Prevalence and Therapeutic Approach of Acute Pain in Emergency Provided by Triage Nursing

Objective: This work sought to assess the effectiveness of the treatment applied in patients with acute pain in the emergency service by triage nursing. Materials and Methods: Cross-sectional, observational descriptive study of quantitative approach, with measures of central tendency in 348 patients, conducted in 2016. An ad hoc questionnaire was used, elaborated by the emergency service, which assesses the intensity of pain through a numerical scale and a pain intervention protocol that includes physical and pharmacological measures. Results: After applying the first treatment, 80.17 % of the patients experienced improvement; 7.18 % required a second treatment and, of these, 87.5 % improved and 12.5 % suffered no modifications. The nursing staff treated the patients according to the protocol, with AINES and Metamizole, primarily. The rest were remitted to medical evaluation and another 40 patients rejected treatment. Conclusions: A high percentage of patients exist who improve their perception of pain after the first treatment administered by the triage nursing personnel. The results suggest revising and updating the protocol in the first treatment.

According to this research, nurses make decisions about providing care to patients who attend the emergency service with pain, bearing in mind their individual needs and according to a stipulated protocol.
It must be considered that a timely intervention is more effective, rapid, and economic. This study demonstrates that a timely intervention improves the quality of care to patients attending emergency services with pain.

Introduction
Pain is a highly unpleasant and very personal sensation that cannot be shared with others; it is difficult for the patient to communicate it and nurses cannot feel or see what the patient experiences. Differences in the perception of pain, as well as the different causes that produce it, face the nursing professional with the objective of developing a standard plan to relieve it and provide comfort (1-3).
The evaluation and effective treatment of pain is an important part of nursing care and represents a high-priority problem in itself, given that it is one of the most frequent motives for consultation in emergency services. Besides supposing physiological and physical danger to health and recovery, severe pain requires care and immediate treatment (4)(5)(6)(7).
According to the World Health Organization (WHO) and Human Rights Watch, treatment against pain is a human right. Globally, between 25 % and 29 % of the population suffers pain (8), and this is the principal motive for consulting in emergency services (approximately 78 %, of which one third reports intense pain). In spite of this, treatment is far from being optimum; a standard of care must be developed ranging from non-pharmacological strategies to protocolized therapeutic regimens, seeking to make the emergency service a place for comprehensive and humanized management of pain (9).
According to the Spanish Society of Pain, pain is one of the most frequent motives of consultation in emergency services, either for his exclusive condition, or for the pathologies that cause it. Although its prevalence (near 78 %) is very high, numerous studies have demonstrated that management of this symptom is often inadequate and that patients may receive suboptimal analgesic treatment due to inadequate guidelines, insufficient doses, or inappropriate medications (1,8). To treat pain, it is primordial to detect and evaluate it, both in triage, as during the stay in emergency.
One in every five Europeans suffers from pain and, of those who endure it, four experience acute pain. Only in the 28 countries of the European Union, 100-million people live with pain and half of these receive no treatment or are not even treated seriously (10). These data show the need to consider the treatment of pain and access to medical care a public health priority (11).
Currently, the intake of analgesics and antialgic neuromodulation techniques are the most-often used to mitigate pain, while invasive techniques remain relegated in the background. The importance of the patients' self-management and self-control is highlighted, as long as they do not fall into indiscriminate selfprescription. Some of the non-pharmacological techniques used in the treatment of pain are pressure/massage, vibration, surface heat and cold; application of cryogenic fluids, like menthol; transcutaneous electrical nerve stimulation, and other techniques could be added to these, like distraction and relaxation (12)(13).
According to data from the Spanish Society of Pain and the World Bank (an organism dependent on the United Nations), 182 pain units exist (14), which represents for Spain, with its 45,840,050 inhabitants in 2018, a special pain treatment unit for every 251,868 inhabitants (15).
Compared with neighboring countries of the European Union, and as indicated by the French Ministry of Health and Social Protection, throughout the French region, including Réunion, Martinique, Guadeloupe, Guyana, Corsica, and Mayotte, there are 266 pain treatment units or centers, that is, one unit for every 248,898 inhabitants (16).
Each hospital in Spain has a pain unit dependent on the Ministry of Health, Social Policy, and Equality according to ministry sources (17).
The Spanish Society of Pain reports not having any record of the assessment and treatment protocol of acute pain in hospital emergency services, and this is the reason for this study.
The general objective of this study was to evaluate the acceptance and effectiveness in the initial and secondary treatment applied in patients with acute pain in the emergency service by triage nursing. The specific objectives are 1) evaluate the acceptance of initial and secondary treatments of the protocol applied and 2) evaluate the effectiveness of initial and secondary treatments of the protocol applied.

