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Emergency Medicine Australasia (2018) doi: 10.1111/1742-6723.



Association between pain control and patient

satisfaction outcomes in the emergency department
Tristam BROWN ,1 Amith SHETTY ,1,2 Dong Fang ZHAO,1 Nathan HARVEY,1 Teresa YU1 and
Margaret MURPHY2,3
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia, 2Emergency Department, Westmead Hospital,
Sydney, New South Wales, Australia, and 3Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia

Abstract pain score). Median time to analge-

Key findings
sia was 87.5 min (IQR 66.1–108.9).
Objective: Pain management and Patient satisfaction was inversely • Early and adequate pain
patient satisfaction are key markers associated with male sex, and posi- management and patient sat-
for health systems performance. tively correlated (Spearman’s rank isfaction in ED remain key
There is a lack of consensus on the correlation P < 0.05) with increasing ED management challenges.
role of analgesia, its adequacy, and age, significant change in pain score • We did not find strong cor-
its links to patient satisfaction in the (2) and compassion scores. relations between analgesia
ED. The present study aimed to Conclusion: In the present study of
assess the relationship between ade- and overall patient satisfac-
patients presenting to the ED with
quacy of analgesia and patient satis- pain, oligoanalgesia remains a signif- tion, with staff compassion
faction in the ED setting. icant issue. Male sex was inversely during ED patient interac-
Methods: Consenting adult patients associated with satisfaction, whereas tions highlighted as the
(n = 115) presenting to the ED with compassion, and significant change strongest predictor.
pain were enrolled, and their pain in pain score were associated with • Health systems should invest
tracked throughout admission with improved patient satisfaction. Of the in more specific patient satis-
11 point numerical pain scores. factors analysed, staff compassion faction tracking tools to better
Eleven point numerical scores were demonstrated the strongest correla- understand specific patients
also utilised to measure satisfaction tion with satisfaction. needs and expectations from
and compassion at the end of each
healthcare providers.
ED stay. The primary outcome was
patient satisfaction score ≥7. Key words: analgesia, emergency
Results: Of 115 enrolled patients, medicine, oligoanalgesia, pain, adequacy of analgesia delivered
94 (81.7%) were eligible for satisfaction. within the ED setting remains an
analysis. Median time to physician issue of contention, with authors
evaluation was 54.0 min (inter- divided between adequacy of analge-
quartile range [IQR] 35.0–98.0) and
Background sia and intolerably poor
median ED length of stay was Pain has been cited as a common ‘oligoanalgesia’.5–7 However, there is
205 min (IQR 129.0–280.0). Fifty- cause for presentation to the ED1 and strong suggestion that in Australia,
four patients (57.5%) received anal- is not only frequent, but is often also oligoanalgesia may prevail; a large,
gesia during their stay, of whom severe.2–4 Therefore, adequate and Australian, multicentre, initiative, the
36 (38.3%) had a significant timely analgesia has the potential to ‘National Health and Medical
response to analgesia (≥2 change in reduce morbidity and suffering. The Research Council – National Institute
of Clinical Studies National Pain
Correspondence: Dr Tristam Brown, Sydney Medical School, The University of Syd- Management Initiative’ demonstrated
ney, Camperdown, NSW 2050, Australia. Email: poor median times to analgesia,
Tristam Brown, BMedSc, MBBS, GCertPainMgt, Anaesthetic Registrar; Amith Shetty, exceeding agreed benchmarks, and
MBBS, FACEM, Staff Specialist, Clinical Senior Lecturer, Co-Director, Honorary nil change in treatment efficacy for
Research Fellow; Dong Fang Zhao, MD, Junior Medical Officer; Nathan Harvey, patients in severe pain, despite post-
MBBS, BAppSc (Physio) (Hons), Resident Medical Officer, Clinical Associate Lecturer; intervention improvements in docu-
Teresa Yu, BA (Advanced) (Hons), MBBS, Resident Medical Officer; mentation and adherence to analgesia
Margaret Murphy, RN, GradDip ICU Nursing, GradDip Change Management and guidelines.8
Government, MHlthSc (Ed), Clinical Nurse Consultant, Clinical Senior Lecturer. Past studies have suggested associ-
Accepted 24 January 2018 ations between increased patient

