The effect of emergency department crowding on the management of pain in older adults with hip fracture

OBJECTIVES: To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults. DESIGN: Retrospective review of ED records from a prospective cohort study. SETTING: Urban, academically affiliated, tertiary medical center. PARTICIPANTS: One hundred fifty-eight patients, aged 50 and older, evaluated and hospitalized from the ED with hip fracture. MEASUREMENTS: Patient-related risk factors: age, sex, nursing home residence, ED triage status, dementia, Acute Physiology in Age and Chronic Health Evaluation II physiological score, and RAND comorbidity score. ED crowding risk factors: ED census and mean length of stay. Outcomes: documentation of pain assessment, time to pain assessment, time to pain treatment, patients reporting pain receiving analgesia, and meperidine use. RESULTS: Mean age was 83 (range 52-101), 81.0% of patients complained of pain, mean time to pain assessment was 40 minutes (range 0-600), time to treatment was 141 minutes (range 10-525), and mean delay to treatment was 122 minutes (range 0-526). Of those with pain, 35.9% received no analgesia, 7.0% received nonopioids, and 57.0% received opioids. Of those receiving opioids, 32.8% received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment (P=.05) and longer times to pain assessment (P=.01). CONCLUSION: Older adults with hip fracture are at risk for underassessment of pain, considerable delays in analgesic administration after pain is identified, and treatment with inappropriate analgesics (e.g., meperidine) in the ED. Higher levels of ED census are significantly associated with poorer pain management.