**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Acute Pain Care for Older Adults in the Emergency Department Setting**

**Presenter: Ula Hwang, MD**

**July 2, 2013**

Bob:Good morning everybody. This is Bob Kern. I am National Program Director for Pain Management and I welcome you all to today’s presentation as a component of our monthly Spotlight on Pain Management. I will join Heidi in apologizing for some of the technical challenges today, but, I think we will move ahead and hope that we can overcome those challenges.

I want to remind everybody that this is a monthly program, and it is offered as a partnership between the National Pain Management Program Office in VA Central Office, the Pain Research, Informatics, Medical Comorbidities and Education (PRIME) Center, and HSR&D-funded pain research center based at VA Connecticut, for which I am the Director, and also the Center for Information, Dissemination, and Educational Resources in HSR&D-sponsored resource center. I also want to take this opportunity to thank the leadership insider and Heidi Schluter [PH] in particular, who is instrumental in supporting this program. I want to encourage all of you who are listening today, if you are new to this program, to stay tuned for updates about future sessions. We meet monthly during this time spot, the first Tuesday of each month at 11:00 Eastern time, or 10:00 Central time.

Today, it is my great pleasure to introduce a colleague, Dr. Ula Hwang. Ula is a physician and also has a Master’s in Public Health. She is based at the Bronx VA, where she is core investigator at the GRECC there, the Geriatric Research, Education and Clinical Center, at the James J. Peters VA Medical Center in the Bronx, New York. And, she is also an associate professor in the Department of Emergency Medicine, and Brookdale Department of Geriatrics and Palliative Medicine, also in the Bronx. 

Today, Ula is going to presenting an important topic and one that is often neglected, really the combination of two topics that are often neglected, or I would say under-represented in our typical Spotlight on Pain Management program series, both on acute pain and pain in the emergency department, and with a specific focus on older adults. The title of her presentation is Acute Pain Care for Older Adults in the Emergency Department Setting. With that, I am going to turn things over to Ula.

Ula:Great. Thank you so much, Dr. Kern. Thanks everybody for the invite and also for your quick reaction time in getting on board this other modality for the Webinar. 

So, we are going to go ahead and jump right in. So, to start I want to say that I have no financial conflicts of interest to report. Some of the research that you will be hearing later on has been funded by the NIA and by the VA HSR&D.

So, today’s talk is going to focus on acute pain care for older adults, and I emphasize acute care because I think, as sort of implied earlier, this is a little bit different from what I think we are most used to hearing discussion and research and education, which is focused more on chronic pain. In this presentation, I would like to really talk about the constraints of providing quality care in the ED setting, and this would focus on acute pain care. In particular, we will discuss the association of ED crowding and how this impacts the ability to provide pain care, using hip fracture as a model. We will also further discuss the impact of patient-related characteristics and the quality of pain care received. And, finally, briefly discuss a pilot study, reviewing the results about the quality of VA ED pain care.

So, this is going to start with a couple of survey questions. I am not sure we can do that with the Adobe Connect, but really more as an opportunity so that I can learn who the audience and try to target the talk, and that you can all learn from each other who you are in this presentation. So, I think with the other modality, we would all be able to kind of say what type of participant you are. So, I was curious to know what your background is. I am an emergency physician by training, and so, in particular, I was very interested in figuring out if there any that would have signed off for number eight, emergency medicine. And, then my third question was going to really ask, “How do you personally define acute pain care?” It has been interesting in my years as trying to be researcher in this field, I think how we go about and define acute pain care. The process of pain care measure is debatable.

So, let us jump right in. With the silver tsunami, older adults will increasingly make up a predominant portion of our ED visit population. It is projected that they will comprise over a quarter of total ED visits by 2035. Between 2001 and 2009 alone, their visit volumes increased by 25%, with older adults, 75 and older, being, those patients 75 and older being more likely than all age groups to have had at least one ED visit per year. Because older adults often present with unusual atypical presentations and have cognitive or functional impairments, and because of their multiple medical problems and thus multiple medications, I propose they should be regarded as a vulnerable population within the ED setting.

Unfortunately, extensive evaluation of the general quality of care that older adults receive in the ED setting is relatively limited. There is now a slow growing body of evidence that is in development that has begun to focus on factors that might impact their clinical care and the outcomes older adults receive from ED care. I would like to propose that acute pain care may also serve as a very good model to evaluate the general quality of care that older adults receive in the ED.

