ORIGINAL RESEARCH

Simple clinical targets associated with a high

level of patient satisfaction with their pain
managementemm_1397 195..201
Kathy Jao,
1
David McD Taylor,
1,2
Simone E Taylor,
2
Munad Khan
1
and John Chae
1
1
Departments of Medicine, University of Melbourne, Melbourne, and
2
Austin Health, Heidelberg,
Victoria, Australia
Abstract
Introduction: We aimed to determine factors that are signicantly associated with a high level of patient
satisfaction with their pain management.
Methods: We undertook an observational study in a large metropolitan ED. Adult patients with a
triage pain score of 4 (010 scale) were enrolled. Data collected included demographics,
presenting complaint, pain scores every 30 min, whether nurse-initiated analgesia was
administered, the nature of the pain relief administered, time to rst dose of analgesia,
elements of staff communication and whether adequate analgesia was provided (dened
as a decrease in pain score to <4 and a decrease from the triage pain score of 2). The
primary end-point, determined at follow up within 48 h, was the level of satisfaction with
pain management (6-point scale: very unsatisedvery satised).
Results: One hundred and sixty-seven (82.7%) of 202 enrolled patients were followed up mean
(SD) age 46.4 (18.3) years, 75 (44.9%) men. Eighty-one (48.5%) patients were very satised
with their pain management. Only two clinical variables were signicantly associated with
a high level of satisfaction: receipt of adequate analgesia (as dened) and specic com-
munication regarding pain management. Forty-four (58.7%) versus 37 (40.2%) patients
who did/did not receive adequate analgesia, respectively, were very satised (difference
18.5%, 95% CI 2.334.7, P = 0.027). Seventy-seven (53.9%) and four (16.7%) patients who
were/were not advised by ED staff that their pain management was important, respec-
tively, were very satised (difference 37.2%, 95% CI 17.756.6, P = 0.002).
Conclusions: Our adequate analgesia denition might provide a useful clinical target, which, combined
with adequate communication, might help maximize patient satisfaction.
Key words: analgesia, ED, pain, patient satisfaction.
Correspondence: A/Prof David McD Taylor, Emergency Department, Austin Health, PO Box 5555, Heidelberg, Vic. 3084, Australia.
Email: david.taylor@austin.org.au
Kathy Jao, BMedSci, Medical Student; David McD Taylor, MD, MPH, DRCOG, FACEM, Director of Emergency and General Medicine Research;
Simone E Taylor, PharmD, GradDipClinResMeth, Pharmacist; Munad Khan, BMedSci, Medical Student; John Chae, BMedSci, Medical Student.
doi: 10.1111/j.1742-6723.2011.01397.x Emergency Medicine Australasia (2011) 23, 195201
2011 The Authors
EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Introduction
Oligoanalgesia, dened as the inadequate use of anal-
gesics in the face of valid indications,
1
is a widely rec-
ognized problem affecting ED patients.
2
Providing a
standard of pain relief that achieves patient expecta-
tions plays the largest role in determining patient satis-
faction.
2,3
Arguably therefore, the ultimate goal of pain
management is a high level of patient satisfaction
with that management. Indeed, patient satisfaction is
associated with increased compliance, decreased mal-
practice litigation, less utilization of medical services
and a greater willingness to return to the health-care
provider.
4,5
A number of initiatives have attempted to improve
ED pain management. These include staff training,
time-to-analgesia key performance indicators, nurse-
initiated analgesia and mandatory recording of pain
scores.
611
Although well intended, the end-points of
these initiatives do not necessarily relate to patient sat-
isfaction, for example, although nurse-initiated analge-
sia might result in short times-to-analgesia, there might
be no account of the effectiveness of that analgesia.
Good patient satisfaction does not require the elimi-
nation of pain, but rather that pain should be at a
manageable level.
12
Intuitively, adequate analgesia
should decrease a patients pain by a clinically signi-
cant amount and to a level that is no more than mild.
Using a verbal Numerical Rating Scale (pain score range
0 [no pain] to 10 [worst possible]), it has been reported
that a clinically signicant decrease in pain is a
decrease in the pain score of 2
13
and that a score of <4
is clinically equivalent to mild pain.
