Emergency Medicine Australasia (2018) doi: 10.1111/1742-6723.

12945

ORIGINAL RESEARCH

Association between pain control and patient

satisfaction outcomes in the emergency department
setting
Tristam BROWN ,1 Amith SHETTY ,1,2 Dong Fang ZHAO,1 Nathan HARVEY,1 Teresa YU1 and
Margaret MURPHY2,3
1
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia, 2Emergency Department, Westmead Hospital,
Sydney, New South Wales, Australia, and 3Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia

Abstract pain score). Median time to analge-

Key findings
sia was 87.5 min (IQR 66.1–108.9).
Objective: Pain management and Patient satisfaction was inversely • Early and adequate pain
patient satisfaction are key markers associated with male sex, and posi- management and patient sat-
for health systems performance. tively correlated (Spearman’s rank isfaction in ED remain key
There is a lack of consensus on the correlation P < 0.05) with increasing ED management challenges.
role of analgesia, its adequacy, and age, significant change in pain score • We did not find strong cor-
its links to patient satisfaction in the (2) and compassion scores. relations between analgesia
ED. The present study aimed to Conclusion: In the present study of
assess the relationship between ade- and overall patient satisfac-
patients presenting to the ED with
quacy of analgesia and patient satis- pain, oligoanalgesia remains a signif- tion, with staff compassion
faction in the ED setting. icant issue. Male sex was inversely during ED patient interac-
Methods: Consenting adult patients associated with satisfaction, whereas tions highlighted as the
(n = 115) presenting to the ED with compassion, and significant change strongest predictor.
pain were enrolled, and their pain in pain score were associated with • Health systems should invest
tracked throughout admission with improved patient satisfaction. Of the in more specific patient satis-
11 point numerical pain scores. factors analysed, staff compassion faction tracking tools to better
Eleven point numerical scores were demonstrated the strongest correla- understand specific patients
also utilised to measure satisfaction tion with satisfaction. needs and expectations from
and compassion at the end of each
healthcare providers.
ED stay. The primary outcome was
patient satisfaction score ≥7. Key words: analgesia, emergency
Results: Of 115 enrolled patients, medicine, oligoanalgesia, pain, adequacy of analgesia delivered
94 (81.7%) were eligible for satisfaction. within the ED setting remains an
analysis. Median time to physician issue of contention, with authors
evaluation was 54.0 min (inter- divided between adequacy of analge-
quartile range [IQR] 35.0–98.0) and
Background sia and intolerably poor
median ED length of stay was Pain has been cited as a common ‘oligoanalgesia’.5–7 However, there is
205 min (IQR 129.0–280.0). Fifty- cause for presentation to the ED1 and strong suggestion that in Australia,
four patients (57.5%) received anal- is not only frequent, but is often also oligoanalgesia may prevail; a large,
gesia during their stay, of whom severe.2–4 Therefore, adequate and Australian, multicentre, initiative, the
36 (38.3%) had a significant timely analgesia has the potential to ‘National Health and Medical
response to analgesia (≥2 change in reduce morbidity and suffering. The Research Council – National Institute
of Clinical Studies National Pain
Correspondence: Dr Tristam Brown, Sydney Medical School, The University of Syd- Management Initiative’ demonstrated
ney, Camperdown, NSW 2050, Australia. Email: tristambrown@gmail.com poor median times to analgesia,
Tristam Brown, BMedSc, MBBS, GCertPainMgt, Anaesthetic Registrar; Amith Shetty, exceeding agreed benchmarks, and
MBBS, FACEM, Staff Specialist, Clinical Senior Lecturer, Co-Director, Honorary nil change in treatment efficacy for
Research Fellow; Dong Fang Zhao, MD, Junior Medical Officer; Nathan Harvey, patients in severe pain, despite post-
MBBS, BAppSc (Physio) (Hons), Resident Medical Officer, Clinical Associate Lecturer; intervention improvements in docu-
Teresa Yu, BA (Advanced) (Hons), MBBS, Resident Medical Officer; mentation and adherence to analgesia
Margaret Murphy, RN, GradDip ICU Nursing, GradDip Change Management and guidelines.8
Government, MHlthSc (Ed), Clinical Nurse Consultant, Clinical Senior Lecturer. Past studies have suggested associ-
Accepted 24 January 2018 ations between increased patient

© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
2 T BROWN ET AL.
satisfaction and pain scores;9
whereas failure to relieve pain has
been associated with higher rates of
re-presentation.10 Debate still exists
about the relationship between pain,
analgesia and satisfaction with some
reporting an association,10,11 some
finding no such associations,12 others
proposing that satisfaction is related
to factors such as communication,
attitudes and interpersonal interac-
tion13,14 or to factors such as patient
understanding and perception.14–16
We hypothesised that levels of
patient satisfaction are positively
correlated with adequacy of analge-
sia and negatively correlated with
time to physician evaluation and
time to analgesia.
