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Understanding the High Frequency Use of the Emergency Department for Patients With Chronic Pain

A Mixed-Methods Study

Glynn, Brittany A.; Brulé, Madeleine; Kenny, Samantha L.; Khoo, Eve-Ling; Shergill, Yaadwinder; Smyth, Catherine E.; Poulin, Patricia A.

The Journal for Healthcare Quality (JHQ): July/August 2019 - Volume 41 - Issue 4 - p 195–211
doi: 10.1097/JHQ.000000000000073
Original Article
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CE
Continuing Education

Introduction: Chronic pain (CP) is a common driver of emergency department (ED) visits despite the ED not being the ideal setting for CP because of increased risk of adverse events and high costs.

Purpose: The purpose of this study is to understand factors contributing to CP-related ED visits, patients' care experiences, and patients' perspectives on alternatives to the ED.

Methods: We used a mixed-methods design combining semi-structured interviews and questionnaires with 12 patients with CP who had 12 or more ED visits over 1 year. We analyzed test scores using descriptive statistics and interviews using applied thematic analysis.

Results: Four themes emerged. Factors contributing to ED visits included the following: fear (e.g., pain and its impact); inability to cope with pain; family suggestions to go to the ED; and access to other services and resources. Patients had validating and invalidating experiences in the ED: needs were met or not met; and feeling acknowledged or unacknowledged. Patients' experiences with their family physician included feeling supported or unsupported. Alternatives to the ED included working with an interdisciplinary team, developing personalized care plans, and increased community-based resources.

Conclusions: Patients with CP and frequent ED use present with complex pain and care experiences, requiring careful attention to management strategies and the patient–provider relationship.

For more information on this article, contact Brittany A. Glynn at bglynn@ohri.ca.

Funders: This project was supported by The Ottawa Hospital Department of Anesthesiology and a Canadian Institutes of Health Research (CIHR) grant to the Chronic Pain Network (cpn-rdc.ca).

The authors declare no conflicts of interest.

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Introduction

Chronic pain (CP) accounts for 10–16% of emergency department (ED) visits. 1 Chronic pain was the most common chief complaint among patients of a large United States (US) urban center with at least six ED visits per year. 2 Similarly, in a large Canadian tertiary care center, 36.5% of patients with greater than 12 ED visits per year were presenting because of CP conditions. 3 Managing CP in the ED is associated with increased risks of adverse events 4 and high costs. 5 It is therefore worth exploring the factors driving patients to the ED, patients' care experiences, and alternatives to ED visits. This may lead to better care and clinical outcomes and more efficient use of healthcare resources.

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Literature Review

Chronic pain is a complex condition with high human, social, and financial costs. 1,6-11 Many patients with CP do not have their needs met in the community and turn to the ED for care, sometimes frequently. Optimal CP care requires a well-coordinated longitudinal approach, 12,13 addressing persistent pain that the ED cannot provide. In addition, the use of the ED is problematic because it is associated with high risk of adverse events 4 and high costs; for example, one study demonstrated that the cost per ED visit for CP ranges from $399-$1943 and is compounded among high-frequency users (HFUs) of the ED. 5

High-frequency user accounts for 4.5–8% of all ED patients, yet 21–28% of all visits. 7 A systematic review reported significant heterogeneity in HFUs of the ED and emphasized the difficulty in making generalizations and developing policies to improve their care and address the issue. 7 Furthermore, a report from a large US urban center of patients with at least six ED visits per year found that the most common chief complaint was CP. 2 The data suggest that a significant proportion of HFUs of the healthcare system suffer with CP, and a better understanding of this demographic is warranted.

