Pain Assessment in the Emergency Department: A Prospective Videotaped Study

Abstract

Introduction: Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician's perception of a patient's pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment.

Methods: We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos.

Results: A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0-6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain (correlation coefficient, 0.46; P <0.001), with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001).

Conclusion: Patients' self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors.

Figure 1

Flow diagram of patient selection process for study comparing patient and physician pain scoring at emergency department triage.

Figure 2

The scatterplot of self-reported pain scores and physicians’ ratings of pain. The line indicates the best-fit linear regression line. The sizes of circles are proportional to the number of observations.

Figure 3

The Bland-Altman plot of the agreement between self-reported pain scores and physicians’ ratings of pain. The green line represents the mean difference between the patient and physician scores. The shaded box is bounded by the statistical limits of agreement (defined as the mean difference ± 1.96 SD of differences).