14,15
Combining this
information, we dene adequate analgesia as provid-
ing a reduction in the triage pain score of 2 and to a
level <4.
We planned to take a different approach to pain man-
agement research by determining the variables that sig-
nicantly impact upon patient satisfaction with their
pain management. We aimed specically to determine
whether the provision of adequate analgesia (as
dened) was signicantly associated with a high level
of patient satisfaction. If so, it might have a place as a
useful clinical target that ED staff could aim for in order
to achieve best practice in pain management.
Methods
This was a prospective cohort study of pain manage-
ment, undertaken between August 2009 and April 2010.
It was conducted in the ED of the Austin Hospital, an
urban university-afliated centre in Victoria, Australia,
that treats approximately 70 000 patients per year. The
study was approved by the Austin Health Human
Research Ethics Committee and all participants gave
informed verbal consent.
A consecutive sample of patients was enrolled.
Patients aged 18 years with moderate/severe pain
(triage pain score 4) were included. Patients who
declined participation, had suspected cardiac chest pain,
who were triage category 1 or 2 (consent logistically
difcult), who could not communicate a pain score
(dementia, delirium, signicant illness, poor English) or
who could not be followed up (no telephone) were
excluded.
Data were collected during three separate, 3 week
periods (approximately) in August 2009, November
2009 and April 2010. This provided data likely to be
representative of an extended (9 month) period. Con-
secutive patients meeting the entrance criteria were
enrolled when the principal investigator (KJ) was
present in the ED. This was variable but generally
between 08.00 hours and 18.00 hours, 7 days a week.
Potential patients were identied at triage and invited to
participate within 30 min thereafter.
A standardized collection document was employed to
record patient demographics, presenting complaint,
pain scores, analgesia administered (drug, dose, route,
time) and whether nurse-initiated analgesia was admin-
istered. Pain scores were determined using the pain
Numerical Rating Scale, an accurate substitution for the
visual analogue pain scale in the ED setting.
16
Pain
scores were recorded at triage and every 30 min there-
after until adequate analgesia (as dened above) had
been administered.
Each patient was subsequently contacted by the prin-
cipal investigator within 48 h of discharge from the ED.
This was either by telephone for patients at home or
face to face interview for patients admitted. No pub-
lished questionnaire has specically addressed patient
satisfaction with pain relief in the ED. For the purposes
of the present study, the Patient Outcomes Question-
naire (APS-POQ), developed by the American Pain
Society, was employed. The APS-POQ utilizes a number
of questions sourced from validated questionnaires. It
has been used in the evaluation of patient satisfaction
with acute and oncology pain management and is easy
to use in an interview format.
17
Two questions, slightly
adapted for the ED setting, were asked. The rst was
How satised or dissatised are you with the results of
your pain treatment [in the ED], overall? Responses to a
K Jao et al.
196 2011 The Authors
EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
6-point Likert scale (very dissatisedvery satised)
were recorded. The second was [During your stay in the
ED], did your doctor or nurse make it clear to you that
they consider treatment of pain very important and that
you should be sure to tell them when you have pain?.
The primary study end-point was patient satisfaction
with their pain management. Secondary end-points
were the receipt of adequate analgesia (as dened),
whether patients had been advised to tell the ED staff
about their pain and the time-to-analgesia. These
allowed determination of which factors are associated
with patient satisfaction.
It was estimated that approximately 50% of patients
would receive adequate analgesia. Therefore, a total of
170 patients were required to demonstrate a clinically
signicant difference in the proportions of patients
who were very satised with their pain management
(75% of those who did receive adequate analgesia vs
50% who did not; level of signicance 0.05, two-sided,
power 0.9).