The most prominent reasons for HFUs to visit the ED include believing that their problem is emergent, believing that the ED is the only option, referral by their doctor, or based on convenience. 14 Patients with chronic pain report believing that they use the ED appropriately, frustrations in communications with physicians, and helplessness regarding the management of their condition. 15 Issues to adequately manage care for patients with CP in the ED include (1) time limitation for consultation; (2) low triage priority for CP concerns; (3) lack of a primary care physician; (4) finances; (5) frequency of presentation to the ED; and (6) healthcare provider attitudes of patients with CP as being annoying or having addictions. 16

Studies have found depression and CP to coexist. 14,17 The presence of pain can negatively influence the recognition and treatment of depression, whereas depression is associated with more pain complaints and increased impairment. 17 Suggested treatments include an interdisciplinary approach involving healthcare professionals (i.e., pain specialist, physical therapist, psychologist, etc.) working together to develop care plans that address the biopsychosocial factors that may be contributing to patients' pain and functioning. 15,18,19 For example, Donovan et al 15 found that a pain management program resulted in significant changes in patients' beliefs and behaviors associated with the ED, where patients reported greater attention to trying other strategies and resources before contemplating going to the ED. In addition, when queried about possible alternatives to the ED, frequent ED users described the need for an after-hours option for minor health issues, a nurse call line, symptom cards, or similar resources to aid in their decision of where to seek treatment. 14 These findings suggest that patients with CP who are HFUs of the ED are a suitable demographic for program development to address pain management issues in more efficient and effective ways.

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Specific Objectives

The purpose of this study was to understand the factors that motivate patients to visit the ED repeatedly for their CP and to better understand their care experiences, as well as understand patients' perspectives on possible alternatives to visiting the ED. Information from patients will inform the development of potential solutions to improve clinical outcomes and reduce acute care utilization among patients with CP.

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Methods

Design

We used a mixed-method design combining descriptive quantitative and inductive qualitative methods. Data collection methods included semi-structured interviews and administered questionnaires. Data from these sources were triangulated. This study was reviewed and approved by the host hospital institution's research ethics board (Protocol # 20140092-01H). Research ethics board approval is required before proceeding with recruitment or data collection at our institution.

This study was conducted at an academic hospital located in a large urban Canadian city. At the time of this study, the hospital hosted a pain medicine clinic staffed by pain medicine specialists (physicians), nursing staff, and a psychologist, as well as a 4-week intensive interdisciplinary CP management program. The study was designed by pain clinic staff after they found that 10.4% of ED visits at their center were attributable to CP and that 93 of the 255 HFUs (patients with more than 12 ED visits per year) were repeatedly presenting for CP-related concerns. 20

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Participants

Participants were 12 adults who were living with CP (e.g., pain lasting longer than 12 weeks) and had visited the ED 12 or more times during the 2013–2014 fiscal year (FY), with 50% of visits attributable to CP and a minimum of one CP-related visit in the 2 months preceding enrollment. An indication that the patient was presenting for an ongoing or recurrent pain problem (e.g., low back pain) for at least 3 months had to be present in the chart and confirmed by a healthcare professional (physicians or chiropractor associated with the study) through a review of their chart.

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Procedure

We obtained a list of patients with 12 or more ED visits during the 2013–2014 FY. Three staff members reviewed the HFUs' medical charts to identify the most responsible diagnosis. This was performed in duplicate, and any disagreement was resolved during a consensus meeting. Informed consent was obtained from all participants.

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Data Collection

Participants completed eight questionnaires, including demographic and medical information (Table 1) and several psychometrically validated questionnaires recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. 21 These questionnaires collected information about specific clinical outcomes, including pain and pain cognition using Brief Pain Inventory 22,23 ; insomnia using Insomnia Severity Index 24,25 ; risk of opioid misuse using Screener and Opioid Assessment for Patients with Pain-Revised 26 ; and posttraumatic stress symptoms using (Patient Health Questionnaire [PHQ-9]), 27 Pain Catastrophizing Scale, 28 Generalized Anxiety Disorder scale (GAD-7), 29,30 and the Posttraumatic Stress Disorder Checklist (PCL-5). 31

