Defining the need for analgesia in the emergency department: an international consensus statement

Background and importance – The high prevalence of acute pain in the emergency department (ED) underscores the need for accurate pain assessment to guide effective interventions. A pain assessment tool for ED patients with acute pain should enable clinicians to distinguish those who require analgesia from those who do not. However, a universally accepted definition of the ‘need for analgesia’ is lacking. Objective – To identify predictors of the need for analgesia in ED patients through a consensus-based interdisciplinary approach. Design/setting and participants – A three-stage modified Delphi was conducted. In stage 1, 63 international panel members, including clinicians, researchers, patients, and patient representatives from 15 countries, answered three open-ended questions to generate candidate predictor variables. In stage 2, the same participants rated these variables using a five-point Likert scale. In stage 3, randomly selected clinicians and patients were recruited internationally to complete a survey rating the consensus-derived variables. Outcome measures and analysis – The primary outcome was the identification of variables defining the need for analgesia in ED patients without communication or cognitive impairments. Consensus was defined a priori as more than or equal to 80% of participants selecting ‘agree’ or ‘strongly agree’ after stage 2. Variables meeting this threshold were considered in the final consensus-derived items. Stage 3 aimed to evaluate agreement with these variables among a broader panel of frontline clinicians and patients, to assess alignment with the expert panel, primarily composed of researchers, while also addressing potential geographic and professional biases. Results – Stage 1 generated 20 potential clinical predictor variables to define the need for analgesia. In stage 2, the six consensus-derived variables were: (a) patient’s perception of pain, (b) patient’s desire for analgesia, (c) pain tolerance, (d) patient observation, (e) caregiver/relative’s perception of the patient’s pain, and (f) provider’s perception of the patient’s pain. In stage 3, the rating of these variables reached combined agreement (‘agree’ or ‘strongly agree’) ranging from 72% to 91%. Conclusion – The six consensus-derived variables provide a foundation for a multidimensional, patient-centered pain assessment framework, which will serve as the basis for developing and validating a new tool to improve analgesia for ED patients with acute pain.