{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T02:01:05Z","timestamp":1791597665072,"version":"4.3.4"},"reference-count":45,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T00:00:00Z","timestamp":1750982400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Pain remains as a prevailing cause, prompting patients to seek medical attention, comprising approximately 40% of all emergency department (ED) visits annually. Timely and effective pain management is crucial for patient comfort, satisfaction, and optimal recovery. However, there is increasing evidence highlighting the concern that patients often receive inadequate pain management in both emergency departments and prehospital settings. Despite the simplicity and potential for the repetitive use of pain scales throughout a patient\u2019s stay, it appears that a greater emphasis is often placed on monitoring hypotension or low saturation values rather than addressing pain levels above 7 on the numeric rating pain scale. Methods: This article represents an ambitious attempt to implement process improvement methodologies such as Lean Management and SixSigma, both which have been well established in service and industrial fields, within the hospital environment to improve the process of pain management in the emergency department. Results: The implementation of pain management improvement processes in the emergency department led to a statistically significant but clinically modest increase in the administration of analgesics and improved pain reporting practices. The percentage of patients receiving no analgesia decreased from 96.6% to 94.8% (p = 0.008), and the documentation of pain characteristics during triage improved. However, the escalation of pain therapy remained limited, and strong analgesics were still underutilized. Conclusions: Despite partial improvements, the lean management-based interventions did not sufficiently address the problem of oligoanalgesia in the emergency setting. Sustainable change requires enhanced clinical engagement, ongoing staff training, and the broader adoption of structured analgesia protocols across prehospital and hospital care.<\/jats:p>","DOI":"10.3390\/jcm14134566","type":"journal-article","created":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T13:06:17Z","timestamp":1751288777000},"page":"4566","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Barriers to Improving Pain Management in the Emergency Department: Lessons from a Lean-Driven Quality Improvement Initiative"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8765-233X","authenticated-orcid":false,"given":"Jakub","family":"No\u017cewski","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Dr Jan Biziel\u2019s University Hospital No. 2, 85-168 Bydgoszcz, Poland"},{"name":"Lean Medic Foundation, Ul. W\u0142adys\u0142awa \u0141okietka 24, 05-230 Koby\u0142ka, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rados\u0142aw","family":"Bondarczuk","sequence":"additional","affiliation":[{"name":"Lean Medic Foundation, Ul. W\u0142adys\u0142awa \u0141okietka 24, 05-230 Koby\u0142ka, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Grzegorz","family":"Ho\u0142ody","sequence":"additional","affiliation":[{"name":"Lean Medic Foundation, Ul. W\u0142adys\u0142awa \u0141okietka 24, 05-230 Koby\u0142ka, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meabh","family":"Kitt","sequence":"additional","affiliation":[{"name":"University Hospital Galway, H91 YR71 Galway, Ireland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natalia","family":"Mu\u0107ka","sequence":"additional","affiliation":[{"name":"Collegium Medicum, Nicolaus Copernicus University, 85-094 Bydgoszcz, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1434-2138","authenticated-orcid":false,"given":"Urszula","family":"Religioni","sequence":"additional","affiliation":[{"name":"School of Public Health, Centre of Postgraduate Medical Education, 01-826 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2018","DOI":"10.1016\/j.injury.2016.03.012","article-title":"Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation","volume":"47","author":"Spilman","year":"2016","journal-title":"Injury"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1016\/j.injury.2014.10.045","article-title":"Pain management in trauma patients in (pre)hospital based emergency care: Current practice versus new guideline","volume":"46","author":"Scholten","year":"2015","journal-title":"Injury"},{"key":"ref_3","unstructured":"Anderson, W.G. (2025, June 14). Improving Pain Management for Hospitalized Medical Patients. Available online: https:\/\/www.hospitalmedicine.org\/globalassets\/clinical-topics\/clinical-pdf\/shm_painmanagement_guide.pdf."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1136\/emermed-2019-208994","article-title":"How can pain management in the emergency department be improved? Findings from multiple case study analysis of pain management in three UK emergency departments","volume":"37","author":"Sampson","year":"2020","journal-title":"Emerg. Med. J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"967","DOI":"10.1016\/j.pain.2012.01.013","article-title":"More educated emergency department patients are less likely to receive opioids for acute pain","volume":"153","author":"Hunold","year":"2012","journal-title":"Pain"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1016\/j.healthpol.2020.01.002","article-title":"Quality improvement in healthcare: Six Sigma systematic review","volume":"124","year":"2020","journal-title":"Health Policy"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1111\/wrr.12870","article-title":"Analyzing factors affecting quality of life in patients hospitalized with chronic wound","volume":"29","author":"Yan","year":"2021","journal-title":"Wound Repair Regen."