The principal investigator (KJ) entered all data into a
Microsoft Excel spreadsheet. Data on a random sample
of 20%of cases were reviewed by a co-investigator (DT)
and data entry accuracy conrmed. Most data analysis
is descriptive with measures of variability (95% con-
dence interval [CI], interquartile range) tted around
point estimates, where appropriate. The patient groups
were compared using the MannWhitney U-test
(non-parametric continuous data) and the c
2
-test (cat-
egorical data). The level of signicance was 0.05. SPSS
for Windows statistical software (version 18.0, SPSS,
Chicago, IL, USA) was employed for all analyses.
Results
Of 301 patients screened, 202 were enrolled. However,
complete data were available for a total of 167 (Fig. 1).
The basic demographics (age, sex, triage pain score) of
the 35 patients who did not provide satisfaction data did
not differ from the 167 who did (P < 0.05).
Overall, 81 (48.5%) patients were very satised with
their pain management and 86 (51.5%) patients were
not. Table 1 describes the demographic and clinical
variables of these two groups. Of the demographic vari-
ables, patients who were very satised were signi-
cantly older. There was also a signicant difference in
ethnicity between the two groups. Patients with
Australian/British/Irish background were most likely
very satised and patients with Asian or Italian back-
grounds were least likely.
Only two clinical variables were signicantly associ-
ated with being very satised. Patients who received
adequate analgesia (reduction in the triage pain score
of 2 and to a level <4) were signicantly more likely to
be very satised (difference in proportions 18.5%, 95%
CI 2.334.7, P = 0.027). Also, patients whose doctor or
nurse make it clear that treatment of pain was very
important and that the patient should tell staff when
they have pain were signicantly more likely to be very
satised (difference in proportions 37.2%, 95% CI 17.7
56.6, P = 0.002). Importantly, no other clinical variable
was associated with the patient being very satised
including time-to-analgesia, nurse-initiated analgesia
and the administration of an opioid.
Discussion
It is well known that a high proportion of patients
present to the ED with signicant pain.
1719
Currently,
suboptimal pain management practices remain a major
challenge for emergency medicine.
1,2,14
One recent mul-
ticentre study found that 74% of patients were dis-
charged from EDs in moderate to severe pain, that only
60% received analgesics following lengthy delays and
that 42% who did not receive analgesia had desired
pain relief.
14
Fosnocht et al.
20
reported that, on average,
patients expect pain relief within 23 min of arrival in the
ED. Achieving analgesia administration within 20 min
of patient arrival is a standard that is often used as a
benchmark for quality pain management.
6
A broad range of initiatives have attempted to
improve ED pain management. In 2001, the United
States Joint Commission on Accreditation of Healthcare
Organisations (JCAHO) prioritized pain assessment and
management across all health-care departments, includ-
ing EDs.
7,8
There is now evidence that ED pain manage-
ment has improved since the release of the JCAHO
standards.
14
In Victoria, Australia, the initiatives of the
Breakthrough Collaborative on Reducing Waits and
Delays and Improving Patient Satisfaction in the Emer-
gency Department were introduced across a group of
hospitals in 1999.
6
These included the objective to
improve management of pain by reducing times to
initial analgesia dose to 20 min or less. Consequently, all
but one hospital involved had made improvements in
reducing time-to-analgesia by 2001.
6
Nurse-initiated analgesia was, in part, designed as a
mechanism to increase the opportunity for the adminis-
tration of analgesia soon after the patients arrival in the
ED. In approved circumstances, analgesia can be
Pain management satisfaction
197 2011 The Authors
EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
administered before the patient is seen by a doctor.
There is evidence that this initiative can improve the
timeliness of analgesia. Wong et al.
21
reported a signi-
cant reduction in time to rst analgesic dose from 93 to
9 min. Kelly et al.
11
reported that nurse-initiated analge-
sia resulted in a signicant decrease (26 min) in median
time to rst analgesic dose. Also, Fry et al.
10,22
reported
that nurse-initiated analgesia resulted in decreases in
both times to rst analgesia and pain scores.
Most intervention studies have reported improve-
ments in time-to-analgesia and pain scores. However,
there is a paucity of work examining the effects of pain
management interventions on patient satisfaction. The
present study found that almost half of patients were
very satised with their pain management. This nding
is consistent with that of Marinsek et al.
