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.
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.
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.
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.
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.
IV. [Domain—Performance Measurement and Improvement]
1. Todd KH, Cowan P, Kelly N, Homel P. Chronic or recurrent pain in the emergency department
: National telephone survey of patient experience. West J Emerg Med. 2010;11:408–415.
2. Milbrett P, Halm M. Characteristics and predictors of frequent utilization of emergency services. J Emerg Nurs. 2009;35:191–198.
3. Caluyong M, Tremblay S, Nelli J, et al. Understanding chronic pain
in TOH emergency departments: What are the characteristics of patients who seek treatment in the emergency department
?. At the 13th Annual Conference of The Ottawa Hospital Research Institute; 2013; Ottawa, ON.
4. Dixon WJ, Fry Ka. Pain recidivists in the emergency department
. J Emerg Nurs. 2011;37(4):350–356.
5. Jorgensen DJ. Fiscal analysis of emergency admissions for chronic back pain: A pilot study from a Maine hospital. Pain Med. 2007;8(4):354–358.
6. Poulin PA, Nelli J, Tremblay S, et al. Chronic pain
in the emergency department
: A pilot mixed-methods cross-sectional study examining patient characteristics and reasons for presentations. Pain Res Manag. 2016;2016:3092391.
7. LaCalle E, Rabin E. Frequent users of emergency departments: The myths, the data, and the policy implications. Ann Emerg Med. 2010;56(1):42–48.
8. MacLeod DB, Swanson R. A new approach to chronic pain
in the ED. Am J Emerg Med. 1996;14:323–326.
9. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain
in United States adults: Results of an internet-based survey. J Pain. 2010;11(11):1230–1239.
10. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain
in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287–333.
11. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain
in Canada. Pain Research & Management: The Journal of the Canadian Pain Society. 2011;16(6):445–450.
12. Latremoliere A, Woolf CJ. Central sensitization: A generator of pain hypersensitivity by central neural plasticity. J Pain. 2009;10(9):895–926.
13. Woolf C. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2011;152(3):S2–S15.
14. Birmingham LE, Cochran T, Frey JA, Stiffler KA, Wilber ST. Emergency department
use and barriers to wellness: A survey of emergency department
frequent users. BMC Emerg Med. 2016;17(1):16.
15. Donovan E, Ranney ML, Reid AM, Baird J, Green TC. Chronic pain
in the emergency department
. R Med J. 2017;100(2):25.
16. McLeod D, Nelson K. The role of the emergency department
in the acute management of chronic or recurrent pain. Australas Emerg Nurs J. 2013;16:30–36.
17. Wilson M, Roll J, Pritchard P, Masterson B, Howell D, Barbosa-Leiker C. Depression and pain interference among patients with chronic pain
after ED encounters. J Emerg Nurs. 2014;40(3):e55–e61.
18. Singhal NR. Pediatric patients with chronic pain
in the emergency department
. Clin Pediatr Emerg Med. 2017;18(4):292–297.
19. Bhatt S. The chronic pain
patient in the emergency department
. Curr Emerg Hosp Med Rep. 2016;4(2):33–39.
20. Tremblay S, Nelli J, Poulin P, et al. Understanding the burden of visits for chronic pain
to the Ottawa hospital emergency department
. In: Annual Gary Johnson Anesthesiology Research Day; 2014; Ottawa, ON.
21. Dworkin RH, Turk DC, McDermott MP, et al. Interpreting the clinical importance of group differences in chronic pain
clinical trials: IMMPACT recommendations. Pain. 2009;146(3):238–244.
23. Cleeland CS. Measurement of pain by subjective report. In: Chapman CR, Loeser JD, eds. Advances in Pain Research and Therapy. Vol 12. New York, NY: Raven Press; 1989:391–403.
24. Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307.
25. Morin CM, Belleville G, Bélanger L, Ivers H. The insomnia severity Index: Psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–608.
26. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised screener and opioid assessment for patients with pain (SOAPP-R). J Pain. 2008;9(4):360–372.
27. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
28. Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: Development and validation. Psychol Assess. 1995;7(4):524–532.
29. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006;166:1092–1097.
30. Swinson RP. The GAD-7 scale was accurate for diagnosing. Evid Based Med. 2006;11(6):184.
31. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM-5
(PCL-5): Development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489–498.
32. IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.
33. NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 10, 2012.
35. Ando H, Cousins R, Young C. Achieving saturation in thematic analysis: Development and refinement of a codebook 1, 2, 3. Compr Psychol. 2014;3(4):2165–2228.