},{"key":"ref_8","first-page":"304","article-title":"Improved patient satisfaction: Effectiveness of a pain management protocol in the emergency department","volume":"42","author":"Scherer","year":"2016","journal-title":"J. Emerg. Nurs."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"935","DOI":"10.1111\/anae.13893","article-title":"Patient controlled analgesia: Effective and cost-effective management of acute pain within the Emergency Department?","volume":"72","author":"Doleman","year":"2017","journal-title":"Anaesthesia"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"3433","DOI":"10.2147\/JPR.S376586","article-title":"Pain Management in a Prehospital Emergency Setting: A Retrospective Observational Study","volume":"15","author":"Ferri","year":"2022","journal-title":"J. Pain Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1097\/j.pain.0000000000000095","article-title":"Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: A longitudinal cohort study","volume":"156","author":"Sampson","year":"2015","journal-title":"Pain"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Nadeau, S.E., Wu, J.K., and Lawhern, R.A. (2021). Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence. Front. Pain Res., 2.","DOI":"10.3389\/fpain.2021.721357"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1111\/iwj.12951","article-title":"Assessment of pain in chronic wounds: A survey of Australian health care practitioners","volume":"15","author":"Frescos","year":"2018","journal-title":"Int. Wound J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1111\/j.1742-481X.2007.00311.x","article-title":"Managing painful chronic wounds: The Wound Pain Management Model","volume":"4","author":"Price","year":"2007","journal-title":"Int. Wound J."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"King, N.B., and Fraser, V. (2013). Untreated pain, narcotics regulation, and global health ideologies. PLoS Med., 10.","DOI":"10.1371\/journal.pmed.1001411"},{"key":"ref_16","first-page":"10","article-title":"Healthcare practitioners\u2019 views on the assessment and management of pain in chronic lower limb wounds","volume":"22","author":"Frescos","year":"2021","journal-title":"J. Wound Manag."},{"key":"ref_17","first-page":"782","article-title":"The impact of improved pain management in the emergency department on hospital length of stay and costs","volume":"17","author":"Adler","year":"2016","journal-title":"Pain Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1016\/j.jpain.2012.03.009","article-title":"The economic costs of pain in the United States","volume":"13","author":"Gaskin","year":"2012","journal-title":"J. Pain."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"361","DOI":"10.2147\/CEOR.S134130","article-title":"The economic and humanistic costs of chronic lower back pain in Japan","volume":"9","author":"Montgomery","year":"2017","journal-title":"Clin. Outcomes Res."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"International Pain Summit of The International Association for The Study of Pain (2011). Declaration of Montr\u00e9al: Declaration that access to pain management is a fundamental human right. J. Pain Palliat. Care Pharmacother., 25, 29\u201331.","DOI":"10.3109\/15360288.2010.547560"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1785","DOI":"10.1093\/pm\/pnw222","article-title":"Access to Pain Management-Still Very Much a Human Right","volume":"17","author":"Brennan","year":"2016","journal-title":"Pain Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1070","DOI":"10.1016\/j.jpainsymman.2015.12.340","article-title":"Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis","volume":"51","author":"Hochstenbach","year":"2016","journal-title":"J. Pain Symptom Manag."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Toba, H.A., Samara, A.M., and Zyoud, S.H. (2019). Nurses\u2019 knowledge, perceived barriers, and practices regarding cancer pain management: A cross-sectional study from Palestine. BMC Med. Educ., 19.","DOI":"10.1186\/s12909-019-1613-z"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"669","DOI":"10.1111\/jocn.13992","article-title":"Pain assessment by emergency nurses at triage in the emergency department: A qualitative study","volume":"27","author":"Vuille","year":"2018","journal-title":"J. Clin. Nurs."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"538","DOI":"10.1016\/j.annemergmed.2019.02.018","article-title":"The Reality of Pain Scoring in the Emergency Department: Findings From a Multiple Case Study Design","volume":"74","author":"Sampson","year":"2019","journal-title":"Ann. Emerg. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"811","DOI":"10.1097\/j.pain.0000000000001165","article-title":"Professionals underestimate patients\u2019 pain: A comprehensive review","volume":"159","author":"Seers","year":"2018","journal-title":"Pain"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1002\/ams2.201","article-title":"Practices and perceived barriers regarding pain management among Emergency Department physicians: A nationwide multicenter survey in Moroccan hospitals","volume":"3","author":"Louriz","year":"2016","journal-title":"Acute Med. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"190","DOI":"10.4235\/agmr.19.0037","article-title":"Barriers and Solutions for Improving Pain Management Practices in Acute Hospital Settings: Perspectives of Healthcare Practitioners for a Pain-Free Hospital Initiative","volume":"23","author":"Akbar","year":"2019","journal-title":"Ann. Geriatr. Med. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1007\/s40122-018-0103-z","article-title":"Systematic Review of Pain Medicine Content, Teaching, and Assessment in Medical School Curricula Internationally","volume":"7","author":"Shipton","year":"2018","journal-title":"Pain Ther."},{"key":"ref_30","first-page":"363","article-title":"Connecting the Dots: A Comparative Global Multi-Institutional Study of Prohibitive Factors Affecting Cancer Pain Management","volume":"18","author":"Addison","year":"2017","journal-title":"Pain Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1093\/pm\/pnaa086","article-title":"The HHS Pain Management Best Practice Inter-Agency Task Force Report Calls for Patient-Centered and Individualized Care","volume":"21","author":"Cheng","year":"2020","journal-title":"Pain Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"861","DOI":"10.1111\/j.1526-4637.2010.00868.x","article-title":"Reasons for Under-Use of Prescribed Opioid Medications by Patients in Pain","volume":"11","author":"Lewis","year":"2010","journal-title":"Pain Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3677688","DOI":"10.1155\/2022\/3677688","article-title":"Polish Experiences of Pain Treatment by Paramedics in relation to Good Practices of Pain Treatment: A Register-Based Study","volume":"2022","author":"Koral","year":"2022","journal-title":"Emerg. Med. Int."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"van Zanden, J.E., Wagenaar, S., Ter Maaten, J.M., Ter Maaten, J.C., and Ligtenberg, J.J.M. (2018). Pain score, desire for pain treatment and effect on pain satisfaction in the emergency department: A prospective, observational study. BMC Emerg. Med., 18.","DOI":"10.1186\/s12873-018-0189-y"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.ienj.2016.02.001","article-title":"A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain","volume":"27","author":"Pierik","year":"2016","journal-title":"Int. Emerg. Nurs."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1016\/j.jpain.2006.12.005","article-title":"Pain in the emergency department: Results of the pain and emergency medicine initiative (PEMI) multicenter study","volume":"8","author":"Todd","year":"2007","journal-title":"J. Pain"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e002815","DOI":"10.1136\/bmjoq-2024-002815","article-title":"Improving door-to-analgesia timing in musculoskeletal injuries in an academic emergency department in India: A quality improvement project","volume":"13","author":"Sadasivam","year":"2024","journal-title":"BMJ Open Qual."},{"key":"ref_38","first-page":"e69789","article-title":"Optimizing Pain Management in Emergency Departments: A Comprehensive Review of Current Analgesic Practices","volume":"16","author":"Nagpal","year":"2024","journal-title":"Cureus"},{"key":"ref_39","first-page":"e52879","article-title":"Strategies to Measure and Improve Emergency Department Performance: A Review","volume":"16","author":"Mostafa","year":"2024","journal-title":"Cureus"},{"key":"ref_40","unstructured":"(2025, February 26). Choosing Wisely Campaign. Available online: https:\/\/www.choosingwisely.org."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1613","DOI":"10.1007\/s11739-023-03356-y","article-title":"Why we all need Choosing Wisely?","volume":"18","author":"Lang","year":"2023","journal-title":"Intern. Emerg. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.ejim.2021.07.008","article-title":"Impact of implementing a Choosing Wisely educational intervention into clinical practice: The CW-SIMI study (a multicenter-controlled study)","volume":"93","author":"Costantino","year":"2021","journal-title":"Eur. J. Intern. Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1001\/archinte.166.9.1033","article-title":"Improving the management of pain in hospitalized adults","volume":"166","author":"Morrison","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1016\/j.pmn.2021.04.006","article-title":"Philosophical Assumptions Used in Research on Barriers for Effective Cancer Pain Management: A Scoping Review","volume":"22","author":"Almasri","year":"2021","journal-title":"Pain Manag. Nurs."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1016\/j.pmn.2020.03.003","article-title":"Facilitators, Barriers, and Solutions in Pain Management for Older Adults with Dementia","volume":"21","year":"2020","journal-title":"Pain Manag. Nurs."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4566\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:00:12Z","timestamp":1760032812000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4566"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,27]]},"references-count":45,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["jcm14134566"],"URL":"https:\/\/doi.org\/10.3390\/jcm14134566","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,27]]}}}