Methods
Trial design
The prospective observational quali-
tative study was conducted in the ED
on consenting patients who presented
with the symptom of pain and met
the inclusion criteria. Data collection
occurred on a preformatted survey
tool, which collected information on
a series of 11 point numerical scales
patient ratings of pain, compassion
and satisfaction, administered during
pre-specified time points during the
patient’s journey in the ED (Appen-
dix S1). The 11 point numerical rat-
ing scale utilised is validated for
quantification of pain17 and is com-
monly utilised in marketing for rapid
quantification of satisfaction.
A follow-up telephone call made
at least 2 weeks post-departure of
patient from the ED collected further
end-point data about their experi-
ence in ED (Appendix S1).
Population and inclusion/
exclusion criteria
Patients were recruited during times
of researcher availability, with
recruitment shifts running intermit-
tently at any time between 08.00
and 23.00 hours, over weekdays and
weekends, over a period of approxi-
mately 1 year. During recruitment
periods, all patients eligible for par-
ticipation were approached for
enrolment into the study.
© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
All adult patients (≥18 years old)
presenting to Westmead Hospital’s
(Sydney, New South Wales,
Australia) ED with pain as, or
accompanying, the primary present-
ing complaint, and in non-critical
condition (triage categories three to
five). Any patient unable to consent
to participation because of clinical
reasons, for example, impaired levels
of consciousness, were excluded by
research staff at consent for partici-
pation in the study.
Study procedures
Following review and approval by a
New South Wales Local Health Dis-
trict Human Research Ethics Com-
mittee, the research project was
conducted as follows.
Patients who met the study eligibil-
ity criteria provided informed consent
to participate in the study. Consenting
participants were then tracked within
the department by the research assis-
tant. At enrolment, the inclusions
were assigned a unique study identi-
fier with individual medical record
numbers used to facilitate retrospec-
tive data verification and linkage of
prospective pain rating data with
information from follow-up telephone
surveys. Utilising the pre-developed
survey tool, information relating to
analgesia and end-points were col-
lected at pre-specified time points in
the journey of the patient:
• As a baseline at the time of enrol-
ment into the study.
• Immediately following evaluation
by their treating doctor.
• At least 60 min post-administration
of initial analgesia or at 60 min
post-physician evaluation if no anal-
gesia was provided, reasons for
same were recorded.
• Rating of staff compassion and
overall satisfaction occurred at
ED discharge (to home or to inpa-
tient unit) or at the end of 4 h into
their journey, whichever occurred
earliest.
• All patient ratings (pain, compas-
sion and satisfaction) were cap-
tured utilising 11 point numerical
scales.
ED length of stay (LOS) and out-
come data were collected through
retrospective chart review of patient
journey in case of patients with ED
LOS >4 h and those who were
admitted to hospital. An option to
provide general comments about
their experience was also provided.
A follow-up post-discharge tele-
phone call was made to patients at
least 2 weeks post-discharge from hos-
pital; this survey collected information
around: perceived time to physician
evaluation, perceived time to analge-
sia, perceived pain scores (admission,
post-evaluation and post-analgesia)
and finally, the patient’s overall satis-
faction with their ED experience.
Sample size
At the research site, 75% of the
annual census (categories three to five)
is 60 000. With approximately 50%
predicted to present with the primary
symptom of pain, and with an
expected survey response rate of 50%,
a sample of 200 was initially consid-
ered significant. With 100 patients, an
error rate of 8.21% with a confidence
level of 90% was expected.
Data analysis
Patients with incomplete datasets
were excluded from the final analysis.
Exceeding minimum standards set
by validation studies, a change in
numerical pain score of ≥2, was con-
sidered clinically significant in our
analyses.18 In keeping with other
research into satisfaction in health-
care, where numerical and Likert
scoring systems commonly employ
scales rating satisfaction from ‘poor
to excellent’ or ‘very poor to very
good’ on 0–5 or 0–10 numerical
scales,19 an arbitrary cut-off score of
≥7 was used as a marker of signifi-
cant patient satisfaction and satisfac-
tion rating outcomes.