Table 1-a

Table 1-a

Table 1-b

Table 1-b

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Interviews

Two registered nurses interested in CP care, who were clinical research graduate students with no connections with the hospital's pain clinic or the ED, completed the interviews. They had previous clinical experience, as well as qualitative research training through a graduate class, and mentorship from their professor. The 60–90 minute semi-structured interviews asked open-ended questions (Table 2), did not use a rating scale, and occurred at a time and location that was convenient for the participants (e.g., hospital meeting room or off-site at the participant's home). The overarching questions guiding the interviews were as follows: (1) What are the factors contributing to ED visits; (2) How is CP care in different contexts experienced by the patient; and (3) What are the possible alternatives to ED visits? Participants were also asked to provide feedback on alternatives to ED visits (e.g., access to an interdisciplinary pain program with regular follow-up and pain management plans).

Table 2

Table 2

Data collection and analyses were performed in iterative cycles, including weekly meetings with the research team to discuss findings and refine the interview guide.

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Data Analyses

Quantitative Data

Demographic characteristics (e.g., age and sex), medical information (e.g., pain location), and questionnaire data were entered into Statistical Package for the Social Sciences 32 to calculate descriptive statistics (Table 1).

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Qualitative Data

All interviews were transcribed, verified for accuracy, deidentified, and entered into QSR NVivo10. 33 The principles of Applied Thematic Analysis (ATA) 34 using interpretive and quantitative techniques were used, including the following: (1) reading the transcripts several times to identify significant text; (2) considering significant text and emergent meanings; (3) labeling meaningful components and defining themes; (4) line-by-line coding; (5) comparing and contrasting themes across and within transcripts; and (6) reviewing the overall thematic patterns and developing a thematic scheme. 34 This approach was considered appropriate for its rigor and its ability to generate new information including potential hypotheses for future studies looking at alternative approaches to presentation in the ED.

To enhance credibility and dependability, the transcripts were first read and coded independently by three researchers. Then, the codes and development of the thematic scheme were discussed at weekly coding meetings. During these discussions, we also integrated the quantitative data collected with attention to points of divergence and convergence, which aimed to validate and enrich our understanding of the problems and to consider potential solutions for high use of the ED for CP. These findings were interpreted with attention to the extant literature, highlighting similarities and differences that would warrant further study.

Based on the results of previous chart reviews conducted in 2012–2013, where we found 93 patients with CP who met the minimum number of visits to qualify for an HFU, 3 we anticipated that a minimum of 60 patients would be eligible to participate. We aimed at enrolling 12 participants, which is adequate in qualitative research using thematic analysis. 35

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Results

Twelve of the 19 patients who were approached for the study agreed to participate. Participants were predominantly women (58.33%) between the ages of 26 and 68 years (M = 46.2; SD = 13.8). Pain locations and medical comorbidities contributing to pain were heterogeneous (i.e., Crohn disease and headache). All participants reported moderate or severe pain (M = 5.75; SD 2.63) and moderate or severe pain interference (M = 5.95, SD = 2.67). The domain most severely affected by pain was sleep (M = 7.27, SD = 1.95), and 54.5% of participants met the cutoff score for clinically significant insomnia. Mood, anxiety, and trauma-related symptoms were common, with 54.55% of participants endorsing moderate or severe depressive symptoms, 45.5% of participants endorsing moderate or severe anxiety, and 27.27% scoring above the clinical cutoff, suggesting posttraumatic stress disorder. A clinically significant level of pain catastrophizing 28 was endorsed by 27.27% of participants (M = 26.66, SD = 14.15). More than half of all the participants scored above the cutoff number, suggesting high risk of opioid drug misuse (Table 3).

