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While the 2026 EUSEM guidelines provide evidence\u2010based pharmacological recommendations, translating these into the crowded ED environment is often constrained by systemic overcrowding and a traditional reliance on technical skills, with limited integration of human factors and nontechnical skills relevant to suffering. The objective of this position paper is to propose a practical, human\u2010centred operational framework that bridges scientific guidelines with clinical realities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>The resulting 10\u2010domain cognitive and operational toolkit synthesises technical and nontechnical skills without implying a mandatory sequence. The domains comprise: (1) establishing psychological safety and therapeutic engagement; (2) multidimensional assessment, including potential indicators of pain and selective neuropathic screening; (3) shared goals and care planning; (4) context\u2010triggered caregiver integration; (5) severity\u2010matched, mechanism\u2010informed multimodal analgesia; (6) individualised opioid stewardship for opioid exposure, tolerance and Opioid Use Disorder; (7) an independent palliative and end\u2010of\u2010life domain, including proportional palliative sedation only for appropriately assessed refractory suffering; (8) contextual assessment of broader palliative and social needs; (9) anticipatory workflow, reassessment and rescue planning and (10) handoff and continuity of care. Domains 1, 2, 3, 5, 9 and 10 are core; domains 4, 6, 7 and 8 are context\u2010triggered. All 10 are briefly considered, while specific tools and actions are activated only when clinically relevant.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Perspective<\/jats:title>\n                    <jats:p>This position paper addresses the persistent gap between evidence\u2010based guidelines and the operational realities of overcrowded EDs. By integrating pharmacology with essential nontechnical skills, the proposed 10\u2010domain toolkit provides a human\u2010centred cognitive and operational model for daily clinical practice. It is nonsequential: all domains are briefly considered, while core and context\u2010triggered actions are activated according to clinical relevance. The model requires local adaptation and prospective evaluation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Effective pain management is an ethical imperative that requires both pharmacological competence and nontechnical skills. This framework serves as a cultural, cognitive and operational guide, helping clinicians embed proactive, individualised pain relief, reassessment and continuity into the demanding workflow of the modern ED. As an expert\u2010informed toolkit rather than a validated pathway, it requires local adaptation and prospective evaluation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1155\/prm\/9154388","type":"journal-article","created":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T12:40:16Z","timestamp":1792586416000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Beyond the Ladder: A 10\u2010Domain Cognitive and Operational Toolkit to Humanise and Implement Acute Pain Guidelines at the Bedside"],"prefix":"10.1155","volume":"2026","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2285-327X","authenticated-orcid":false,"given":"Michele Domenico","family":"Spampinato","sequence":"first","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Department of Translational Medicine University of Ferrara  Ferrara Italy  unife.it"},{"name":"Emergency Department Ferrara University Hospital  Ferrara Italy  unife.it"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9281-3601","authenticated-orcid":false,"given":"Sossio","family":"Serra","sequence":"additional","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Emergency Department Ramazzini Hospital  Carpi Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4936-1531","authenticated-orcid":false,"given":"Alessandro","family":"Riccardi","sequence":"additional","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Emergency Department Santa Corona Hospital  Pietra Ligure Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mario","family":"Guarino","sequence":"additional","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Emergency Department AORN dei Colli CTO Hospital  Naples Italy  unito.it"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia Sara","family":"Cimmino","sequence":"additional","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Emergency Department AORN dei Colli CTO Hospital  Naples Italy  unito.it"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Enrico","family":"Gandolfo","sequence":"additional","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Emergency Medicine Unit 3 ASL Citt\u00e0 di Torino Martini Hospital  Turin Italy  aslcagliari.it"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-1155-4792","authenticated-orcid":false,"given":"Fabio","family":"De Iaco","sequence":"additional","affiliation":[{"name":"National Study Group on Pain Management and Procedural Sedation and Analgesia (SAU Group) Italian Society of Emergency Medicine (SIMEU)  Turin Italy"},{"name":"Emergency Department ASL Citta di Torino Maria Vittoria Hospital  Turin Italy  aslto2.piemonte.it"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,21]]},"reference":[{"key":"e_1_2_9_1_2","doi-asserted-by":"publisher","DOI":"10.1016\/0735-6757(89)90286-6"},{"key":"e_1_2_9_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.annemergmed.2003.11.019"},{"key":"e_1_2_9_3_2","first-page":"205","article-title":"Italian Intersociety Recommendations on Pain Management in the Emergency Setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC)","volume":"81","author":"Savoia G.","year":"2015","journal-title":"Minerva Anestesiologica"},{"key":"e_1_2_9_4_2","doi-asserted-by":"publisher","DOI":"10.3109\/15360288.2010.547560"},{"key":"e_1_2_9_5_2","unstructured":"Legge 15 Marzo 2010 n. 38. 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