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

satisfaction and pain scores;9 All adult patients (≥18 years old) journey in case of patients with ED
whereas failure to relieve pain has presenting to Westmead Hospital’s LOS >4 h and those who were
been associated with higher rates of (Sydney, New South Wales, admitted to hospital. An option to
re-presentation.10 Debate still exists Australia) ED with pain as, or provide general comments about
about the relationship between pain, accompanying, the primary present- their experience was also provided.
analgesia and satisfaction with some ing complaint, and in non-critical A follow-up post-discharge tele-
reporting an association,10,11 some condition (triage categories three to phone call was made to patients at
finding no such associations,12 others five). Any patient unable to consent least 2 weeks post-discharge from hos-
proposing that satisfaction is related to participation because of clinical pital; this survey collected information
to factors such as communication, reasons, for example, impaired levels around: perceived time to physician
of consciousness, were excluded by evaluation, perceived time to analge-
attitudes and interpersonal interac-
research staff at consent for partici- sia, perceived pain scores (admission,
tion13,14 or to factors such as patient
pation in the study. post-evaluation and post-analgesia)
understanding and perception.14–16
and finally, the patient’s overall satis-
We hypothesised that levels of
faction with their ED experience.
patient satisfaction are positively Study procedures
correlated with adequacy of analge-
Following review and approval by a
sia and negatively correlated with
New South Wales Local Health Dis-
Sample size
time to physician evaluation and
trict Human Research Ethics Com- At the research site, 75% of the
time to analgesia.
mittee, the research project was annual census (categories three to five)
conducted as follows. is 60 000. With approximately 50%
Methods Patients who met the study eligibil- predicted to present with the primary
ity criteria provided informed consent symptom of pain, and with an
Trial design to participate in the study. Consenting expected survey response rate of 50%,
The prospective observational quali- participants were then tracked within a sample of 200 was initially consid-
tative study was conducted in the ED the department by the research assis- ered significant. With 100 patients, an
on consenting patients who presented tant. At enrolment, the inclusions error rate of 8.21% with a confidence
with the symptom of pain and met were assigned a unique study identi- level of 90% was expected.
the inclusion criteria. Data collection fier with individual medical record
occurred on a preformatted survey numbers used to facilitate retrospec-
tool, which collected information on tive data verification and linkage of
Data analysis
a series of 11 point numerical scales prospective pain rating data with Patients with incomplete datasets
patient ratings of pain, compassion information from follow-up telephone were excluded from the final analysis.
and satisfaction, administered during surveys. Utilising the pre-developed Exceeding minimum standards set
pre-specified time points during the survey tool, information relating to by validation studies, a change in
patient’s journey in the ED (Appen- analgesia and end-points were col- numerical pain score of ≥2, was con-
dix S1). The 11 point numerical rat- lected at pre-specified time points in sidered clinically significant in our
ing scale utilised is validated for the journey of the patient: analyses.18 In keeping with other
quantification of pain17 and is com- • As a baseline at the time of enrol- research into satisfaction in health-
monly utilised in marketing for rapid ment into the study. care, where numerical and Likert
quantification of satisfaction. • Immediately following evaluation scoring systems commonly employ
A follow-up telephone call made by their treating doctor. scales rating satisfaction from ‘poor
at least 2 weeks post-departure of • At least 60 min post-administration to excellent’ or ‘very poor to very
patient from the ED collected further of initial analgesia or at 60 min good’ on 0–5 or 0–10 numerical
end-point data about their experi- post-physician evaluation if no anal- scales,19 an arbitrary cut-off score of
ence in ED (Appendix S1). gesia was provided, reasons for ≥7 was used as a marker of signifi-
same were recorded. cant patient satisfaction and satisfac-
• Rating of staff compassion and tion rating outcomes.
Population and inclusion/
overall satisfaction occurred at
exclusion criteria ED discharge (to home or to inpa-
Patients were recruited during times tient unit) or at the end of 4 h into
Statistical analysis
of researcher availability, with their journey, whichever occurred Data were recorded in paper format,
recruitment shifts running intermit- earliest. and were then transcribed into
tently at any time between 08.00 • All patient ratings (pain, compas- an encrypted Excel spreadsheet
and 23.00 hours, over weekdays and sion and satisfaction) were cap- (Microsoft® Excel® 2013, USA) and
weekends, over a period of approxi- tured utilising 11 point numerical analysed using the statistical analysis
mately 1 year. During recruitment scales. software package SPSS (released 2013;
periods, all patients eligible for par- ED length of stay (LOS) and out- IBM SPSS statistics for Windows, ver-
ticipation were approached for come data were collected through sion 22.0; IBM Corp., Armonk, NY,
enrolment into the study. retrospective chart review of patient USA). Tests for normality were run on