Table 3

Table 3

Analyses of the interviews resulted in four thematic schemes (Figure 1): (1) factors and processes contributing to ED visits; (2) patients' experiences with a family physician or specialist; (3) patients' experiences of CP care in the ED; and (4) possible alternatives to ED visits. The descriptive quantitative questionnaires corroborated the thematic schemes generated from the qualitative ATA approach. This support is noted in the Discussion section, including the participants' emotional experiences of pain (e.g., fear and grief) and needing access to pain resources in the evening, which are corroborated by the assessment measurements reporting patients' significant levels of pain catastrophizing, anxiety, depression, and insomnia.

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Factors Contributing to Emergency Department Visits

Participants' inability to cope with pain and unsuccessful attempts of pain management influenced the decision to visit the ED (Table 4). Many times, patients described having exhausted their home pain management strategies (e.g., medication, rest, and exercise) before ED presentation. One patient explained, “The reason I'm [at the ED] is because I've extinguished all options at home that I could.” The ED is a final resort after other pain management resources have proven unsuccessful.

Table 4

Table 4

We found that emotional responses to pain also contribute to participants' decisions and experiences. Fear, for example, was a frequently coded subtheme, including fear of the pain escalating, which would influence patients' decisions to go to the ED and seek help in managing their apprehension that the pain would become unbearable. As one patient described, “I tried a couple Tramacet and I still didn't get enough pain relief from it. I think part of it too, I was scared it was going to get worse. I think there was a big fear component there as well.” In addition, patients noted fear of what their pain might mean (e.g., disease reoccurrence) and fears about the impact on their quality of life, which included a sense of grief and loss of what life used to be like and fears about their future: becoming immobile; losing social connections and becoming isolated; being unable to take care of their children, maintain employment, or complete activities of daily living.

Social influence also played a role in the patients' decisions to visit the ED; many described acting on suggestions from family members or healthcare providers when unable to relieve their pain. In addition, participants noted the ED as a means to gain access to other services and resources. One participant stated “My hematologist is [at the hospital], so that's why I go [to the ED]. The hematology in the specific hospital I go to deals with me immediately.” Thus, the ED may offer direct access to a specialist. Furthermore, patients presented to the ED to obtain medication, such as one participant who explained “I end up coming to the hospital…either when I have had pain for a length of time and I just become frustrated, or I have used up the amount of meds that they say I should.”

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Patients' Experience With a Family Physicians or Specialists

Two predominant themes emerged about patients' experiences with family physicians or specialists: presence (supportive or unsupportive) and limitations (perceived limitations or physician-acknowledged limitations; Table 5). A supportive presence involved feeling validated and their physician showing genuine interest in helping them manage their pain, whether this was through encouraging self-directed pain management strategies (e.g., lifestyle management or seeing a pain specialist) or offering resources to help manage their pain directly (e.g., prescribing pain medication, adjunctive therapies, etc.). A supportive presence was described by one participant as knowing exactly what he was going through and “…he's compassionate about it and he's like ‘I wish I could take it away’ you know.”

Table 5

Table 5

Conversely, an unsupportive presence included a perceived lack of empathy and disregard for the patient's pain symptoms. Participants described moments when their family physician or specialist vocalized disapproval of attending the ED or taking medications to manage pain. In addition, some patients perceived physicians as being limited by a lack of time (e.g., too busy to help manage pain) and/or a lack of knowledge (e.g., the physician does not know how to manage pain nor understands his/her pain condition), which in some cases was corroborated by their physicians themselves. For example, one participant explained that she felt her family physician was empathetic, yet was informed by this physician that she had “her own moral beliefs about certain pain killers and she would rather a specialist who does understand a little bit more to deal with that.” This perceived lack of understanding, support, and knowledge contributed to participants then attending the ED.

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Patients' Experience of Chronic Pain Care in the Emergency Department

Two primary themes emerged: (1) validating experiences and (2) invalidating experiences (Table 6). A validating experience consisted of the patient feeling that their pain was taken seriously by the ED staff, experiencing compassion and genuine concern from the ED staff, and believing their pain management needs were met. A participant explained the validation of having his needs met and pain relieved: “[The ED staff is] pretty caring about me. They're quick to respond to my needs and they do the job right. They get the pain out of my body and out of my system. So that's why I go there.” This contributed to patient confidence and validation in the decision to visit the ED (e.g., believing that she/he made the right choice).