Statistical analysis
Data were recorded in paper format,
and were then transcribed into
an encrypted Excel spreadsheet
(Microsoft® Excel® 2013, USA) and
analysed using the statistical analysis
software package SPSS (released 2013;
IBM SPSS statistics for Windows, ver-
sion 22.0; IBM Corp., Armonk, NY,
USA). Tests for normality were run on
PAIN CONTROL AND PATIENT SATISFACTION
Total number of consenting adult patients during trial period
n=115
In-hospital data endpoints not
completed
Exclusions
n=21 (18.3%)
Number of patients who received analgesia
n= 54 (57.5% inclusions)
36 (38.3% of inclusions) significant response to
analgesia (≥ 2 change in pain score)
18 (19.2% of inclusions) no significant change
in pain score
Figure 1. Consort flow diagram of participants and analgesia use in the pain control
and patient satisfaction study.
TABLE 1. Key demographic data of inclusions in the pain control and patient
satisfaction study
Age (years)
Triage category
Sex
Admission status (admit vs discharge)
Time to evaluation (min), n = 94
Time to analgesia (min), n = 54
ED LOS (min)
IQR, interquartile range; LOS, length of stay.
all individual variables (Shapiro–
Wilk). The Spearman’s rank-order
correlation coefficient (ρ) was analysed
for each investigated variable for ordi-
nal patient satisfaction score as out-
come. In view of the sample size, all
variables with significant correlation
(P < 0.10) were further included in a
logistic model to predict primary out-
come of patient satisfaction score ≥7.
Results
Datasets
Of the 115 initially enrolled partici-
pants, 94 (81.7%) completed ‘in-hos-
pital’ data end-points (Fig. 1). Of the
115 patients, 21 were excluded
© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Number of patients who did not receive
analgesia
n = 40 (42.5% inclusions)
27 (28.7% of inclusions) declined analgesia
13(13.8% of inclusions) not offered analgesia
Median (IQR)
39.0 (28.0–55.0)
3.0 (3.0–4.0)
Male, n = 46 (49%)
Admit, n = 46 (49%)
54.0 (35.0–98.0)
87.5 (66.1–108.9)
205.0 (129.0–280.0)
because of incomplete data comple-
tions. Only 69 patients from the origi-
nal cohort could be contacted for
post-discharge follow-up call, result-
ing in significant attrition around
completion of surveys. Despite prelim-
inary statistical analysis revealing no
significant difference in mean satisfac-
tion ratings between ‘in-hospital’ and
‘follow-up’ groups (Mann–Whitney
P-value 0.8364, confidence interval
[CI, −1.000 to 0.000]), the follow-up
arm was abandoned because of the
risk of significant selection bias.
Demographics
The median age of the study partici-
pants was 39 years, with a sex ratio
3
49:51 (male:female) (Table 1). Fur-
ther demographic data are presented
in Table 1. Median pain at presenta-
tion was 7.0/10 (Table 2).
Analgesia delivery
Of the 94 inclusions in the study,
54 patients (57.4%) received analge-
sia during their stay in ED of whom
36 (38.3%) had a significant response
to analgesia (≥2 change in pain score).
Of the 40 patients who did not receive
any analgesia, 27 patients (28.7%)
refused analgesia and 13 patients
(13.8%) desired yet did not receive
any analgesia by the end of the trial
period for the patient (approximately
4 h) (Fig. 1).
Compassion scores
At the pre-defined cut-off of 7/11 for
significant staff compassion, staff
were noted as compassionate by
85 patients (90.4%). Across the
entire cohort, the median compassion
rating was very high at 9.0 (95% CI
8.0–10.0).
Satisfaction scores
At the pre-defined cut-off of 7/11
on a numerical scale rating for ‘satis-
faction’ with ED experience,
74 patients (78.7%) were ‘satisfied’
with their experience. Similarly, the
median satisfaction rating was 8.0
(95% CI 7.0–10.0) (Table 2).
Correlation coefficients
Recorded variables were analysed
for correlation with the primary out-
come of satisfaction with ED experi-
ence (Table 3). Increasing age,
significant change in pain score (2
points) and ED compassion scores
(P < 0.05) were noted to have signif-
icant positive correlations with the
primary outcome of patient satisfac-
tion with their ED journey, while
male sex demonstrated an inverse
association (Table 3). Of factors ana-
lysed, compassion scores showed the
strongest correlation with satisfac-
tion (Spearman’s rank correlation
0.51 [95% CI 0.34–0.64,
P < 0.001]) (Table 3, Fig. 2).
4 T BROWN ET AL.
TABLE 2. Numerical rating scale pain and outcome scores at time points in
patient journey through ED
Factor
Pain at presentation
Pain post-evaluation
Pain post-analgesia
Change in pain score post-evaluation (n = 94)
Change in pain score post-analgesia (n = 54)
Patient perception of staff compassion
Satisfaction scores with ED journey
IQR, interquartile range.