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

49:51 (male:female) (Table 1). Fur-

Total number of consenting adult patients during trial period
ther demographic data are presented
in Table 1. Median pain at presenta-
tion was 7.0/10 (Table 2).

In-hospital data endpoints not Analgesia delivery

Exclusions Of the 94 inclusions in the study,
n=21 (18.3%) 54 patients (57.4%) received analge-
sia during their stay in ED of whom
36 (38.3%) had a significant response
to analgesia (≥2 change in pain score).
Number of patients who received analgesia Of the 40 patients who did not receive
Number of patients who did not receive
n= 54 (57.5% inclusions) analgesia any analgesia, 27 patients (28.7%)
36 (38.3% of inclusions) significant response to n = 40 (42.5% inclusions) refused analgesia and 13 patients
analgesia (≥ 2 change in pain score)
27 (28.7% of inclusions) declined analgesia (13.8%) desired yet did not receive
18 (19.2% of inclusions) no significant change
13(13.8% of inclusions) not offered analgesia any analgesia by the end of the trial
in pain score
period for the patient (approximately
4 h) (Fig. 1).
Figure 1. Consort flow diagram of participants and analgesia use in the pain control
and patient satisfaction study.
Compassion scores
At the pre-defined cut-off of 7/11 for
TABLE 1. Key demographic data of inclusions in the pain control and patient significant staff compassion, staff
satisfaction study were noted as compassionate by
85 patients (90.4%). Across the
Median (IQR) entire cohort, the median compassion
rating was very high at 9.0 (95% CI
Age (years) 39.0 (28.0–55.0) 8.0–10.0).
Triage category 3.0 (3.0–4.0)
Sex Male, n = 46 (49%)
Satisfaction scores
Admission status (admit vs discharge) Admit, n = 46 (49%)
At the pre-defined cut-off of 7/11
Time to evaluation (min), n = 94 54.0 (35.0–98.0) on a numerical scale rating for ‘satis-
Time to analgesia (min), n = 54 87.5 (66.1–108.9) faction’ with ED experience,
ED LOS (min) 205.0 (129.0–280.0)
74 patients (78.7%) were ‘satisfied’
with their experience. Similarly, the
IQR, interquartile range; LOS, length of stay.
median satisfaction rating was 8.0
(95% CI 7.0–10.0) (Table 2).

all individual variables (Shapiro– because of incomplete data comple-

Wilk). The Spearman’s rank-order tions. Only 69 patients from the origi- Correlation coefficients
correlation coefficient (ρ) was analysed nal cohort could be contacted for Recorded variables were analysed
for each investigated variable for ordi- post-discharge follow-up call, result- for correlation with the primary out-
nal patient satisfaction score as out- ing in significant attrition around come of satisfaction with ED experi-
come. In view of the sample size, all completion of surveys. Despite prelim- ence (Table 3). Increasing age,
variables with significant correlation inary statistical analysis revealing no significant change in pain score (2
(P < 0.10) were further included in a significant difference in mean satisfac- points) and ED compassion scores
logistic model to predict primary out- tion ratings between ‘in-hospital’ and (P < 0.05) were noted to have signif-
come of patient satisfaction score ≥7. ‘follow-up’ groups (Mann–Whitney icant positive correlations with the
P-value 0.8364, confidence interval primary outcome of patient satisfac-
[CI, −1.000 to 0.000]), the follow-up tion with their ED journey, while
Results arm was abandoned because of the male sex demonstrated an inverse
risk of significant selection bias. association (Table 3). Of factors ana-
Datasets lysed, compassion scores showed the
Of the 115 initially enrolled partici- strongest correlation with satisfac-
pants, 94 (81.7%) completed ‘in-hos-
Demographics tion (Spearman’s rank correlation
pital’ data end-points (Fig. 1). Of the The median age of the study partici- 0.51 [95% CI 0.34–0.64,
115 patients, 21 were excluded pants was 39 years, with a sex ratio P < 0.001]) (Table 3, Fig. 2).