Well, what do we know about pain care in the ED setting? As this particular audience is very familiar with, pain is regarded as a vital sign and has been identified as an area of quality improvement. It is an ideal condition to study in the ED setting, because of its predominance. More than 70% of ED chief complaints involve pain, and over a third of all ED medications are for analgesics. Unfortunately, studies about the quality of ED pain care rendered indicate it is usually inadequate and inconsistent. So much so, that the emergency medicine world created the term oligoanalgesia to describe our inadequacies in providing optimal pain relief. 

Disparities in pain care are known to exist based on race, ethnicity, by gender, by age, and more specifically for older adults. Recent studies have demonstrated that these disparities exist in the ED setting. _____ [00:07:25] study sites and national administrative data sets using _____ [00:07:28] for ED pain-related visits, even when adjusted for other known covariates, such as gender and race, ethnicity, and pain severity, have found that older adults are less likely to receive analgesics. Unfortunately, unrelieved pain care is associated with adverse outcomes. And, these include the development of persistent paid, longer hospital lengths of stay, delays to functional ability including ambulation, and for older adults in particular, the risk for developing delirium.

The downside about all of this is the pain is highly prevalent in older adults, and its treatment can be challenging, because of the many associated risks secondary to aging. A survey of ED physicians found that more than half are uncomfortable treating pain for older adults. 

So, let us go into a little more detail about these factors. As mentioned earlier, a majority of older adults are on multiple medications. Over 90% are on more than one, and over 40% are more than five medications. ED physicians often treat and prescribe new medications to patients when they are discharged from the ED, and this may place patients at great risk for adverse reactions or outcomes of patients. These multiple and new medications, coupled with an atypical and decreased physiological reserve in metabolizing and processing the medications can make prediction of how these drugs will work difficult. It is for these reasons we should be cautious in our choice of analgesics, carefully dose, carefully _____ [00:09:09] when treating pain.

Acute pain care in the ED should follow the mantra that you just saw before, start low and go slow, and consist of frequent pain assessment, first doing no harm, and then when treating pain,, involving multiple follow-up assessments and giving pain medication at titrated doses to improve the pain. I consider acute pain care akin to treating diabetic ketoacidosis. Without frequent assessments of patients’ fingersticks for their glucose level, and in this case pain levels, we have no way to know how much insulin we should be dosing and titrating, or in this case, how much pain medication we should be giving.

To prompt and define one pain care might be bad and actually follow the level of good care and into the realm of poor care. Geriatric ED quality indicators have been developed by a consensus for ED pain care for older adults. These include the timely evaluation of pain, the reassessment of pain, the treatment of pain, and the treatment of pain if the patient has moderate to severe pain. And, specifically for older adults, if they receive opioid medications at discharge, they should also receive a bowel regimen of stool softener and laxative to counter the effects of constipation from the opioid.

Now, let us go and give you some more background about the ED environment and crowding. As hopefully many of you know, the ED is a specialized environment that provides medical care to those that are acutely ill and injured, and functions as a safety net to our healthcare system. As such, EDs are increasingly becoming crowded as hospitals close and that is confirmed by a very recent RAM study. More and more patients are turning to the ED for care, or are referred for diagnostic evaluation. 

As described in an IOM report in 2006, these all threaten to push our EDs to the breaking point. And, primary drivers for crowding in the last decade were increased lengths of stay and intensity of services, which include diagnostic testing, treatment and procedures during the ED evaluation. These will only likely increase as our population ages and as the patients present with greater multi-morbid conditions and complex cases.

What do we know about crowding? Well, unfortunately, it is bad for patient care and outcomes. It has been demonstrated to be associated with increased mortality during weeks of higher visit volumes, increased patient mortality, length of stay and costs, delays of thrombolytic for patients with heart attacks, and has been associated with patients not getting timely antibiotics and not surprisingly, decreased patient satisfaction.

So, my questions are, is crowding associated with poorer pain care for older adults, and are there, so, in essence, do older adults get poorer, receive poorer care when it is crowded, and are there differences in pain management for older adults in the ED when compared to younger patients?

So, we will start off first by evaluating the quality of pain care that patients receive for hip fracture. Hip fracture is a model conditioned to evaluate, because it is relatively unique to older adults. You do not usually see kids with hip fractures, but this is a condition more predominant in older adults. 