Table 6-a

Table 6-a

Table 6-b

Table 6-b

Invalidating experiences were defined by the relationship between the patient and the ED staff or the patient–provider relationship. Invalidation included the following: feeling unacknowledged and misunderstood; experiencing a lack of compassion and disregard from the staff; and feeling judged by others and critical of themselves. One participant explained “…there's not one minute I'm in the hospital that I'm not uncomfortable, because I feel I should not be here.” Invalidation also involved the patients feeling judged by the staff about possible drug-seeking behaviors or as one participant stated “…the worst time of my life, is the time walking in the emergency door and [being] told I sought medication.”

Participants noted that their reason for presenting to the ED seemed to influence the care they received; certain types of pain were perceived to be taken more seriously than other types of pain. For example, one participant noted that when seeking pain relief at the ED for kidney problems, he was treated very seriously. Conversely, when he went in for back problems, the ED staff questioned him more rigorously and in a way that suggested that drug seeking was suspected, and he had to wait longer to receive care. Participants also noted that frequent visits prompted more questions from staff members about potential drug-seeking behaviors. Some participants explained that although their frequent ED visits may have been questionable to some staff, their ED experience was improved because frequent visits created a sense of familiarity with the ED staff and comfort in knowing they would not have to re-explain their medical history.

Participants also spoke of actively self-regulating to have better experiences of care. One participant talked about doing everything he could to be perceived as the best patient possible, working hard at regulating his emotions so that he never “snapped” at anyone in the ED, despite feeling frustration in the setting of his intense pain. Patients also spoke about the importance of managing their expectations and accepting that their pain may not go away and thereby focusing on pain management strategies as opposed to holding on to a potential cure.

Finally, participants described various positive care outcomes such as achieving pain relief, having additional tests or procedures done, and/or being admitted for hospitalization.

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Possible Alternatives to Emergency Department Visits

Eleven of the 12 participants believed that an interdisciplinary approach would be helpful, along with personalized care plans with step-by-step strategies provided by their healthcare team. In addition, participants believe that follow-ups (e.g., a phone call or an appointment with a pain specialist) would be helpful (Table 7).

Table 7-a

Table 7-a

Table 7-b

Table 7-b

Participants suggested community resources as an alternative to ED visits. Resources included exercise classes, adjunctive therapies, and assistance with their lifestyle (e.g., sleep and nutrition habits) and were considered a much-needed means to learn pain management. As one participant exclaimed “I'd be a sponge. I'd take in anything I can. I'd go anywhere I could to learn anything.” Participants explained that there is a lack of community-based medical resources, particularly resources that are available in the evening or at night. Participants also suggested having a home management system involving the opportunity to receive the same medication at home as they would in the ED.

In contrast to the majority, three participants said that there are no other alternatives to the ED for managing their acute-on-chronic pain and that they would continue presenting to the ED because they found it to be the most useful approach when in crisis.

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Limitations

Limitations for this study include the research being conducted at only one institution and only featuring participants who agreed to be part of the study. Because of these limitations, it is not possible to ascertain whether the results are generalizable to other CP-HFUs. In addition, the interview questions exploring the patients' experiences with their primary care provider and receptivity to an interdisciplinary care team may be considered leading, particularly when asked about the role of their provider in pain management and if they would like an interdisciplinary care team. This may have limited the exploration of alternative care approaches to specifically an interdisciplinary care team. However, we also note that patients did bring other interesting ideas forward, which could be explored in further studies or trialed in health systems.

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Discussion

This study contributes to a better understanding of the factors influencing presentation to the ED by CP-HFUs, their experiences of care in the ED and in the community, as well as potential alternatives to visiting the ED.

