The present study investigated the administration of both pharmaceutical and non-pharmaceutical analgesic medication in patients who were admitted to the ED of a public hospital, mainly due to acute musculoskeletal pain. Patients who visited the orthopedic physician received pharmaceutical analgesia in 51.2% and non-pharmaceutical analgesic medication in 51.2%. The mean intensity of the pain at the first measurement with NRS, at first time point, was 7.95±1.11 and at the second time point 2.83±2.51, thirty minutes post analgetics or at the time of discharge, if no analgesia was provided. Even at the second measurement of the pain intensity, it was found to have a median of 2.57 ±2.24 if it was given analgesia and 2.83 ±2.51 if it was not given, indicating that the pain remained and was low or mild.
Ιn the Pierik J. et al. study, the patients reported high intensity of pain both at arrival and exit. The mean intensity changed from 6.50 to 5.64 at discharge. They received medication at 35.7% and 14.3% refused to take medication that was offered. The other patients, although reported pain, were not offered analgesia. A total of 12.5% was offered sufficient analgesia. Non-pharmaceutical analgesic innervations were made in 78.9%.1
In a similar study of Stainikowitz R et al., related to under treatment of acute musculoskeletal pain, 70% of the patients had received analgesia in a mean time of 80±68 min. Following educational intervention, introducing VAS in the patient chart and establishing a protocol for the management of pain, with clear guidelines for nursing staff, the administration of analgesia raised to 82% and mean time was significantly reduced to 58±37 min.8
Another study of Goodacre SW & Roden RK, in an orthopedic ED, shows that administration of analgesia was significantly improved, after introducing protocols of analgesia. Unsatisfactory analgesia in fractures reduced from 91% to 69% and in the other orthopedic cases, from 39% to 22%. Also, IV opioid administration was increased from 9% to 37%. Although, many patients remained untreated or undertreated.9
The study of Butti L, in order to check the effectiveness and efficiency of the timely implementation of the Pain Management Protocol by triage, showed
that 84.8% of patients received analgesia during the triage, while in 97.4% of the cases received paracetamol 1000mg. Opioids were given in 2.5%. The mean time of medicine administration was 5.9 min and 60 min later, reassessing the pain, there has been a reduction of at least two degrees in 65.9%. Revaluating at the exit, 33.2%% of patients had a reduction in pain intensity >50%, while mean decrease was 39%.10
In contrast, in the study of Patrick P. et al., the proportions of patients with severe pain who received analgesia within 30 min, the mean time of administration and the mean time of pain relief were compared, six months earlier and six months after the implementation of the new pain management policy, surprisingly, the mean waiting time for analgesic delivery increased from 64 to 80 min and the proportion of patients who received analgesia within 30 min decreased from 17% to 7%. The mean time to relieve severe pain wasn’t significantly different (130.5 vs 153 min). They justified this increase in greater patient attendance, the priority of non-hemodynamically stable cases, staff shortage and problematic pain assessment, as some patients were unable to quantify their pain, some patients reported it elevated in order to advance and some of them have hidden the pain, raising doubts about the urgency of the administration of analgesia.11
In this study, the mean duration of patient’s pain to analgesia was 17.37±39.21 min. This cannot be considered to be in line with the international guidelines for the management of pain as it was measured by the patient’s approach to the doctor and not by his arrival in the Emergency Department. The lack of measurement and record of the pain during the triage and the absence of analgesia protocols had an inhibitory effect. In the study of Jennings N et al., the aim was to estimate the average duration to analgesia in patients that were administered by nursing specialists to the ED. This is a rapidly developing model in Australia, but there has been insufficient assessment of their participation in quality of care provision in the patient.12
Similar studies emphasize that when nursing staff undertook the granting of analgesics, based on protocols, resulted in a remarkable reduction in mean time to first analgesia at 26 minutes and reduction in pain intensity.13, 14 The study of Jennings et al. reports mean time to the assessment of 33.5 minutes, with 45.3% of patients being evaluated within 30 minutes of their approach. The mean time to analgesia was 60.5 min and 26.6% of patients received analgesia within 30 min of admission.12
The study of Fry et al., in many Emergency Departments in Australia, in a sample of 2.166 patients, showed that 95% of patients reached the hospital using an ambulance. Analgesia had been given to patients by paramedics and it consisted of morphine (14.2%), morphine products and methoxyflurane (29.3%). They had already registered the intensity of pain using the VAS and non-pharmaceutical analgesic interventions had been provided. Of all patients who suffered from pain, 74.9% received analgesia. Opioids were administered at 32.7%. The mean time of administration was 70 min. In Australia, in 69.4% of Emergency Departments policies are in place to allow nursing staff to provide analgesia, without medical prescription, including opioids, nitrite, NSAIDs and paracetamol. Also, regular training is provided to staff to manage the pain.15
In this study, analgesia provided consisted of 9.8% opioids, 25.5% NSAIDs, 29.3% non-opioids analgesics and 2.4% anxiolytics. Opioid administration reduced the pain by 50% from the first to the second measurement. Opioid administration was low and is inconsistent with international guidelines recommending opioids as the most appropriate for the management of severe pain. Most patients, with acute pain, can receive opioids without a major risk of respiratory depression. However, health professionals are taught to fear undesirable opioid effects, especially respiratory depression.
The possibility of respiratory depression is very small if proper titration of the dose is made.16 The study of Bounes V et al., in patients receiving opioids in a prehospital setting, supports the safety of opioids, as none of them showed respiratory insufficiency or needed an opioids antagonist.17
NSAIDs have elevated risk of bleeding, kidney and cardiac complications, and myocardial infarction. Also, they have a ceiling dose above which there is no additional therapeutic effect.18 NSAIDs are treatment of choice for mild musculoskeletal pain and the recent guidelines recommend giving the lowest dose for the shortest time due to their side effects.18, 19
In this study there was no statistically significant association between sex and medication, as opposed to the review of Rupp T & Delaney K., where more analgesic was given in women after they reported greater pain.20
Many studies have shown that the application of protocols to the management of pain has resulted in a reduction in the onset of analgesia and an increase in the number of patients receiving analgesia.9, 21 However, the general guidelines issued for the management of pain are not adopted by all hospitals, but they simply provide a framework around which they can be approached for the pain. Thus, improving the management of pain in emergency cases is a slow process.22
Limitations in the survey were the small size of the sample and the use of only one hospital, factors that do not help to draw safe conclusions and generalize the results. Also, it was not possible to accurately measure the time of administration of analgesia, since the patient’s registration was initiated upon entering the orthopedic and the waiting time was unknown.