What we have here is a retrospective observational sub-study of a large prospective cohort study of hip fracture patients. We reviewed about 158 patients, who received ED care and were admitted for hip fractures in the late ‘90s. The list of variables included age, gender, severity of illness, comorbidities and ED crowding, which we measured as ED census, so this was the total number of patients that were in the ED during the first hour of the index patient’s arrival, in this case, the hip fracture patient. Outcomes studied were documentation of pain assessment, treatment of pain and times to these activities.

What we found, surprisingly, or not so surprisingly, is 81% of these hip fractures were very long, this is the long bone fracture, 81% of these patients complained of pain. The mean times to first pain assessment was 40 minutes and receipt of analgesics took over two hours. Delay to treatment, which I define as when the pain was first documented to when they finally received an analgesic was also over two hours. Of those in pain, over a third did not receive analgesics, and over half of those receive an opioid. And, at that time, a third of those receiving opioids received Demerol, or meperidine, which is considered an inappropriate analgesic in older adults.

With regards to crowding, during periods when ED census was above bed capacity, so if there were 40 beds in the ED, this was over 40, more patients than in the ED, patients were less likely to receive a documented pain assessment and took longer in having their first assessment.

So, the implications of this study findings are that at least, or in this case, at least hip fracture patients received relatively poor pain management, and it was worsened during periods of crowding. By studying a condition that is relatively unique to older adults, it may be possible to develop models for future studies and target areas of quality improvement.

So, that was a basic model of pain care for conditions specific to older adults. What do we know about general pain care, and how does it compare for older adults to younger adults? So, the next study we are going to look at is an observational study of pain assessment and treatment for adult patients in the ED.

Here we are hoping to determine if older age and greater ED census were associated with poor process of care measures for pain management within the ED setting. This is a retrospective chart review of ED visits with conditions that warranted analgesics, so we excluded patients with chest pain, since these generally are treated as cardiac patients.

The study took place during the months of July and December of 2005, so that we could have seasonal variation, and it took place at Mount Sinai, which is an urban academic tertiary care ED. And, at that time, we had over 75,000 visits annually. Sinai is fortunate to have a comprehensive EMR, where we have patient tracking, physician and nurse documentation, and order entry. So, it was very easy for us to pull data.

All adults who had a chief complaint involving a pain and a final ED diagnosis of a painful condition, so we were really trying to target those patients that warranted pain care. So, examples include if a chief complaint of patient came in with toe pain and their final diagnosis was gout, they were included. But, if their initial chief complaint was toe pain and their final diagnosis was CHF, they were excluded.

Data were pulled from the EMR and included patient demographic, clinical and pain care data. And ED census was generated using ADT registration data, similar to what we had heard earlier of total patient census in ED during the first hour of index patient’s arrival.

Primary variables that we were focused on, the primary predictors included ED census. So, we sub-categorized into the groups of younger, 18-64, older, 65-84, and oldest, so greater than 85. And, we included covariate gender, race/ethnicity, the Emergency Severity Index or triage score, degree of pain. And, here in this case, because we were able to have greater access to patient charts, we included comorbidity, Charlson comorbidity score, and the number of prior medications that these patients were on.

_____ [00:17:03] are features that I think are more specific to older adults and so we are really trying to now hone in on those patient-related characteristics that may be related to potential disparities for older adults.

Process of pain care measures included, again, documentation of pain assessment, any follow up, whether pain was treated and if so, with what, and times to activities.

So, over a thousand patients were reviewed. These are just characteristics of our ED at the time, and what we found were than during periods of crowding, when ED census was above median levels now, there were statistically significant differences in pain care with regards to treatment. Patients were less likely to receive analgesics, any analgesics, opiate or NSAIDs, during periods of crowding. During periods of crowding, we also found that patients had significant delays to assessment and receipt of their analgesics. So, what you are seeing here is, again, the red is when it is crowded, and the green is when it is not crowded, so below median levels and above median levels.

So, during periods of crowding, patients were less likely to receive treatment and longer times to patient assessment and treatment. By identifying factors associated with the quality of pain care, we can now target interventions to improve care for older adults. While we cannot necessarily control and manage the volume of patients, what we can do instead is think about ways we can develop interventions to get earlier pain treatment to these patients. So, for example, you, if you know a patient has identified hip fracture, you might want to consider a femoral nerve block. There might be opportunities to have nurse initiating analgesics for select conditions.