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

the recruitment process leading to a

TABLE 2. Numerical rating scale pain and outcome scores at time points in sampling bias towards a collabora-
patient journey through ED tive consenting patient cohort.
Factor Median (IQR)
Researcher presence could have
caused procedural bias through an
Pain at presentation 7.0 (5.0–9.0) indirect influence on treating physi-
cians, whose behaviour may have
Pain post-evaluation 7.0 (5.0–8.0)
altered given knowledge of the
Pain post-analgesia 4.8 (3.0–6.0) study, by influencing patients’ scor-
Change in pain score post-evaluation (n = 94) 0.0 (0.0–0.0) ing with negative ratings possibly
more difficult to provide in person,
Change in pain score post-analgesia (n = 54) 3.0 (2.0–4.0)
or by directly influencing the
Patient perception of staff compassion 9.0 (8.0–10.0) patients’ perspectives by providing
Satisfaction scores with ED journey 8.0 (7.0–10.0) the patient with consistent attention
and ongoing enquiry into wellbeing
IQR, interquartile range. throughout their ED journey.
As a single centre study, the pro-
ject also suffers limitations in terms
of diversity of its patient cohort.
TABLE 3. Spearman’s rank correlation for variables investigated against sat-
Some of these demographic limita-
tions were minimised through the
isfaction with ED experience
selection of a busy quaternary centre
Spearman’s rank serving an ethnically and socioeco-
Factors correlation (95% CI) P-value nomically diverse population. How-
ever, others such as the young
Age (years) 0.22 (0.02 to 0.4) 0.02 median patient age of our cohort
Sex (male) −0.19 (−0.38 to 0.01) 0.04 remain to be addressed by further
studies in alternate locations.
Pain score at presentation −0.30 (−0.23 to 0.17) 0.39
The impacts of such selection bias
Pain score post-evaluation −0.08 (−0.28 to 0.12) 0.21 and impact of face-to-face interac-
Time to evaluation (min) −0.15 (−0.34 to 0.06) 0.08 tion by the researcher on the primary
outcome of satisfaction cannot be
Time to analgesia (min) 0.113 (−0.16 to 0.37) 0.42
discounted or quantified in our
Change in pain score −0.1 (−0.3 to 0.1) 0.16 study. While this effect may have
Any change in pain score (2) −0.27 (−0.45 to −0.07) 0.005 been mitigated by follow-up tele-
phone interview, the significant loss
Compassion score 0.51 (0.34 to 0.64) <0.001
to follow up meant that the latter
could not be completed. This is a
CI, confidence interval.
major limitation of our study and
possibly impacts the transferability
of our findings.
Logistic regression model sample size, which can lead to bias Despite the possibility of signifi-
in the results of the logistic regres- cant bias, our findings are in keeping
In a logistic regression model includ-
sion analysis. Other limitations with current literature. The propor-
ing factors with significant correlation
include possible selection bias and tions of patients receiving analgesia,
(P < 0.10) for primary outcome of
bias potentially introduced through the mean delay to analgesia, and the
patient satisfaction with their ED
the presence of the researchers them- proportion of patients not receiving,
journey (cut-off ≥7), male sex (odds
selves. The small sample size of but desiring, analgesia are similar to
ratio [OR] 0.24, 95% CI 0.07–0.9)
94 completed ‘in-hospital’ datasets those reported in the significantly
and compassion scores (OR 1.86,
and high attrition rate to follow up, larger, North American, pain and
95% CI 1.23–2.8) were retained as
with only 64 of the ‘follow-up’ emergency medicine initiative study.4
significant associations with satisfac-
datasets being completed, reduces In our study, the majority of patients
tion (Table 4). Males were least likely
the study’s power and introduces reported satisfaction with their expe-
to be satisfied, whereas patients whose
the potential for both type 1 and rience in ED with compassionate
ratings of staff compassion were high
2 errors. Larger studies are therefore staff interaction noted to have the
were most likely be satisfied.
required to confirm the validity of strongest link with overall patient
the present study’s findings. satisfaction. This, too, is in keeping
Discussion Selection bias exists because of the with past literature, in which inter-
The present study has various limita- use of convenience sampling, the personal interaction13 and patient–
tions, most importantly our small absence of overnight recruitment and practitioner communication20 have