TABLE 3. Spearman’s rank correlation for variables investigated against sat-
isfaction with ED experience
Factors
Age (years)
Sex (male)
Pain score at presentation
Pain score post-evaluation
Time to evaluation (min)
Time to analgesia (min)
Change in pain score
Any change in pain score (2)
Compassion score
CI, confidence interval.
Logistic regression model
In a logistic regression model includ-
ing factors with significant correlation
(P < 0.10) for primary outcome of
patient satisfaction with their ED
journey (cut-off ≥7), male sex (odds
ratio [OR] 0.24, 95% CI 0.07–0.9)
and compassion scores (OR 1.86,
95% CI 1.23–2.8) were retained as
significant associations with satisfac-
tion (Table 4). Males were least likely
to be satisfied, whereas patients whose
ratings of staff compassion were high
were most likely be satisfied.
Discussion
The present study has various limita-
tions, most importantly our small
© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
the recruitment process leading to a
sampling bias towards a collabora-
tive consenting patient cohort.
Median (IQR)
Researcher presence could have
caused procedural bias through an
7.0 (5.0–9.0) indirect influence on treating physi-
cians, whose behaviour may have
7.0 (5.0–8.0)
altered given knowledge of the
4.8 (3.0–6.0) study, by influencing patients’ scor-
0.0 (0.0–0.0) ing with negative ratings possibly
more difficult to provide in person,
3.0 (2.0–4.0)
or by directly influencing the
9.0 (8.0–10.0) patients’ perspectives by providing
8.0 (7.0–10.0) the patient with consistent attention
and ongoing enquiry into wellbeing
throughout their ED journey.
As a single centre study, the pro-
ject also suffers limitations in terms
of diversity of its patient cohort.
Some of these demographic limita-
tions were minimised through the
selection of a busy quaternary centre
Spearman’s rank serving an ethnically and socioeco-
correlation (95% CI) P-value nomically diverse population. How-
ever, others such as the young
0.22 (0.02 to 0.4) 0.02 median patient age of our cohort
−0.19 (−0.38 to 0.01) 0.04 remain to be addressed by further
studies in alternate locations.
−0.30 (−0.23 to 0.17) 0.39
The impacts of such selection bias
−0.08 (−0.28 to 0.12) 0.21 and impact of face-to-face interac-
−0.15 (−0.34 to 0.06) 0.08 tion by the researcher on the primary
outcome of satisfaction cannot be
0.113 (−0.16 to 0.37) 0.42
discounted or quantified in our
−0.1 (−0.3 to 0.1) 0.16 study. While this effect may have
−0.27 (−0.45 to −0.07) 0.005 been mitigated by follow-up tele-
phone interview, the significant loss
0.51 (0.34 to 0.64) <0.001
to follow up meant that the latter
could not be completed. This is a
major limitation of our study and
possibly impacts the transferability
of our findings.
sample size, which can lead to bias Despite the possibility of signifi-
in the results of the logistic regres- cant bias, our findings are in keeping
sion analysis. Other limitations with current literature. The propor-
include possible selection bias and tions of patients receiving analgesia,
bias potentially introduced through the mean delay to analgesia, and the
the presence of the researchers them- proportion of patients not receiving,
selves. The small sample size of but desiring, analgesia are similar to
94 completed ‘in-hospital’ datasets those reported in the significantly
and high attrition rate to follow up, larger, North American, pain and
with only 64 of the ‘follow-up’ emergency medicine initiative study.4
datasets being completed, reduces In our study, the majority of patients
the study’s power and introduces reported satisfaction with their expe-
the potential for both type 1 and rience in ED with compassionate
2 errors. Larger studies are therefore staff interaction noted to have the
required to confirm the validity of strongest link with overall patient
the present study’s findings. satisfaction. This, too, is in keeping
Selection bias exists because of the with past literature, in which inter-
use of convenience sampling, the personal interaction13 and patient–
absence of overnight recruitment and practitioner communication20 have
PAIN CONTROL AND PATIENT SATISFACTION
Figure 2. Scatterplot of satisfaction scores versus compassion scores.
TABLE 4. Logistic regression model including significant investigated factors
(P < 0.1) for primary outcome of satisfaction score ≥7
Parameter
Age (years)
Sex (male)
Time to evaluation (min)
Any change in pain score (2)
Compassion score
OR, odds ratio.
each been demonstrated to correlate
with satisfaction.
We found patient sex (male) to be
negatively associated with satisfac-
tion scores. However, our study was
not powered for a subset sex-based
analysis to draw conclusions about
this link. Although no specific mech-
anism for sex-related differences is
inferable from our research, a sys-
tematic review21 focusing on the role
of sex-related influences on pain and
analgesia suggests sex-related differ-
ences exist in pain prevalence, pro-
cessing and analgesia response,
providing possible mechanisms to
explain our findings.