So, what about patient-related factors? So, that same cohort, this is a descriptive table of our group, broken down by age category. And, what you can see is a breakdown by younger, older, and oldest with regards to gender, race/ethnicity, and ESI. Again, ESI here is the lower the number the more acute the patient is. And, so in this case, you can see as patients became older they were more likely to have higher acuity. 

And, we have further breakdown now of the Charlson comorbidity score and number of medications that the patients are on. In this case, the older patients had greater comorbidities and were also on more medications.

And, what we see here is that there were actual no differences in pain assessment and analgesic times, between younger and older patients. Regardless of this, however, what we found is that older adults had a lower reduction in pain scores. So, think of it this way, they had less relief of their pain when compared to younger patients. That is the first row, difference in initial to final pain score. With regard to pain assessment, again, we see no differences in pain care between younger versus older patients. 

But, in adjusted analyses, even when accounting for clustering effects by treating clinicians and our multiple covariates, we found some significant differences in pain treatments. In older adults were likely to receive opioid analgesics when compared to younger patients. When breaking it down by mild versus moderate and severe pain, we also found that older adults continued to be less likely to receive opioids and were, there was a slight trend for them to be more likely to receive NSAIDs.

So, in our findings for this particular study, older adults had a poorer reduction of pain scores and also decreased opioid use. So, it is a trend for preferential use of NSAIDs in the initial treatment of mild pain for older adults.

What are the implications of these findings? Well, with acute pain, older adults did in fact have lower reduction in pain scores with decreased use of analgesics. Do these differences represent disparities or inadequate pain care?

So, my next survey question was to ask, if you were treating acute pain, what you preferentially use to treat it?

To move forward, we will now discuss a little more about multicenter studies. So, it is the previous studies you have heard were all single center studies. Modeled after the last study that you heard, which took place at Mount Sinai, we move forward with a multicenter observational study of pain assessment and treatment for adult patients in the emergency department.

In this case, again, we were interested in understanding ED pain care processes in comparing younger versus older patients and trying to determine if pain-related characteristics, what patient-related characteristics were unique to older adults and how they might influence the quality of care they received. Our hypothesis was that older adults would receive poorer pain care with decreased pain assessments, decreased use in analgesics, decreased use of opioids, potential increased use of NSAIDs and a poor reduction in their pain scores.

Similar to the previous study, this was also a retrospective, observational cohort review of adult patients, 18 and older, who came to the ED. They had to have a chief complaint of pain and in particular, focused on patients who had abdominal or fracture pain. This took place at five geographically disparate EDs throughout the country. And, now we sampled patients from January, April, July and October of 2009.

The outcomes measured were similar as before, documentation of pain assessment and follow-up, whether or not analgesics were administered, and what the reduction in pain scores were. Our primary predictor, again, focused on age. So, we compared younger to older and oldest patients and the covariates were similar in terms of gender, race/ethnicity, triage severity, initial reported pain score, comorbidity, number of medications and in this case, because we had a much large sample, we were able to cluster by clinician and by site level.

So, here is the descriptive characteristics of our cohort with similar findings, as expected, with regard to ESI, number of medications and comorbidities. And, here are results. While older adults were less likely to have received an initial pain assessment, they were more likely to receive follow-up assessments. In contrast to the prior study where there were some differences in analgesic administration, we found that older adults here were less likely to receive analgesics at all.

These associations continued in our multivariable hierarchical modeling and overall, older adults were less likely to receive any analgesics of any type for this cohort, consistent with national trends. Interestingly enough, however, despite this and in contrast to our previous study, we were surprised to find that older adults had greater reduction in their pain scores, but then overall reduction of 3.84 versus 3.1 compared to younger patients. So, this would mean that there is a, this was a, there was a greater difference from their initial to final recorded pain scores when you compare younger to older and oldest patients. There is a greater reduction for older and oldest patients.

When we looked more closely at the types of pain conditions, however, we found differences in pain care. While both had found them on fracture pain had good follow-up pain assessments, older adults with abdominal pain were less likely to receive initial pain assessments when compared to fracture pain. Older adults with abdominal pain were also less likely to receive analgesics, but still continued to have better reduction in their recorded pain scores, which was very surprising to us. These differences continued when evaluated whether or not patients received analgesics, and older adults were more likely to receive pain medications for fracture pain, but not for abdominal pain.