23
who reported
that only 60% of patients with abdominal pain were
satised with the pain relief. Also, Blank et al.
12
reported
that 82% of the patients they examined rated their
overall satisfaction between good and excellent.
Patient age and ethnicity were both associated with
being very satised. Patients who were very satised
were older and more likely of Australian/British/
Irish background. Boudreaux et al.
24
also reported an
Screened for eligibility
(n = 301)
Enrolled (n = 202)
Excluded (n = 99)
communication difficulties (34)
ischaemic chest pain (22)
declined participation (20)
triage category 1 or 2 (10)
previously recruited (2)
inability to follow up (1)
Lost to follow up
(n = 32)
Data collection in the
emergency department
complete (n = 202)
Data collection at
follow up complete
(n = 167)
Declined satisfaction
survey (n = 3)
Figure 1. Patient ow diagram.
K Jao et al.
198 2011 The Authors
EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
association between patient age and satisfaction with
their ED care. However, this association was weak, not
consistent over time and related to overall satisfaction
rather than satisfaction with pain management. Our
ndings regarding ethnicity are consistent with those of
Carrasquillo et al.
25
who reported that non-English
speakers are less satised with their ED care overall.
Other investigators have also reported that age and
ethnicity inuence overall ED satisfaction,
5,26,27
but not
all.
28
It is not clear why ethnicity is associated with
patient satisfaction. Although it might relate to differing
expectations or language difculties, it has been
reported that Hispanic patients are much less likely
than non-Hispanic white patients to be given analgesia
in one US hospital.
29
Our results indicate that the provision of adequate
analgesia is signicantly associated with being very
satised with pain management. This nding was
expected as it was based upon earlier research.
1315
It is
consistent with the ndings of Marinsek et al.
23
who, in
a study of patients with abdominal pain, reported that a
decrease in pain score of 20 mm independently pre-
dicted patient satisfaction. Also, Barletta et al.
30
reported
that a decrease in pain score from admission to dis-
charge of 24 mm correlated with patient reports of suf-
cient pain relief and increased satisfaction with overall
pain management.
The signicant association between being very satis-
ed and being advised that pain management is impor-
tant (and asked to notify staff of pain) is also of interest.
This highlights the importance of adequate communi-
cation with the patient regarding their pain. This
nding is consistent with those of Boudreaux et al.,
31
who reported that patient perception of care is one of the
best predictors of overall satisfaction. Another possible
explanation for this signicant association is that staff
members who did provide this communication might
have been more pro-active in their pain management.
Table 1. Factors associated with being very satised with the pain management provided
Patient variable Not very satised (n = 86) Very satised (n = 81) P-value
n (%) unless specied otherwise
Demographics
Age in years 40 (24) 49 (27) 0.02
Men 43 (57.3) 32 (42.7) 0.17
Australian/British/Irish 43 (50.0) 57 (70.4)
Italian 13 (15.1) 3 (3.7)
Greek 7 (8.1) 7 (8.6) 0.02
Asian 6 (7.0) 1 (1.2)
Other 17 (19.8) 13 (16.1)
Presenting complaint
Chest pain 30 (34.9) 19 (23.5)
Musculoskeletal pain 14 (16.3) 14 (17.3)
Abdominal pain 2 (2.3) 7 (8.6) 0.10
Headache 3 (3.5) 6 (7.4)
Other 24 (27.9) 29 (35.8)
Not recorded 13 (15.1) 6 (7.4)
Triage pain score 7 (3) 7 (2) 0.24
Pain details and management
Advice about pain given 66 (46.2) 77 (53.8) 0.001
Adequate analgesia given 31 (41.3) 44 (58.7) 0.03
Nurse-initiated analgesia given 32 (57.1) 24 (42.9) 0.30
Time to rst analgesia, min 11 (97) 30.5 (54) 0.88
Time to reach adequate analgesia, min 90 (128) 90 (120) 0.44
Analgesia given at all 62 (50.0) 62 (50.0) 0.51
Opioid given (oxycodone, morphine) 26 (30.2) 29 (35.8) 0.55
Discharged 69 (48.9) 72 (51.1) 0.12
Level of satisfaction with pain management. Median (interquartile range). Whether the doctor or nurse make it clear that treatment
of pain was very important and that the patient should tell staff when they have pain. Adequate analgesia resulting in a reduction in the
triage pain score of 2 and to a level <4.
