19% of these patients received them anyway (Singer 2008)

.Talk to patients and find out if pain is tolerable or intolerable, identify a common goal

.Education on need for accurate pain scores to assess treatment –Discuss reality of pain relief- pain scores of 0 are unrealistic The Bottom Line . Pain is multifactorial thus assessment should reflect this

. Tailor assessment to the patient – How you assess the 4 yo with a laceration will differ from the 45 yo with chronic back pain on a pain contract

. Recognize the role psychosocial factors play in pain assessment

. Don’t forget about reassessments – Assess functional status with each re-evaluation The Bottom Line .Finally…..

– Know your limitations and those of your work environment – Consider patient acuity and reasonable goals of care Questions Thank you! Please share your ideas on how to perform a rapid ED pain assessment.

Email: [email protected] or [email protected] Phone: 904-244-4986 Website: http://pami.emergency.med.jax.ufl.edu References

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