Method
Cross-sectional, observational descriptive study of quantitative approach, with measures of central tendency (mean, median, and mode) (19)(20) and a type of non-random convenience or accidental sampling.
The sample was constituted by all the patients who attended emergency services with pain, independent of the type of pathology, and who needed treatment against said symptom in a hospital emergency service during a six-month period (July to December 2016). It includes a total of 348 subjects, bearing in mind the following exclusion criteria: Patients without pain, those under 14 years of age, and those who, due to deficiencies, could not answer the questionnaire.
An ad hoc protocol was created to treat acute pain in the emergency service, created by the medical and nursing staff, and endorsed with the approval by the Center's teaching/research commission, the pharmacology service, and the ethics service.
The questionnaire has three parts, with a total of six questions, varying dichotomous and closed questions with multiple answer and closed questions (annex I) 6 .
According to Grinspun (18), to collect the data, it is recommended to use a questionnaire previously approved and validated by the hospital center, besides including different quantitative measurement instruments to assess pain.
The first part collects sociodemographic data of the sample; the second part evaluates the pain on arrival to emergency; the third specifies the first treatment after the assessment of pain; and the fourth estimates the pain after 45 minutes from the start of the first treatment and indicates a second treatment, if needed, with its subsequent reevaluation.
Prior to putting into practice the questionnaire, a pretest was performed on 10 % of the sample of 348 patients to evaluate the efficacy and reliability of the questionnaire. These 35 questionnaires, out of the total 348, are not been part of the final result, nor were they part of the sample and served to adapt and demonstrate the suitability of the data collection instrument.
The respondent answered the questionnaire with the intervention of a pollster (nurses from the emergency service who were instructed on the management of the questionnaire during a two-month period, through seminars and training) in charge of asking the patient, through informed consent, to participate in the study (annex II).
According to the protocol, the triage nurse interviews the patient and evaluates the intensity of the pain suffered, through the pain numerical scale (NS) (0: No pain; 1-3: Slight; 4-6: Moderate; 7-10: Intense); then, the starts the non-pharmaceutical therapeutic measures (postural, local cold) if the pain ranges from slight to moderate (1-3), or the pharmaceutical therapeutic measures if the pain ranges from moderate to severe (4-6). When intense pain exists (7-10), the nurse remits the patient to the physician to indicate other therapy not included in the protocol, as in allergies or extreme pain. After 45 minutes, the patient is reevaluated and, in function of the new evaluation, the protocol is followed, varying or repeating the treatment, if necessary.
The study was approved by the Ethics, Research, and Teaching Committee at the Doctor Negrín University Hospital of Gran Canaria, according with current legislation, and was conducted with respect to the principles stated in the Helsinki Declaration and the norms of good clinical practice.
Description of the sample characteristics is made by summarizing the nominal variables with the absolute and relative frequencies of their categories, and those of the scale with mean or median and percentiles (P5 -P95), once proven its normal distribution of probabilities with the exploration of its histograms and results from the Kolmogorov-Smirnov test.
All the statistical tests used were bilateral at a significance level of p <0.05, and the corresponding calculations were exe-cuted with the IBM Statistical Package for Social Sciences (SPSS Statistics 19) for Windows.