As expected, our research sug-
gested an association between signifi-
cant shifts in pain scores and
satisfaction scores. Although we
found a correlation between signifi-
cant changes in pain scores with
patient satisfaction, we found no
correlations between pain scores at
© 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
OR 95% CI P-value
1.02 0.98–1.06 0.24
0.24 0.07–0.9 0.03
0.99 0.98–1 0.03
0.98 0.24–4.04 0.98
1.86 1.23–2.8 0.003
individual different time points in
patients’ ED journey with our pri-
mary outcome. The latter is in keep-
ing with previous findings.12,22
Conflicting with previous
research,9,13 we found no significant
association between time to evalua-
tion and satisfaction scores. How-
ever, this finding may be secondary
to the study’s small sample size,
which may have led to an inability
to detect such a difference. The pre-
sent study was unable to quantify
the effect of perceived time to inter-
ventions because of the abandon-
ment of the follow-up arm of the
study following unacceptably high
rates of loss to follow up. This is
unfortunate as perceived time to
intervention has been shown to be a
greater determinant of satisfaction
than actual time.15
Despite median wait times to anal-
gesia, which, at 87.5 min, were sig-
nificantly higher than suggested best
5
practice of 30 min23 and exceeded
National Pain Management Initiative
pre- and post-intervention mean
times to analgesia of 61 and 41 min,
respectively,8 mean satisfaction rat-
ings remained consistently high in
our study.
A significant proportion (42.5%)
of the patient cohort did not receive
any analgesia, either by choice or by
not being given the option by clini-
cians, a finding also in keeping with
current literature.3 While this adds
to the knowledge around oligoanal-
gesia in ED, this also raises questions
about patients’ expectations from
healthcare events and potential fail-
ings in clinician identification of the
need for analgesia.
Our study raises the need for
future research into factors that lead
to improved patient satisfaction
including staff–patient interactions.
Past research on patients with non-
critical illness has highlighted themes
such as discussion of biomedical
issues, emotional support and part-
nership expectations of patients,
which suggest possible areas for
education of future ED healthcare
providers to improve outcomes.24,25
Interventions aimed at improving
staff/patient interaction, such as
communication training,26 may be
more beneficial in improving satis-
faction ratings than those addressing
efficacy of analgesia. With possibili-
ties raised of improvements in
patient satisfaction deliverable
through compassion training or
through alteration in recruitment
patterns, further research into the
efficacy of such interventions, and
into the mechanisms behind the
influence of compassion on satisfac-
tion, is indicated.
Our study identified the persis-
tence of oligoanalgesia, particularly
regarding timeliness of analgesia,
and failure to deliver analgesia to all
who desired it. Future possible inter-
ventions that have demonstrated effi-
cacy in reducing time to effective
analgesia include implementation of
nurse initiated analgesia pro-
grammes,27,28 decreasing barriers to
nurse initiation of analgesia and
improving pain score documenta-
tion.29 Interventions shown to affect
detection and identification of those
6 T BROWN ET AL.
requiring analgesia including routine
direct questioning to ascertain
patients’ desire for analgesia, regard-
less of pain score,30 and increased
provider education regarding acute
pain guidelines, which have been
demonstrated to improve both pain
management and satisfaction.11
Conclusion
In this small study looking at pain
management and patient satisfaction
scores, we found oligoanalgesia
remains a significant issue. We found
that compassionate patient care was
associated with better patient satis-
faction outcomes than other factors
such as time to evaluation, time to
analgesia, change in pain score and
demographic factors. Owing to the
small sample size and power, larger
studies are required to validate this
finding.
Acknowledgements
The authors acknowledge the contri-
butions made by all medical and
nursing staff in identifying and fol-
lowing patients presenting to the
ED with pain. Furthermore, we
acknowledge the efforts of the medi-
cal students and nursing staff who
conducted the patient surveys, phone
interviews and data entry, with a
special mention to Ms Somayeh
Ebrahimi, whose efforts in data col-
lection and data entry were particu-
larly notable.
Author contributions
AS and MM are employees of West-
mead Hospital, ED, and neither
were directly involved in data collec-
tion and their clinical roles were
strictly separated from the project,
with neither having any clinical
involvement with patients enrolled in
the study.
Competing interests
None declared.
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Supporting information
Additional supporting informa-
tion may be found in the online ver-
sion of this article at the publisher’s
web site:
Appendix S1. The pain control
and patient satisfaction data
collection tool.