So, in conclusion, older adults appear to receive poorer pain care in the sense that they are less likely to receive initial pain assessments and less likely to receive analgesics overall. These results are dependent on the type of presenting pain, so not all pain are treated equally. However, overall, older adults still continue to have better reduction in pain scores, despite these disparities in the quality of pain care they received.

Could improvement of pain care lead to even greater reduction in pain scores? And, why are different types of pain not treated equally? This brought us to wonder as well, what should be the benchmark for the quality of pain care. Should it be a process of pain care measure, or should it be a patient-reported outcome? I would argue, despite the fact that patients had resolved or improved pain scores when comparing younger to older, that the process of pain care is more important. Again, the same thing with diabetes management, you still need to assess and treat, before you can actually have your final outcome. So, in this case, you still need to assess and treat the pain, before you can actually have an improved pain score.

So, these would have been my final survey questions, basically asking if you have treated acute pain care in the past, especially since this is a VA recorded session, and did you routinely document pain assessment in your clinical note? And, the reason I ask these questions, I will go into now for more discussion about VA data that we preliminarily found.

So, what so we know about the quality of VA ED pain care? So, what we have here is a pilot study that was funded in the hopes of establishing the feasibility to collect VA ED pain care data, and the goal to eventually develop a technique to automate the extraction process of gathering pain care data from the EMR and VA databases.

Our specific aims were to determine whether or not chart review was feasible to assess for pain care, and this would allow us to then develop a gold standard human record review, because ultimately, we are hoping to develop an automated process, potentially using natural language processing. Our second aim was to determine what sources of data were available within the VA and identify local, regional, and national sources with regards to ED pain care, processes of pain care. Finally, we wanted to, our hope was to provide recommendations about the quality of ED pain care data structures. And, again, the hope was to develop this into a larger scale study proposal.

Our method, we randomly selected VA ED visits during 2009 and we looked at three study VA sites, West Haven VA, West L.A. VA, and then the Bronx VA. And, we reviewed these randomly selected ED visits, the DPRS medical records charts for the ED visits. We explored and compared alternate national VA sources that contained ED pain care data.

And, what we found were, most of these are our preliminary findings. So, for the chart review process we reviewed 435 randomly selected ED visits. These were completed by a trained RA, with 10% of these abstractions also completed and adjudicated by two physician investigators. And, over 60% of the ED visits, so these are just randomly selected ED visits, involved a chief complaint of a painful condition. Only 80% of these, however, had pain score data in our national VA data sources. The initial mean pain score was over 5, and less than 40% of these had any type of pain assessment documented by the physician, and less than half received analgesics. The main time to analgesics for those that did receive it was over 100 minutes. And, we found significant variation in pain assessment documentation and receiving analgesics. So, anywhere from 8% of the charts for a particular site had pain assessment documentation to 64% for another site. And, with regard to treatment of pain, the range of pain treatment was from 14% at one site to 41% for another site. Interestingly enough, or in a very good way, there were no differences in care based on age, race, or gender.

So, the implications of our study findings were, as I had said before, we were hoping to develop a gold standard human record review of pain care documentation, and use this as a gold standard for an automated process. But, the problem with the automated process is if there is nothing to actually scan or look for, this would be a limited search. So, it is essentially, earlier steps are needed right now in terms of improved documentation and assessment of pain in the emergency department setting. And, then, for future, later steps we could focus on interventions to then try to improve the pain treatment. So, again, trying to get a better process of pain care with regard to documentation of pain assessment, and then hopefully, later on, move forward with the treatment.

So, in summary, this presentation I would like to describe basically acute pain care to me involves both the assessment and treatment of patient pain. Without pain assessment, we cannot treat the pain. Acute pain care in ED setting is influenced by environmental factors such as crowding, and also by patient-related characteristics. Crowding appears to worsen the quality of pain care patients receive and it appears that older adults receive disparate acute pain care as well. These differences are not only based on age, but also potentially by comorbidities and polypharmacy, and based on the type of condition these patients present with.

And, finally, I would throw out a question that we should all consider is what should be the benchmark for good pain care?

So, I would just like to thank all of my collaborators and support that I have received to conduct some of these studies. And, I want to thank you all for your attention.