Results
Upon breaking down the samples, information provided by the questionnaires was evaluated.
Of the 348 participants, 58.3 % were women, and 41.7 % were men. The mean age was 48.14 years, with a standard deviation of 19.58.
The NS evaluation scale was used by 100 % of the nurses.
The values yielded by the pain index, after evaluating the 348 patients, are reflected in Table 1. After applying the protocol with the initial treatment, 80.17 % of the patients experience improvement, which permits considering an appropriate index for the comparative evaluation of the methodologies to reduce pain in patients, according to what is shown in Table 2.
Twenty four patients (7.18 % of the sample) required a second treatment. The assessment of pain after the second treatment is shown in Table 3.  On their arrival to the emergency service, and after the pain assessment, patients were proposed the application of a first pharmacological treatment, according to the protocol (AINES or Metamizole), or non-pharmacological (local cold or heat or postural change). Some patients, according to the criteria of the triage nurse or upon doubt, were evaluated outside the protocol in a "medical evaluation" or, simply rejected any therapeutic measure against pain. All this is reflected in Table 4, which shows that 145 patients were treated according to the protocol by the nursing staff, with majority administration of AINES and Metamizole; 13 were treated according to the non-pharmaceutical therapeutic measures; 150 were remitted to medical evaluation; and 40 rejected treatment. The treatment used after the medical evaluation (that is, treatments prescribed outside the nursing protocol) is reflected in Table 5.  Table 6 exposes, after the initial medical and nursing evaluation, the degree of patient satisfaction according to the treatment applied. An improvement of 3.5 % is observed in the patients due to the postural change; of 0.3 % due to local cold; of 0.7 % due to local heat; of 30.1 % due to AINES; of 17.5 % due to Metamizole; of 6.8 % due to Paracetamol 1g; of 11.46 % due to Dexketoprofen; of 12.18 % due to Tramadol; of 1.07 % due to morphine; of 10.75 % due to Buscopan; and of 5.37 % due to other treatments.

Discussion
Pain is one of the principal reasons for consultation in the emergency area. The presentation of a study during the commemoration of the Global Day Against Pain showed that 43 % of those admitted to a hospital emergency service report acute pain as principal symptom (21). According to Abiuso, for cases of pain in general, the percentage increases to 78, and a third of such complain of intense pain (9). In turn, this study reveals that 38.21 % of the patients manifests intense pain and 39.08 % report very intense pain, a figure that reaches 77.29 % when bearing in mind both levels, which coincides with the results by Abiuso (9).
According to Potter (22), pain assessment comprises two important components: A history of pain to obtain data on the patient (onset, location, duration, aggravating factors, prior treatments that were effective or ineffective) and direct observation of the patient's behavioral and physiological responses to achieve objective comprehension of a subjective experience. In patients experiencing acute pain, the nurse focuses on the location, quality, intensity, and early intervention. In this case, pain assessment coincides with data by Abiuso and Potter and centers on the evaluation of acute pain, through an NS, in an emergency service.
According to Moreno (23), pain treatment comprises two basic interventions by nursing: Pharmacological and non-pharmacological. Pharmacological interventions, protocolized and through medical prescription include using opiates, non-opiates/AINES and adjuvant medications; cognitive-behavioral interventions encompass distraction techniques, relaxation techniques, visualization, biofeedback, therapeutic touch, and hypnosis.
This study used the different treatments available in the protocol, after nurse assessment, from physical postural techniques (cold or heat, etc.) to the administration of the medications indicated in the protocol, according to the degree of pain evaluated. Two types of pain assessment scales were permitted: The Algoplus and the NS; the latter was used in all the cases studied by the nurses.
The NS is equivalent to other pain assessment scales and serves as a guide on the effectiveness of the treatments. For most people, the value of 5 or more represents significant interference in daily life and the need to do something to counteract it, although not differentiating the psychological, emotional, and social components. In the protocol (annex III), the evaluation of the patient's pain treatment includes their response to it, modifications of the pain, and the patient's perception regarding the effectiveness of the treatment.
In this study, 14.4 % report slight pain; 21.26 %, moderate pain; 38.21 %, intense pain; and 39.08 %, very intense pain, which is why it is essential to implement these types of protocols with consensual measures and delve into them, given the positive results obtained.
It may be considered that, in their vast majority, patients are satisfied with the treatments applied, with no need to require a second treatment; 80.17 % report improvement after the first treatment and 87.5 %, after the second treatment. These data permit reconsidering the first treatment and the subsequent pain assessment in the protocol used.
Regarding analgesic non-pharmacological treatments, it is highlighted that, discarding patients who rejected any type of treatment against pain, non-pharmacological analgesics were used (postural change, local cold or heat) in 4.2 % of the cases, a treatment proven effective in 100 % of the cases.
An important percentage of patients do not accept the treatment proposed for pain according to the protocol, and the bibliography consulted has not revealed data to compare this information.
The importance and monitoring of the pain treatment in emergency services suggest the need to include pain as the fifth vital sign, performing the nursing assessment through the NS to contemplate it in the nursing care plan (NCP). The idea is to quantify, communicate, and register the intensity from the onset, and provide the data in the anamnesis, physical exam, observation, and follow up to offer more rational and individualized treatment.
In 2001, the Joint Commission for the Accreditation of Health Organizations established new norms to manage pain in hospitalized patients. Thereafter, pain management is recognized as the fifth vital sign. Although pain is a subjective symptom, quite difficult to measure with precision, it was sought for each hospital to develop adequate policies and procedure to assess pain and the use of analgesics as treatment. Adults are urged to evaluate the initial pain, using a scale from 0 to 10, as well as to evaluate the analgesic effect of the medication used (24).
Currently, according to the Spanish Society of Pain, no evidence exists of any protocol on the evaluation and treatment of acute pain in hospital emergency services in Spain, that is, in non-programmed access of patients to the hospital; therein, the validity of this study because it is the first to establish a pain assessment protocol in an emergency service.
In relation with patient satisfaction after the treatment administered by the triage nurse, according to the protocol established on arrival to the emergency service, it may be said that such treatment has a good assessment in terms of pain perception, given that 89.19 % of the patients report improvement.