The primary factor influencing presentation to the ED included the patients' inability to manage pain on their own. This corresponds with the patients wanting to learn self-management techniques as an alternative to the ED. These findings also support results from another survey of patients using the ED to manage CP at our institution. 6

Another major factor in ED presentation was the emotional component of the patients' pain, namely fear and grief. This is corroborated by the results from the assessment measures showing that more than a quarter of participants reported significant levels of pain catastrophizing, as well as moderate to severe levels of anxiety and depression. Fearful thinking is associated with greater attention and hypervigilance to pain, as well as increased pain. 36 Loss and grief have been identified by other researchers as important for people living with pain. 37 Thus, when considering ED presentations, it may be worth exploring the patient's emotional experiences.

Another highlight is the participants' experience with their healthcare providers, both in the ED and with their family physician or specialist. Interactions with their family physician or specialist were described as a supportive or unsupportive presence, and experiences in the ED were considered validating or invalidating, pending their interactions with the ED staff. These emergent themes emphasize the importance of the patient–provider relationship, especially whether or not a patient with CP feels acknowledged and validated, and whether their needs are met. These results parallel results from other studies exploring CP in the ED, where patients described frustration in communicating with their healthcare providers when being questioned about drug-seeking behaviors. 15

Findings from this study emphasize the importance of improving patient–provider relationships in CP care. This may be particularly critical in cases where substance dependence is identified as a factor in ED presentation or when healthcare professionals' opinion about pain management does not meet patients' expectations. Healthcare professionals being able to maintain positive regard, empathy, and an overall validating stance while maintaining boundaries are important skills to refine in these contexts.

Dignity-enhancing care approaches may be promising in this regard. 38,39 These approaches, though predominately known and used in palliative care settings, focus on finding ways to convey respect for the patient and creating a sense of worthiness and esteem. 38,39 Addressing the patient's concerns, fears, and gaining a better understanding of their pain experiences through a holistic dignity approach may help the patient feel acknowledged and that their pain experiences are valid, even in cases where their perspective on medical management differs from that of their healthcare professional.

Results from this study also highlight the need for medical and community resources, including interdisciplinary teams, personalized care plans, follow-up appointments, and home management. An interdisciplinary approach to pain management was considered acceptable by most participants, whereas all participants suggested having a personalized care plan and more community resources to help with pain management. These results parallel other studies assessing the experiences of patients with CP in the ED, specifically where patients identify a lack of an individualized care plan 40 and want resources to help manage their pain outside of attending the ED. Furthermore, participants noted access to resources in the evening would be an important and useful alternative to the ED, such as being able to attend a clinic during the evening or nighttime hours. These reports align with the assessment measures demonstrating that over half of the participants had clinically significant symptoms of insomnia. These findings correspond with other studies examining CP in the ED, which have demonstrated that the time of the day matters for presentation to the ED. 40

A possible solution for frequent presentation to the ED may include increasing medical resources available in the community, as well as implementing home management strategies. Participants indicated that community-based medical care should be designed to provide quick pain relief (e.g., access to pain medication and the opportunity to consult with a specialist) as a viable alternative to the ED. Home management strategies could also help increase a patient's sense of control; this could involve home care when appropriate, with staff who are familiar with the patient's medical history. This would improve access to care in a timely manner and minimize the need for patients to repeat their pain story multiple times.

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Conclusions

Factors leading to repeated ED presentation by patients with CP are complex and multipronged. Approaches targeting ED staff, family physicians, community-based resources, and patients are needed to better meet patients' needs and reduce healthcare cost. Further research exploring patient–provider relationships in CP care is warranted, whereas alternative approaches, such as dignity care approaches that focus on the entire individual, are worth exploring to improve CP patients' healthcare experiences and health outcomes.