Pain management satisfaction
199 2011 The Authors
EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
The present study was not designed to determine the
reason for this association and further investigation is
recommended.
It is notable that time-to-analgesia, nurse-initiated
analgesia, the presenting complaint and the administra-
tion of opioids were not associated with being very
satised. Interestingly, patients who were very satised
had a considerably longer median time-to-analgesia.
However, times-to-analgesia were reasonably short for
both groups and this likely minimized the effect of this
variable on patient satisfaction. Also, a smaller propor-
tion of patients who were very satised had received
nurse-initiated analgesia. There is a likely interaction
between nurse-initiated analgesia and time-to-analgesia
and the present study was not designed to discern the
effect of confounding variables.
The present study has important limitations. For
some aspects of pain management, the tendency exists
to rely on surveys as surrogate markers for the effec-
tiveness of pain management.
12
However, patient satis-
faction surveys might fail to uncover the patients
multidimensional experience with pain.
12,32
Williams
33
reported that patient satisfaction questionnaires do not
assess an independent phenomenon but actively con-
struct one by forcing users to express themselves in
alien terms. Consequently, the results might misrepre-
sent the true beliefs of the patients surveyed. This might
explain, in part, the rather surprising nding that some
patients who received neither adequate analgesia (as
dened) nor advice to report their pain were still very
satised with their pain management. It is likely that a
number of other variables impact upon patient satisfac-
tion and affect the patient response.
The data collection method might have impacted
upon satisfaction. An awareness of the nature of the
study, the regular collection of pain scores and the
follow up might have led patients to perceive that
considerable interest was being given to them as an
individual. This, in turn, might have increased satisfac-
tion.
31
The delay in collection of satisfaction data (up to
48 h) might have introduced recall bias.
Selection bias might have been introduced through the
enrolment of a convenience sample and some loss to
follow up. However, there is no reason to believe that
such bias would have been large enough to substantially
affect the results. Although the researcher who collected
follow-up data (KJ) also had access to the pain score data,
these were not reviewed prior to followup. Also, explicit,
validated questions were asked of the patients.
A number of confounding variables might have
affected the results. Over the study period, staff rotated
in and out of the ED. Also, patient management prac-
tices evolve in response to ow pressures, patient mix
and quality improvement initiatives. The sample size
was modest and insufcient to undertake statistical
analyses to determine the effects of confounding vari-
ables. A Hawthorne Effect might have existed among
the ED staff. As staff were aware that the study was
examining pain management, their practices might
have changed. However, no staff were aware of the
study hypothesis and this effect is difcult to avoid in
this kind of study design.
34
As the study was under-
taken in a single institution, its external validity might
be limited. Other EDs are likely to have different pain
practices, times-to-analgesia and patient mix.
Although the ndings of the present study are impor-
tant, further research is indicated. It is recommended
that a multicentre study with a much larger sample size
be undertaken. Consecutive patients should be enrolled,
follow-up data collection undertaken by blinded inves-
tigators and logistic regression analysis employed to
account for confounding variables.
Conclusion
The study demonstrates that the provision of adequate
analgesia (analgesia providing a reduction in the triage
pain score of 2 and to a level <4) is signicantly
associated with a high level of patient satisfaction with
overall ED pain management. This denition might
provide a valuable clinical target for medical and
nursing staff that, if achieved, should help to maximize
patient satisfaction. Adequate analgesia should be pro-
vided in combination with explicit advice to tell EDstaff
if pain is of concern.
Acknowledgement
The present study was funded by a grant from the
Advanced Medical Science programme, University of
Melbourne, Australia.
Competing interests
DM is a Section Editor (Original Research) for
Emergency Medicine Australasia.
Accepted 19 December 2010
K Jao et al.
200 2011 The Authors
EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Pain management satisfaction
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EMA 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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