Heidi:Thank you so much, Ula. For the audience, I believe you all should have a Q&A screen up on your screen. If you do have any questions from today’s session, please type those in there and we can get those read off to the audience. I know, I do appreciate all of you who have muted your phone lines. It does help keep our audio quality much better, and if possible, I would like to keep those muted and take questions through that Q&A screen. If you are not able to find that Q&A screen there is a chat box in the lower right-hand corner of your screen. You can submit questions there, or you can submit them through the CyberSeminar@VA.gov email address. We can take all of them from right there.

And, I do not have any, oh, okay, thank you. There is our first question. Would you elaborate a little bit more about the unique aspects of managing pain in older adults in the VA ED versus the private setting?

Ula:So, I am going to take this question literally in terms of, I think some of the differences in pain care. So, stepping back and looking at, this is, I am not sure what screen you are seeing, but, so, the VA population has an even greater preponderance of older veterans than compared to the national ED. So, some of the EDs that you saw before describing the proportion of patients that are 65 and older, were represented maybe only anywhere from 10 to 15% of the EDs as a volume. Whereas in the VA, the number of older veterans that are 65 and older is as high as 20% and is projected to continue to increase because of our aging population. So, I think that within the VA setting, the need to really assess and focus acute pain care and, remember that we are dealing with older patients, there is even more of a priority. 

The VA population of course does have unique features, in the sense that it is a veteran population, and we also need to really make sure that we address mental health issues, address the many medications that these patients may be on. I think veterans, in particular, often have chronic pain, maybe to a much greater proportion than the general community population, and may already be on a lot of medications. And, so, the ability to really be cautious about what we are treating with and that where the overlap that the acute pain treatment and assessment, how these may impact patients when they are coming in and out of the emergency department, is another area where, again, that mantra of you know, caution and start low and go slow. But, just really, again, being very aware of what you are doing and first do no harm, is very relevant.

Heidi:Great. Thank you. I am still waiting to see if anyone else has any other questions. There we go. As a follow-up, I imagine that in the VA, given an integrated system, there is more of a need to focus on collaboration with primary care providers for follow-up.

Ula:Yes, so that is an excellent point, and probably I should have continued a little more with my point before. So, I think emergency physicians or the emergency department – some of my earlier slides kind of implied that, you know, we function as the healthcare safety net for acutely ill and injured, and in the past, you know, we were often, you know, we would see patients as a cross-section in their continuum of their health care. But, as such, EDs are becoming more and more, more so relied upon as potential sites where patients may be referred for overflow. So, this is much more in the community setting where the clinics or the physicians’ offices that are now being overwhelmed by a number of patients, or they just do not have the diagnostic capabilities to evaluate patients, that are coming with more complex presentations. And, thus, they are being referred to the ED more frequently.

I think this is also a trend that we may potentially start to see in the VA setting. As such, this partnership now between what goes on during an ED visit during the evaluation,  and whether or not a patient is admitted, or hopefully discharged to the community. That continuum of care and the coordination and transition of care between a past physician, a primary care provider, and what goes on in the emergency department, is going to be all the more important. The beauty of what the VA has, though, is it is integrated, not only is it an integrated healthcare system, but it is also its access to information about patients. The VA patients, you know, our ability to access clinical notes from the multiple outpatient clinics, or, you know, even the inpatient visit will allow for, I think, a better care transition than probably can be seen in the community, where sometimes access to patient records, even in single institutions, is often limited. And, now, the potential that patients may cross hospitals or institutions and maybe the ability for health information exchange to support that. There is a lot of potential out there, but the VA is really sitting at the forefront, I think, of leading that.

Heidi:Great. Thank you. The next question we have here, what cultural or racial differences have you seen in older adults presenting with pain in the ED?

Ula:So, with regard to cultural or racial differences, we actually have not found a significant difference. So, let me go back to some of these other slides that I had. I think one, I do not know if you can see – can you see my slides?

Heidi:Yes, we can.

Ula:Okay, descriptive about the – so, one of the very predominant things is, if you see here, I had mentioned early in the background, there are known gender and race/ethnicity disparities in ED pain care in general. So, studies have shown that patients with fracture for ED pain care, if you are black or Hispanic, and if you are female, you tend to get poor pain care. You are less likely to receive analgesics, you are less likely to receive opioids. With regard to differences in race/ethnicity by age, that is not quite as apparent, and I think one of the reasons maybe if you look at this particular slide – let me turn this up – older adults predominantly tend to be, they have less of a race/ethnicity mix. So, older adults tend to, for whatever reason, those that present in the ED, they tend to more predominantly be white. There are fewer minority patients, and this was, this is the data from all five sites, where we had significant differences in race/ethnicity composition. So, the differences by race/ethnicity were not as apparent when we focused specifically here. But, again, this was targeted, our primary predictor was targeting older adults, so, I do not know if that answered your question. Hopefully, that answered your question.

