How can the management of pain in adult UK emergency departments be improved? (IMPEDE study)

Pain is a common symptom for patients presenting to the Emergency Department (ED) although pain management in the ED is widely recognised as inadequate. Little is known about the barriers and enablers to pain management within the ED. This thesis addresses the question of how pain management in EDs can be improved, using systematic review of interventions to improve pain management and multiple case study analysis of 3 EDs with different pain management outcomes to explore barriers and enablers to pain management. Findings from case studies suggested that ED staff conceptualised pain management as distinct from the core role of the ED, and operated within a framework of beliefs around how pain was managed and prioritised that allowed deficiencies in pain management to be perpetuated. Pain management was not considered one of the core maxims for which staff were accountable and staff had limited awareness of their own performance. Attempts to objectify assessment of pain using pain scores to guide pain management encouraged staff to alter patient report and reduced the validity of the score as a measure of change in patient’s pain. The reductive processes of pain scoring and providing analgesia according to score set out within current guidelines did not conform to patient expectations/conceptualisations of pain management. The three case study EDs differed in how they altered processes and workforce to address structural barriers to pain management and prioritised how pain was managed. This thesis found no evidence to support implementation of any particular intervention to improve pain management but suggests multifaceted changes may help by developing a culture in which pain management is integrated into the core work of the ED. EDs may improve pain management by altering processes to actively enable pain management, particularly at initial assessment. Improved communication and reassurance may improve patient experience.