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

practice of 30 min23 and exceeded

National Pain Management Initiative
pre- and post-intervention mean
times to analgesia of 61 and 41 min,
respectively,8 mean satisfaction rat-
ings remained consistently high in
our study.
A significant proportion (42.5%)
of the patient cohort did not receive
any analgesia, either by choice or by
not being given the option by clini-
cians, a finding also in keeping with
current literature.3 While this adds
to the knowledge around oligoanal-
gesia in ED, this also raises questions
about patients’ expectations from
Figure 2. Scatterplot of satisfaction scores versus compassion scores. healthcare events and potential fail-
ings in clinician identification of the
need for analgesia.
TABLE 4. Logistic regression model including significant investigated factors
Our study raises the need for
future research into factors that lead
(P < 0.1) for primary outcome of satisfaction score ≥7
to improved patient satisfaction
Parameter OR 95% CI P-value including staff–patient interactions.
Past research on patients with non-
Age (years) 1.02 0.98–1.06 0.24 critical illness has highlighted themes
Sex (male) 0.24 0.07–0.9 0.03 such as discussion of biomedical
issues, emotional support and part-
Time to evaluation (min) 0.99 0.98–1 0.03
nership expectations of patients,
Any change in pain score (2) 0.98 0.24–4.04 0.98 which suggest possible areas for
Compassion score 1.86 1.23–2.8 0.003 education of future ED healthcare
providers to improve outcomes.24,25
OR, odds ratio. Interventions aimed at improving
staff/patient interaction, such as
communication training,26 may be
more beneficial in improving satis-
each been demonstrated to correlate individual different time points in faction ratings than those addressing
with satisfaction. patients’ ED journey with our pri- efficacy of analgesia. With possibili-
We found patient sex (male) to be mary outcome. The latter is in keep- ties raised of improvements in
negatively associated with satisfac- ing with previous findings.12,22 patient satisfaction deliverable
tion scores. However, our study was Conflicting with previous through compassion training or
not powered for a subset sex-based research,9,13 we found no significant through alteration in recruitment
analysis to draw conclusions about association between time to evalua- patterns, further research into the
this link. Although no specific mech- tion and satisfaction scores. How- efficacy of such interventions, and
anism for sex-related differences is ever, this finding may be secondary into the mechanisms behind the
inferable from our research, a sys- to the study’s small sample size, influence of compassion on satisfac-
tematic review21 focusing on the role which may have led to an inability tion, is indicated.
of sex-related influences on pain and to detect such a difference. The pre- Our study identified the persis-
analgesia suggests sex-related differ- sent study was unable to quantify tence of oligoanalgesia, particularly
ences exist in pain prevalence, pro- the effect of perceived time to inter- regarding timeliness of analgesia,
cessing and analgesia response, ventions because of the abandon- and failure to deliver analgesia to all
providing possible mechanisms to ment of the follow-up arm of the who desired it. Future possible inter-
explain our findings. study following unacceptably high ventions that have demonstrated effi-
As expected, our research sug- rates of loss to follow up. This is cacy in reducing time to effective
gested an association between signifi- unfortunate as perceived time to analgesia include implementation of
cant shifts in pain scores and intervention has been shown to be a nurse initiated analgesia pro-
satisfaction scores. Although we greater determinant of satisfaction grammes,27,28 decreasing barriers to
found a correlation between signifi- than actual time.15 nurse initiation of analgesia and
cant changes in pain scores with Despite median wait times to anal- improving pain score documenta-
patient satisfaction, we found no gesia, which, at 87.5 min, were sig- tion.29 Interventions shown to affect
correlations between pain scores at nificantly higher than suggested best detection and identification of those

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine