Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study.

BACKGROUND: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit. METHODS: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes. RESULTS: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. CONCLUSIONS: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

Talk-time in the emergency department: duration of patient-provider conversations during an emergency department visit.

BACKGROUND: Analyses of patient flow through the emergency department (ED) typically focus on metrics such as wait time, total length of stay (LOS), or boarding time. Less is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of their in-room visit is also spent waiting. OBJECTIVE: Our aim was to assess the proportion of time that a patient spent in conversation with providers during an ED visit. METHODS: Seventy-four audio-taped encounters of patients with low-acuity diagnoses were analyzed. Recorded ED visits were edited to remove downtime. The proportion of time the patient spent in conversation with providers (talk-time) was calculated as follows: (talk-time = [edited audio time/{LOS - door-to-doctor time}]). RESULTS: Participants were 46% male; mean age was 41 years (standard deviation 15.7 years). Median LOS was 126 min (interquartile range [IQR] 96 to 163 min), median time in a patient care area was 76 min (IQR 55 to 122 min). Median time in conversation with providers was 19 min (IQR 14 to 27 min), corresponding to a talk-time percentage of 24.9% (IQR 17.8%-35%). Multivariable regression analysis revealed that patients with older age, longer visits, and those requiring a procedure had more talk-time: total talk-time = 13 s + 9 s × (total time in room in minutes) + 8 s × (years in age of patient) + 482 s × (procedural diagnosis). CONCLUSIONS: Approximately 75% of a patient's time in a care area is spent not interacting with providers. Although some of the time waiting is out of the providers' control (eg, awaiting imaging studies), this significant downtime represents an opportunity for both process improvement efforts and innovative patient-education efforts to make use of remaining downtime.

Emergency Palliative Care: Acute Presentation of a Nonsurvivable Condition.

In this first segment of the emergency palliative care case series, we present a patient who arrives to the emergency department (ED) with signs of impending death in the setting of a newly diagnosed nonsurvivable condition. The patient has a history of chronic and serious illness including metastatic lung cancer, but her ED presentation is prompted by new symptoms of abdominal pain and diarrhea that are not immediately attributable to her known history and reflect the onset of a catastrophic process. Palliative care consultation is requested after surgery determines that that patient is not a candidate for surgical intervention. The palliative care provider plays an important role in supporting aggressive symptom management, elucidating goals of care, and rapidly facilitating disposition.

Emergency Palliative Care: Early Assessment of an Older Adult With a Fall and Hip Fracture.

In this segment of the emergency department (ED) palliative care case series, we present a patient who arrives to the ED after a fall resulting in a hip fracture. He is also found to have hypernatremia and an acute kidney injury and develops delirium while in the ED awaiting an inpatient bed. The ED-based integrated geriatric palliative care program is consulted and performs a multidimensional assessment. The geriatric palliative care clinician facilitates discussion with his daughter about surgical intervention based on the patient's goals and values, diagnoses delirium, and worsening depression, creates a plan for delirium and pain management, and accelerates postdischarge planning.

Emergency Palliative Care: Nongoal Concordant Care and Time-Limited Trials in the Emergency Department.

When advance care plans are not communicated or goals are in conflict, significant family and clinician distress may result. The distress is especially high when potentially nongoal concordant care is expected by surrogates in the emergency department (ED). To demonstrate the effect of off-hour, phone consultations by palliative care clinicians in reducing the family and clinician distress when nongoal concordant care is expected in the ED. A partnership between palliative care and emergency medicine can decrease the burden of decision making and provide opportunities for modeling a goals-of-care discussion by experts in this important procedure.

Emergency department team communication with the patient: the patient's perspective.

BACKGROUND: Effective communication is important for the delivery of quality care. The Emergency Department (ED) environment poses significant challenges to effective communication. OBJECTIVES: The objective of this study was to determine patients' perceptions of their ED team's communication skills. METHODS: This was a cross-sectional study in an urban, academic ED. Patients completed the Communication Assessment Tool for Teams (CAT-T) survey upon ED exit. The CAT-T was adapted from the psychometrically validated Communication Assessment Tool (CAT) to measure patient perceptions of communication with a medical team. The 14 core CAT-T items are associated with a 5-point scale (5 = excellent); results are reported as the percent of participants who responded "excellent." Responses were analyzed for differences based on age, sex, race, and operational metrics (wait time, ED daily census). RESULTS: There were 346 patients identified; the final sample for analysis was 226 patients (53.5% female, 48.2% Caucasian), representing a response rate of 65.3%. The scores on CAT-T items (reported as % "excellent") ranged from 50.0% to 76.1%. The highest-scoring items were "let me talk without interruptions" (76.1%), "talked in terms I could understand" (75.2%), and "treated me with respect" (74.3%). The lowest-scoring item was "encouraged me to ask questions" (50.0%). No differences were noted based on patient sex, race, age, wait time, or daily census of the ED. CONCLUSIONS: The patients in this study perceived that the ED teams were respectful and allowed them to talk without interruptions; however, lower ratings were given for items related to actively engaging the patient in decision-making and asking questions.

Patient input into the development and enhancement of ED discharge instructions: a focus group study.

OBJECTIVES: Previous research indicates that patients have difficulty understanding ED discharge instructions; these findings have important implications for adherence and outcomes. The objective of this study was to obtain direct patient input to inform specific revisions to discharge documents created through a literacy-guided approach and to identify common themes within patient feedback that can serve as a framework for the creation of discharge documents in the future. METHODS: Based on extensive literature review and input from ED providers, subspecialists, and health literacy and communication experts, discharge instructions were created for 5 common ED diagnoses. Participants were recruited from a federally qualified health center to participate in a series of 5 focus group sessions. Demographic information was obtained and a Rapid Estimate of Adult Literacy in Medicine (REALM) assessment was performed. During each of the 1-hour focus group sessions, participants reviewed discharge instructions for 1 of 5 diagnoses. Participants were asked to provide input into the content, organization, and presentation of the documents. Using qualitative techniques, latent and manifest content analysis was performed to code for emergent themes across all 5 diagnoses. RESULTS: Fifty-seven percent of participants were female and the average age was 32 years. The average REALM score was 57.3. Through qualitative analysis, 8 emergent themes were identified from the focus groups. CONCLUSIONS: Patient input provides meaningful guidance in the development of diagnosis-specific discharge instructions. Several themes and patterns were identified, with broad significance for the design of ED discharge instructions.

Assessing the Impact of a Hospice and Palliative Medicine Mentored Clinical Shadowing Experience for First-Year Medical and Dental Students: A Pilot Study.

Background: All physicians encounter patients with serious illness. Medical students recognize the value of hospice and palliative medicine (HPM) and desire more knowledge and skills in this area. However, both pre-clinical and clinical HPM content are underrepresented within medical school curricula. Objectives: To conduct a pilot study examining the impact of a novel required HPM clinical experience on pre-clinical medical and dental students' learning through mixed methods evaluation of student responses. Design: Students completed a two-part electronic survey following a half-day HPM mentored clinical shadowing experience (HPM-MCSE) which included an introductory session, a faculty-mentored shadowing experience and a debriefing session. Setting/subjects: 163 first-year students at Harvard Medical School in Boston, Massachusetts, USA in 2022. Measurements: The survey collected demographic information and student responses to both closed-ended (Likert-scale) and open-ended prompts. Data were analyzed quantitatively using descriptive statistics and qualitatively using constant comparative methodology. Results: 127 medical and dental students responded (78% response rate). Qualitative analysis yielded three overarching themes: acquisition of knowledge about operational dimensions of HPM, acquisition of knowledge about psychosocial dimensions of HPM, and personal impact including an awareness of discordance between expectations and lived experience of HPM practice. Of the 109 students who completed the entire survey, 67% indicated that this experience increased their interest in palliative care and 98% reported an increase in their understanding of how palliative care enhances patient care. Conclusions: Early clinical exposure to HPM for first year students stimulates multi-dimensional learning about HPM and evokes personal reflection about serious illness care.

What did the doctor say? Health literacy and recall of medical instructions.

BACKGROUND: Limited literacy has repeatedly been linked to problems comprehending health information, although the majority of studies to date have focused on reading various print health materials. We sought to investigate patients' ability to recall spoken medical instructions in the context of a hypothetical clinical encounter, and whether limited health literacy would adversely affect performance on the task. METHODS: A total of 755 patients aged 55 to 74 were recruited from 1 academic internal medicine clinic and 3 federally qualified health centers. Participants' health literacy skills and recall of spoken medical instructions for 2 standard hypothetical video scenarios [wound care, gastroesophageal reflux disease (GERD) diagnosis] were assessed. RESULTS: The majority (71.6%) of participants had adequate health literacy skills, and these individuals performed significantly better in correctly recalling spoken information than those with marginal and low literacy in both scenarios: [wound care-mean (SD): low 2.5 (1.3) vs. marginal 3.5 (1.3) vs. adequate 4.6 (1.1); P<0.001), GERD: low 4.2(1.7) vs. marginal 5.2 (1.7) vs. adequate 6.5 (1.7); P<0.001]. Regardless of literacy level, overall recall of information was poor. Few recognized pain (28.5%) or fever (28.2%) as signs of infection. Only 40.5% of participants correctly recalled when to take their GERD pills. CONCLUSIONS: Many older adults may have difficulty remembering verbal instructions conveyed during clinical encounters. We found those with lower health literacy to have poorer ability to recall information. Greater provider awareness of the impact of low health literacy on the recall of spoken instructions may guide providers to communicate more effectively and employ strategies to confirm patient understanding.

Developing a novel integrated geriatric palliative care consultation program for the emergency department.

With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.

Examining emergency department communication through a staff-based participatory research method: identifying barriers and solutions to meaningful change.

STUDY OBJECTIVE: We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED). METHODS: ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes. RESULTS: A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice. CONCLUSION: Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Making the best of the worst: Care quality during emergency cesarean sections.

OBJECTIVE: This study aimed to identify factors influencing mothers' and their partners' perceptions of care quality, and to identify associated clinical factors. METHODS: Questionnaires were developed based on eight interviews with couples after emergency Cesarean Sections (ECS). The internal structure of the questionnaires was examined using Rasch analysis. Cronbach's alpha was calculated to evaluate internal consistency of questionnaire items. Finally, associations between questionnaire scores and ECS characteristics were determined. RESULTS: Thematic analysis of interview data demonstrated that team-dynamics, professionalism, information, safety, leadership and mother-child continuity of care are important to patient- perceived quality of care. Questionnaire responses from 119 women and 95 partners were included in the validation and demonstrated satisfying fit to the Rasch model. The questionnaires had acceptable internal consistency with Cronbach's alpha 0.8 and 0.7 for mothers and partners, respectively. Perceived quality of care was negatively associated with increasing urgency of the CS. Spearman rank correlation coefficients were -0.34 (p <0.001) and -0.32 (p = 0.004) for mothers and partners, respectively. Perceived quality of care differed significantly across CS indications for both mothers (p = 0.0006) and their partners (p<0.0001). CONCLUSION: Team-dynamics, professionalism, information, safety, leadership and mother-child-continuity affect patients' perceptions of care. Perceptions of care were highly influenced by CS indications and urgency.

Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand?

STUDY OBJECTIVE: To be able to adhere to discharge instructions after a visit to the emergency department (ED), patients should understand both the care that they received and their discharge instructions. The objective of this study is to assess, at discharge, patients' comprehension of their ED care and instructions and their awareness of deficiencies in their comprehension. METHODS: We conducted structured interviews of 140 adult English-speaking patients or their primary caregivers after ED discharge in 2 health systems. Participants rated their subjective understanding of 4 domains: (1) diagnosis and cause; (2) ED care; (3) post-ED care, and (4) return instructions. We assessed patient comprehension as the degree of agreement (concordance) between patients' recall of each of these domains and information obtained from chart review. Two authors scored each case independently and discussed discrepancies before providing a final concordance rating (no concordance, minimal concordance, partial concordance, near concordance, complete concordance). RESULTS: Seventy-eight percent of patients demonstrated deficient comprehension (less than complete concordance) in at least 1 domain; 51% of patients, in 2 or more domains. Greater than a third of these deficiencies (34%) involved patients' understanding of post-ED care, whereas only 15% were for diagnosis and cause. The majority of patients with comprehension deficits failed to perceive them. Patients perceived difficulty with comprehension only 20% of the time when they demonstrated deficient comprehension. CONCLUSION: Many patients do not understand their ED care or their discharge instructions. Moreover, most patients appear to be unaware of their lack of understanding and report inappropriate confidence in their comprehension and recall.

Patient perspectives on communication with the medical team: pilot study using the Communication Assessment Tool-Team (CAT-T).

OBJECTIVE: Effective communication is an essential aspect of high-quality patient care and a core competency for physicians. To date, assessment of communication skills in team-based settings has not been well established. We sought to tailor a psychometrically validated instrument, the Communication Assessment Tool, for use in Team settings (CAT-T), and test the feasibility of collecting patient perspectives of communication with medical teams in the emergency department (ED). METHODS: A prospective, cross-sectional study in an academic, tertiary, urban, Level 1 trauma center using the CAT-T, a 15-item instrument. Items were answered via a 5-point scale, with 5 = excellent. All adult ED patients (> or = 18 y/o) were eligible if the following exclusion criteria did not apply: primary psychiatric issues, critically ill, physiologically unstable, non-English speaking, or under arrest. RESULTS: 81 patients were enrolled (mean age: 44, S.D. = 17; 44% male). Highest ratings were for treating the patient with respect (69% excellent), paying attention to the patient (69% excellent), and showing care and concern (69% excellent). Lowest ratings were for greeting the patient appropriately (54%), encouraging the patient to ask questions (54%), showing interest in the patient's ideas about his or her health (53% excellent), and involving the patient in decisions as much as he or she wanted (53% excellent). CONCLUSION: Although this pilot study has several methodological limitations, it demonstrates a signal that patient assessment of communication with the medical team is feasible and offers important feedback. Results indicate the need to improve communication in the ED. PRACTICE IMPLICATIONS: In the ED, focusing on the medical team rather then individual caregivers may more accurately reflect patients' experience.

Language interpreter utilization in the emergency department setting: a clinical review.

The emergency department (ED) serves as the entry point into the U.S. health care system for many patients with limited English proficiency (LEP). This paper reviews the literature on language interpreter utilization in the ED setting. We focused on three clinical issues related to professional language interpretation: (1) patient satisfaction, (2) health care delivery, and (3) current interpreter utilization practices. Compared with-English speaking patients, LEP patients report less satisfaction with medical encounters, have different rates of diagnostic testing, and receive less explanation and follow-up. Although professional interpretation has been associated with improvements in patient satisfaction, communication, and health care access, these services are largely under-utilized in ED settings. Reliance on untrained ad hoc interpreters, perceived time and labor associated with obtaining and working with an interpreter, and costs of implementing professional interpreter services serve as barriers to implementation and utilization.

Residents' responses to medical error: coping, learning, and change.

PURPOSE: To explore the significant emotional challenges facing resident physicians in the setting of medical mishaps, as well as their approaches to coping with these difficult experiences. METHOD: Twenty-six resident physicians were randomly selected from a single teaching hospital and participated in in-depth qualitative interviews. Transcripts were analyzed iteratively and themes identified. RESULTS: Residents expressed intense emotional responses to error events. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish. For the great majority of residents, their ability to cope with these events was dependent on a combination of reassurance and opportunities for learning. Interactions with medical colleagues and supervisory physicians were critical to this coping process. CONCLUSIONS: Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.

Conversations about analgesics in the emergency department: A qualitative study.

OBJECTIVE: We sought to characterize conversations about analgesics in the Emergency Department (ED) setting. METHODS: A secondary analysis of 47 audio-recorded ED visits containing conversations about analgesics was performed. Data were collected at an urban, academic medical center among adults with one of four diagnoses. Visit transcripts were analyzed qualitatively using content and constant comparative analysis. The speaker, medication being discussed, and overall conversation concordance were categorized. RESULTS: Among the 47 transcripts there were 1102 unique statements related to analgesics. Thirteen codes were identified; however, four codes (discussing details of administration, forecasting, side effects, past history) accounted for over 65% of the conversations. Patient requests, statements related to chronic pain and contentious conversations occurred infrequently, but were present (17% discordant conversations, 83% concordant). Medical providers dominated the conversations with patients' contributions equaling only a quarter of total coded conversation. CONCLUSIONS: These findings characterize the narrow range of topics discussed about analgesics and demonstrate that many risks of opioid medications were not discussed. PRACTICE IMPLICATIONS: Increased counseling about opioids may be warranted given rising opioid-related deaths. To be prepared, providers may wish to reflect on how to approach different topics related to opioids and analgesia prior to engaging in such discussions.

Communication about opioid versus nonopioid analgesics in the emergency department.

