Screening for Chronic Pain in an emergency department: Lessons Learned from a pilot study

Background and Context:
Internationally, a large proportion of emergency department (ED) patients report chronic pain (10-16%). Moreover, many re-present, using a disproportionate amount of ED resources. Currently, the prevalence of chronic pain in Australian EDs is unknown. Chronic pain is difficult to manage and treat in EDs, as it may not be identified as the presenting complaint, it is not easily classified due to the acute focus of EDs, and there are no treatment options beyond opioids. Better identification could provide an essential first step in offering more appropriate management. We aimed to examine (1) the prevalence of chronic pain in an ED, and (2) the feasibility of a brief doctor completed screening tool to better identify chronic pain among ED presenters.

Process: Flinders Medical Centre ED medical staff were asked to screen all adult presentations (excluding ‘extreme presentations’) over a 3-month period during patient assessment, using a 2-item paper-based screening tool. Patients presenting due to chronic pain were asked to participate in a separate therapy study (reported elsewhere). ED social workers assisted in study coordination. All ED medical staff were asked to complete a 5-minute questionnaire regarding screener feasibility.
Analysis: Despite coordinated and constant efforts of investigators, data collection proved extremely difficult. ED staff turnover and shift rotations meant constant education and reminders were required to keep staff informed of the study. This study occurred in one of the busiest EDs in Australia, where ‘code whites’ (i.e., beyond capacity) are common. Furthermore, COVID restrictions led to cessation of staff education, and saw screening become a lower priority. New COVID procedures, and earlier-than-anticipated relocation of one of the ED wards, actively interfered in screening. Consequently, 11% of all adult
presentations were screened (n=1316). Beginning at 12%, screening rates steadily rose to 24% in Week 4, then dropped to 12% by Week 5 – when COVID restrictions began, and trainee staff experienced large turnover. Survey results (n=25) suggested that on average, doctors felt the screener was ‘very’ clearly worded, understood by patients ‘quite’ well, only ‘slightly’ onerous for themselves and ‘moderately’ helpful for their assessments, and perceived as having ‘moderate’ value within EDs, and they felt ‘quite’ confident administering
it. Despite this, all reported screening a small proportion of patients, with commonly-cited reasons being too busy, forgetting, and other ED procedures interfering.
Outcomes: Despite staff buy-in, process-related barriers to implementing this screening were insurmountable. Given EDs are already extremely busy, any unanticipated changes can easily derail research. Screening may be better suited to GPs (potentially during postED discharge follow-up). Alternatively, integrating screening within different ED processes and/or using other staff members (e.g., at nurse triage) may be more successful. Ultimately, complete implementation of new processes in EDs takes a long time, with ongoing education the key to their success.