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Implications

  • Healthcare providers can consider using dignity care approaches to improve patient–provider relationships.
  • Addressing emotional experiences may help CP patients develop healthier coping mechanisms and pain management strategies in relation to their experiences of fear and grief.
  • Healthcare providers in the ED may consider ways to validate the patient's pain symptoms, yet also redirect patients to more appropriate settings for long-term care and pain management.
  • Practitioners may consider collaborating with medical resources in the community, specifically ones available during the evening or nighttime hours.
  • Interdisciplinary teams and personalized care approaches may be cost-effective healthcare solution for treating patients with CP.

Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at www.nahq.org/journal/ce. This continuing education offering, JHQ 280 41.5 (September/October 2019), will provide 1 hour to those who complete it appropriately.

Core CPHQ Examination Content Area

IV. [Domain—Performance Measurement and Improvement]

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Understanding the High-Frequency use of the Emergency Department for Chronic Pain Patients: a Mixed-Methods Study

Learning Objectives:

  1. Describe the factors contributing to chronic pain-related emergency department visits by high-frequency users.
  2. Describe chronic pain patients' care experiences in the emergency department.
  3. Provide examples of alternative options for pain management for patients with chronic pain, rather than visiting the emergency department.
  4. Describe the social and financial issues affecting the treatment and management of care in the emergency department.
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Questions

  • 1. According to previous literature, managing care for patients with chronic pain in the ED is problematic because of the following:
    1. Time limitation for consultations; low triage priority for chronic pain concerns; and lack of a primary care physician
    2. Time limitation for consultations; low triage priority for chronic pain concerns; and lack of medical resources to address pain
    3. Time limitation for consultations; low triage priority for chronic pain concerns; and lack of emergency department staff
    4. Time limitation for consultations; low triage priority for chronic pain concerns; and lack of community-based resources for pain management
  • 2. Research demonstrates that factors influencing the management of care for chronic pain patients in the emergency department include the following:
    1. Healthcare provider's lack of medical training for chronic pain management; finances; and the frequency of chronic pain patients' presentations to the emergency department
    2. Healthcare providers refusal to provide certain medications; finances; and the frequency of chronic pain patients' presentation to the emergency department
    3. Healthcare provider perception of chronic pain patients as having addictions; finances; and the frequency of chronic pain patients' presentation to the emergency department
    4. Healthcare provider's lack of communication with other providers; finances; and the frequency of chronic pain patients' presentation to the emergency department
  • 3. Research examining emergency department use acknowledges that the ED is problematic for the treatment and care of chronic pain because of high costs and __________________:
    1. High probability the patient will return again
    2. High demands placed on the emergency department staff
    3. High volume of patients and long wait times
    4. Higher risk of adverse advents
  • 4. According to this study, a contributing factor influencing chronic pain patients' decisions to visit the emergency department included the following:
    1. Inability to cope with pain and unsuccessful attempts at pain management
    2. Inability to cope with pain and unsuccessful attempts to communicate with their primary care physician or specialist
    3. Inability to cope with pain and lack of sleep
    4. Inability to cope with pain and lack of social support
  • 5. Participants from this study noted their emotional responses to pain as a contributing factor affecting their decisions to visit the emergency department, primarily their experiences of fear and concerns about their pain escalating, the impact on their quality of life, and ____________:
    1. Impact on their financial resources
    2. Fear of disease reoccurrence
    3. Perceived loss of control
    4. Impact on their family members
  • 6. Participants described visiting the emergency department to gain access to other services including the following:
    1. Medication refills and prioritization for medical testing
    2. Medication refills and direct access to emergency department doctors and nurses
    3. Medication refills and support from family members and friends
    4. Medication refills and access to specialists
  • 7. Participants described an unsupportive presence from family care physicians or specialists as a perceived lack of knowledge for how to manage chronic pain, lack of time to meet with patients, and ____________________:
    1. Perceived lack of connection to other providers and specialists to recommend care
    2. Perceived lack of empathy and disregard for the patient's pain symptoms
    3. Perceived lack of resources to provide chronic pain care
    4. Perceived lack of listening skills
  • 8. Validating experiences in the emergency department for patients with chronic pain included the following:
    1. ED staff taking the patient's pain seriously; patients believing their pain management needs were met; and experiencing support from family members
    2. ED staff taking the patient's pain seriously; patients believing their pain management needs were met; and experiencing direct care from specialists
    3. ED staff taking the patient's pain seriously; patients believing their pain management needs were met; and experiencing less stress in the ED setting
    4. ED staff taking the patient's pain seriously; believing pain management needs were met; and experiencing compassion and genuine concern from staff
  • 9. As noted by the participants, possible alternatives to the emergency department included the following:
    1. Interdisciplinary approaches; community resources; and personalized care plans and follow-ups from healthcare providers
    2. Interdisciplinary approaches; community resources; and in-home care from nurses and healthcare providers
    3. Interdisciplinary approaches; community resources; and faster access to appointments with their primary care physician
    4. Interdisciplinary approaches; community resources; and specialized pain management clinics
  • 10. Community Resources suggested by the participants as alternatives to emergency department visits for chronic pain included the following: interdisciplinary approaches; adjunctive therapies; lifestyle management classes (e.g., sleep, exercise, and nutrition); home management system (e.g. medications at home); and ________________:
    1. Pain management support groups
    2. Seminars and workshops for coping with chronic pain
    3. Evening heathcare resources (e.g., nighttime clinics)
    4. Access to a 24-hour pain management helpline
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Authors' Biographies