Conclusions
The scales proposed in the questionnaires were the Algoplus and the NS, the two scales that adapt best to the type of patients attending emergency services, but the NS was chosen by the triage nurses in all the questionnaires studied.
A high percentage of patients exists who assess positively the first treatment after the triage nurse interview and the application of the pain protocol, which shows the importance of treating pain and improving the care quality and healthcare provided to patients attending the emergency service with pain.
During the second treatment, after the medical evaluation, the percentage of patients who assess positively is higher, although there is an important percentage that does not accept the treatment proposed for pain according to the protocol. These results suggest revising and updating the first treatment and the assessment of pain in the protocol applied.
During the initial treatment, the medications used most often were the AINES and Metamizole; after the medical evaluation, these were Dexketoprofen, Paracetamol 1g, Tramadol, Buscopan, and Morphine. This shows the need to evaluate incorporating Paracetamol and opiates to the initial nursing protocol. Likewise, it must be considered that physical means, like cold, local heat, or a simple postural change have served to reduce, by a high percentage, pain in patients treated.
From the data analyzed, it may be considered that, in their majority, patients are satisfied with the treatments applied in the emergency service, after being evaluated by the triage nurse, and waiting to be seen by the medical staff. Use of AINES, Metamizole, Paracetamol 1g, Dexketoprofen, Tramadol, and Buscopan is highlighted. This leads to evaluating positively the effectiveness of the treatment applied in patients with acute pain in the emergency service by triage nursing.

Recommendations
To guarantee the reliability of the use of the protocols or practice recommendations, specific continuous formation programs should be elaborated in the treatment of pain for triage nurses, and medics in the emergency services. Likewise, workshops should be conducted to develop communication skills, self-control of emotions, and adequate management of available tools.
Finally, along with the need for internal coordination among the staff, it is necessary to periodically update the protocols and recommendations, studying the indicators of their compliance through the quality management programs at the hospital center. Pain should be included as fifth vital sign.
Conflict of interests: None declared.