Factors influencing pain management in patients presenting to the emergency department: A mixed-method systematic review

Abstract

BACKGROUND: Up to 80 % of all presentations to the emergency department are due to pain. Although pain management practices have improved over time, suboptimal pain management still occurs in the emergency department. OBJECTIVES: To identify comprehensive factors influencing pain management outcomes among adult patients presenting to the emergency department with pain. DESIGN: A mixed-method systematic review was conducted following the Joanna Briggs Institute convergent segregated integration methodology. METHOD: Six databases were searched from inception to October 2024 for relevant studies, including peer-reviewed primary studies in English. Empirical studies identifying factors influencing pain management outcomes were included. The databases were searched using Medical Subject Headings terms and keywords such as 'pain management' and 'disparities.' The included studies' methodological quality was assessed using Joanna Briggs Institute checklists. Data were synthesised through meta-analysis and narrative description, followed by the convergent segregated integration of quantitative and qualitative data. The Symptom Management Theory guided this review's synthesis, interpretation, and discussion. RESULTS: Included in this review were 109 studies, 107 quantitative and two qualitative, reporting on 45 contributing factors and 25 outcome measures representing the domains and dimensions of the Symptom Management Theory. Thirty papers were included in the meta-analysis for the most common factors (race, age, and sex) and outcome measures (receipt of analgesic medication and opioid medication). African Americans were less likely to receive analgesics (OR 0.80, 95 % CI 0.73-0.88, p < 0.001) and opioids (OR 0.62, 95 % CI 0.53-0.74, p < 0.001) compared to Non-Hispanic White patients. Hispanic patients were also less likely to receive opioids compared to Non-Hispanic White patients (OR 0.83, 95 % CI 0.75-0.92, p = 0.04). There was no evidence of a significant difference in the likelihood of receiving analgesics between the sexes. Older patients were less likely to receive analgesics and opioids compared to younger counterparts (OR 0.74, 95 % CI 0.67-0.83, p < 0.001; OR 0.90, 95 % CI 0.82-0.99, p = 0.03, respectively). The qualitative synthesis reinforced the quantitative findings, providing deeper insights into the role of spiritual and socioeconomic factors, as well as opioid legislation, which shaped patient experiences in the emergency department. CONCLUSION: This mixed-method systematic review demonstrated that several groups of patients still experience potentially inadequate pain management due to factors unrelated to the presenting condition and severity. The lack of standardisation in reporting factors and outcome measures limited the extent to which we can fully identify these associations and their impact on pain management. Future research should incorporate more qualitative designs, patient-reported outcomes, and standardised data measurement and collection. SYSTEMATIC REVIEW REGISTRATION ID: PROSPERO - CRD 42024601076.

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