Brittany A. Glynn, PhD, is a Research Associate at the Ottawa Hospital Research Institute (OHRI) in Ottawa, Ontario, Canada. Brittany oversaw the qualitative data analyses and the development of themes and codebook and wrote the manuscript.

Madeleine Brulé, BSc, Hon., is a volunteer research student at the Ottawa Hospital Research Institute (OHRI) in Ottawa, Ontario, Canada. Madeleine was responsible for the qualitative analyses, developing the codebook, and constructing quote tables and conceptual diagrams.

Samantha L. Kenny, BA Hon., is a Research Assistant at the Ottawa Hospital Research Institute (OHRI) in Ottawa, Ontario, Canada. Samantha was responsible for the quantitative data analyses, constructing data tables, writing about the descriptive measures, and preparing the manuscript for publication.

Eve-Ling Khoo, BSc, Hon, is the Clinical Research Coordinator at the Ottawa Hospital Research Institute (OHRI) in Ottawa, Ontario Canada. Eve was responsible for quantitative data analyses and preparing the manuscript for publication.

Yaadwinder Shergill, DC, is a Research Associate at the Ottawa Hospital Research Institute (OHRI) in Ottawa, Ontario, Canada. Yaadwinder was responsible for conducting the chart reviews, provided study coordination, and assisted in preparing the manuscript for publication.

Catherine E. Smyth, MD, is an Anesthesiologist and Pain Medicine Specialist in the Department of Anesthesiology and Pain Medicine at The Ottawa Hospital and at the University of Ottawa, as well as a Clinical Investigator at the Ottawa Hospital Research Institute (OHRI), Ontario, Canada. Catherine is the study's Co-Principal Investigator; she has co-constructed this research project from inception and takes responsibility for the manuscript as a whole.

Patricia A. Poulin, PhD, is a Clinical Psychologist in the Department of Psychology at the Ottawa Hospital, a Clinical Professor in the School of Psychology and Department of Anesthesiology and Pain Medicine at The University of Ottawa, as well as an Associate Scientist at The Ottawa Hospital Research Institute (OHRI) in Ottawa, Ontario, Canada. Patricia has co-constructed this research project, supervised the project from inception, and also takes responsibility for the manuscript as a whole.

Keywords:

chronic pain; emergency department; mixed methods

© 2019 National Association for Healthcare Quality