36. Crombez G, Viane I, Eccleston C, Devulder J, Goubert L. Attention to pain and fear of pain in patients with chronic pain
. J Behav Med. 2013;36(4):371–378.
37. Dysvik CH, Dysvik E. The experience of loss in patients suffering from chronic pain
attending a pain management group based on cognitive-behavioral therapy. Pain Manag Nurs. 2014;15(1):12–21.
38. Gastmans C. Dignity-enhancing nursing care: A foundational ethical framework. Nurs Ethics. 2013;20(2):142–149.
39. Solomon BK, Wilson KG, Henderson PR, Poulin PA, Kowal J, McKim DA. Loss of dignity in severe chronic obstructive pulmonary disease. J Pain Symptom Manage. 2016;51(3):529–537.
40. Jambunathan J, Chappy S, Siebers J, Deda A. Patient-centered care for chronic pain
in the emergency department
: A qualitative study. Int Emerg Nurs. 2016;24:22–27.
Understanding the High-Frequency use of the Emergency Department for Chronic Pain Patients: a Mixed-Methods Study
- Describe the factors contributing to chronic pain-related emergency department visits by high-frequency users.
- Describe chronic pain patients' care experiences in the emergency department.
- Provide examples of alternative options for pain management for patients with chronic pain, rather than visiting the emergency department.
- Describe the social and financial issues affecting the treatment and management of care in the emergency department.
- 1. According to previous literature, managing care for patients with chronic pain in the ED is problematic because of the following:
2. Research demonstrates that factors influencing the management of care for chronic pain patients in the emergency department include the following:
- Time limitation for consultations; low triage priority for chronic pain concerns; and lack of a primary care physician
- Time limitation for consultations; low triage priority for chronic pain concerns; and lack of medical resources to address pain
- Time limitation for consultations; low triage priority for chronic pain concerns; and lack of emergency department staff
- Time limitation for consultations; low triage priority for chronic pain concerns; and lack of community-based resources for pain management
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 __________________:
- Healthcare provider's lack of medical training for chronic pain management; finances; and the frequency of chronic pain patients' presentations to the emergency department
- Healthcare providers refusal to provide certain medications; finances; and the frequency of chronic pain patients' presentation to the emergency department
- Healthcare provider perception of chronic pain patients as having addictions; finances; and the frequency of chronic pain patients' presentation to the emergency department
- Healthcare provider's lack of communication with other providers; finances; and the frequency of chronic pain patients' presentation to the emergency department
4. According to this study, a contributing factor influencing chronic pain patients' decisions to visit the emergency department included the following:
- High probability the patient will return again
- High demands placed on the emergency department staff
- High volume of patients and long wait times
- Higher risk of adverse advents
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 ____________:
- Inability to cope with pain and unsuccessful attempts at pain management
- Inability to cope with pain and unsuccessful attempts to communicate with their primary care physician or specialist
- Inability to cope with pain and lack of sleep
- Inability to cope with pain and lack of social support
6. Participants described visiting the emergency department to gain access to other services including the following:
- Impact on their financial resources
- Fear of disease reoccurrence
- Perceived loss of control
- Impact on their family members
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 ____________________:
- Medication refills and prioritization for medical testing
- Medication refills and direct access to emergency department doctors and nurses
- Medication refills and support from family members and friends
- Medication refills and access to specialists
8. Validating experiences in the emergency department for patients with chronic pain included the following:
- Perceived lack of connection to other providers and specialists to recommend care
- Perceived lack of empathy and disregard for the patient's pain symptoms
- Perceived lack of resources to provide chronic pain care
- Perceived lack of listening skills
9. As noted by the participants, possible alternatives to the emergency department included the following:
- ED staff taking the patient's pain seriously; patients believing their pain management needs were met; and experiencing support from family members
- ED staff taking the patient's pain seriously; patients believing their pain management needs were met; and experiencing direct care from specialists
- ED staff taking the patient's pain seriously; patients believing their pain management needs were met; and experiencing less stress in the ED setting
- ED staff taking the patient's pain seriously; believing pain management needs were met; and experiencing compassion and genuine concern from staff
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 ________________:
- Interdisciplinary approaches; community resources; and personalized care plans and follow-ups from healthcare providers
- Interdisciplinary approaches; community resources; and in-home care from nurses and healthcare providers
- Interdisciplinary approaches; community resources; and faster access to appointments with their primary care physician
- Interdisciplinary approaches; community resources; and specialized pain management clinics
- Pain management support groups
- Seminars and workshops for coping with chronic pain
- Evening heathcare resources (e.g., nighttime clinics)
- Access to a 24-hour pain management helpline
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.