OBJECTIVE: The Medication Communication Index (MCI) was used to compare counseling about opioids to nonopioid analgesics in the Emergency Department (ED) setting. DESIGN: Secondary analysis of prospectively collected audio recordings of ED patient visits. SETTING: Urban, academic medical center (>85,000 annual patient visits). PARTICIPANTS: Patient participants aged >18 years with one of four low acuity diagnoses: ankle sprain, back pain, head injury, and laceration. ED clinician participants included resident and attending physicians, nursing staff, and ED technicians. MAIN OUTCOME MEASURES: The MCI is a five-point index that assigns points for communicating the following: medication name (1), purpose (1), duration (1), adverse effects (1), number of tablets (0.5), and frequency of use (0.5). Recording transcripts were scored with the MCI, and total scores were compared between drug classes. RESULTS: The 41 patients received 56 prescriptions (27 nonopioids, 29 opioids). Nonopioid median MCI score was 3 and opioid score was 4.5 (p=0.0008). Patients were counseled equally about name (nonopioid 100 percent, opioid 96.6 percent, p=0.34) and purpose (88.9 percent, 89.7 percent, p=0.93). However, patients receiving opioids were counseled more frequently about duration of use (nonopioid 40.7 percent, opioid 69.0 percent, p=0.03) and adverse effects (18.5 percent, 93.1 percent, p<0.001). In multivariable analysis, opioids (ß=0.54, p=0.04), number of medications prescribed (ß=-0.49, p=0.05), and time spent in the ED (ß=0.007, p=0.006) were all predictors of total MCI score. CONCLUSIONS: The extent of counseling about analgesic medications in the ED differs by drug class. When counseling patients about all analgesic medications, providers should address not only medication name and purpose but also the less frequently covered topics of medication dosing, timing, and adverse effects.

Improving patient knowledge and safe use of opioids: a randomized controlled trial.

OBJECTIVES: The use of opioid analgesics in the United States has significantly increased in recent years. However, there is minimal consensus on what discharge counseling should accompany these high-risk prescriptions and large variations in what is done in practice. The objective of this study was to evaluate the effect of a dual-modality (written and spoken) literacy-appropriate educational strategy on patients' knowledge of and safe use of opioid analgesics. METHODS: This was a prospective, randomized controlled trial. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new prescriptions for hydrocodone-acetaminophen were enrolled. Patients were randomized to receive either usual care or the educational intervention. The educational intervention was a one-page information sheet about hydrocodone-acetaminophen, which was both given to the patients and read aloud by the research assistant (nonblinded). Follow-up phone calls were conducted 4 to 7 days after the visit to assess patient knowledge about the medication and self-report of activities associated with safety of use (e.g., double-dipping with acetaminophen, storage, use with alcohol or while driving). RESULTS: A total of 274 patients were enrolled; 210 completed follow-up (110 usual care and 100 intervention). No significant differences in baseline characteristics emerged between the study arms; 42% were male, and 51% were white, with a median age of 43 years. Half of patients had non-back pain orthopedic injuries (49.5%). On follow-up, overall knowledge was poor, with only 28% able to name both active ingredients in the medication. The intervention group had better knowledge of precautions related to taking additional acetaminophen (usual care 18.2%, 95% confidence interval [CI] = 10.9% to 25.5% vs. intervention 38%, 95% CI = 28.3% to 47.7%; difference = 27.6, 95% CI of difference = 21.5 to 33.7) and knowledge of side effects (usual care median = 1, interquartile range [IQR] 0 to 2 vs. intervention median = 2, IQR = 1 to 2; p < 0.0001). Additionally, those who received the intervention were less likely to have reported driving within 6 hours after taking hydrocodone (usual care 13.6%, 95% CI = 7.2% to 20% vs. intervention 3%, 95% CI = -0.3% to 6.3%; difference = 10.6, 95% CI of difference = 3.4 to 17.9). There was no difference between groups related to knowledge about drinking alcohol while taking hydrocodone (overall 18.1%) or knowledge that the opioid could be addictive (overall 72.4%). CONCLUSIONS: This simple strategy improved several, but not all, aspects of patient knowledge and resulted in fewer patients in the intervention arm driving while taking hydrocodone. Integration of a patient education document into conversations about opioids holds promise for improving patient knowledge about these high-risk medications.

Gender differences in acute and chronic pain in the emergency department: results of the 2014 Academic Emergency Medicine consensus conference pain section.

Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas, in May 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacological and nonpharmacological interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the life span; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biological mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biological mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender differences in the assessment and treatment of pain conditions in emergency care settings.