Heidi:Okay. And, the next question here, being that older adults commonly suffer with pain, what do you think about assessing pain as the first vital sign instead of the 5th vital sign in older adults?

Ula:So, I love that this person is asking the question, because I think that would be wonderful. I think our biggest challenge in the emergency department is really that first step of getting, you know, clinicians to even assess for pain. As we saw, with, there were differences in fracture and abdominal pain, for example. And, I think, you know, someone comes in with a fall and like an obvious broken bone, it is pretty like right out there that they have a fracture, so pain might be the very first question, or the first “vital” that is assessed, but for someone who comes in with abdominal pain, where it is a little more subjective, it is a little more kind of cloudy and loose as to like well, you know, how severe is your pain. People might often forget to ask, and so, if we could push pain as the first vital sign, I think that would be a tremendous first step. But, I think, speaking in terms of my experiences working with just the community hospitals that I work in and the academic medical centers that I work in, that...

[The conference is scheduled to end in five minutes.]

...is, is a critical one, and if we can actually get patients, or not patients, clinicians, nurses, physicians, techs, to just even ask a patient like how their pain is, that would be a tremendous first step and I think would, again, along the lines of assessment and treatment, if you can get that, if people are aware that patients are in severe pain, they might actually start treating it. And, I think we could do huge strides to improve the quality of pain care received.

Heidi:Great. Thank you. The next question we have here, is there a recommended time to monitor an older adult after an opioid, prior to discharging to home?

Ula:So, there is not set recommended time. I think a lot of it depends on what kind of opioid is used. As many of you know, opioids due tend to last longer than maybe some other medications, but, and because of the fact that older adults and their pharmaco-dynamics and pharmaco-kinetics is sort of an unknown factor. I will say one thing. For me, whenever I give opioids to patients in the ED, I never discharge them home alone. They always have to go home, driven, or taken home by somebody else. So, I would not, I do not allow patients, young or old, if they have been given Percocet or any kind of opioid or morphine or whatever I use, to go home, unless they have been in the ED for exorbitant lengthy duration, you know, such as 6-plus or 8-plus hours. But, they should be accompanied home, and that is my general recommendation.

Heidi:Great. Thank you. I know that we got that announcement that the phone lines are about to be shut off. I got us a little bit more time if anyone does have any other questions, please feel free to send those in. We have exhausted what we have received at this point. Bob, if you are still on the call, I do not know if you have any remarks you would like to make, or Ula, if you have any other final remarks you would like to make before we wrap things up today.

Ula:So, I think, you know, if people have questions later, I welcome them to like send me an email. I have listed here my Mount Sinai email instead of my VA email. I also have a VA email account. It is UlaHwang@VA.gov. My Mount Sinai account, I am able to see more quickly, so, you know, please send questions my way if you have any thoughts or comments even about today’s presentation.

Bob:And, this is Bob. I want to thank Ula for a really wonderful presentation on a very important combination of topics. I really do, as a pain investigator in VA, and as a policy and practice leader in VA, I want to actually encourage an increased focus on acute pain, pain management in older adults and pain management in the emergency department setting. All three of these domains, certainly in combination, but even individually, as I early stated, is, are areas that are fruitful for research and practice innovation. There is a lot of important work being done, but a lot more that could be done in VA, and so I think there is great room and opportunity.

Again, I really do want to thank Cyber and Heidi for your continuing support for this program, and I want to again thank our presenter today, Dr. Hwang, for her excellent presentation. And, with that, I wish everybody a happy 4th of July and we will resume, actually Heidi, I, do we actually have a program in August, or we took the month off? You will have to remind me.

Heidi:We actually took the month off, so, we will not be holding any Cyber Seminars of any type in the month of August, so we will be back in September. I believe we are scheduled for September 3. Unfortunately, with the server issues I am dealing with this morning, I did not have time to pull up the session information, but, we will be getting information for everyone to register for that session out to everyone when we get closer to that session time.

Bob:Right, thank you. Thank you again everybody. Take care. Bye-Bye.

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