Analgesic usage and reasons for emergency department attendance in ambulatory care patients with minor injury


  • Domini K Martin, MBChB, Emergency Medicine Registrar.

Dr Domini Martin, Emergency Department, Waikato Hospital, Pembroke Street, Private Bag 3200, Hamilton 3240, New Zealand. Email:


Objective: The aim of the present study was to determine the reasons for which patients with minor injury attend the ED, comparing those who have and have not self-administered analgesia. Secondary outcomes were to quantify the proportion of patients who present without having taken analgesia, to describe the reasons why analgesia was not taken, and to compare pain scores between the two groups.

Methods: Prospective observational study of adult patients with minor injury presenting to the Emergency Department of Palmerston North Hospital, Palmerston North, New Zealand. Participants answered a questionnaire about their analgesic usage and reasons for ED attendance.

Results: Four hundred and seventy-three patients were enrolled, of which 63.9% had not self-administered analgesia. The most common primary reasons for ED attendance were for diagnosis (49.6%), and for treatment (31.3%). Patients who had not self-administered analgesia were significantly less likely to be seeking analgesia than those who had (22.8% vs 39.2% [P < 0.001]). They were also less likely to want an X-ray (31.8% vs 46.8% [P= 0.001]) and had a significantly lower pain score than those who had taken analgesia (47.2 vs 59.8, [P < 0.001]). They were significantly more likely to have come primarily for treatment (35.8% vs 23.1% [P= 0.017]). The most commonly cited reasons for not taking analgesia were ‘didn't have any handy’ (31.0%), or ‘didn't have time’ (27.4%).

Conclusion: The majority of patients who attend ED with minor injury have not taken analgesia. They come primarily for diagnosis and treatment, and often believe that their condition is too urgent to stay at home and take analgesia. Pain is usually not their main concern.


Patients with minor injury frequently present to the ED in pain, but without having taken any prior analgesia.1 This can be frustrating for ED medical staff if they believe self-administration of analgesia would have obviated the need for an ED visit. Some clinicians might consider these presentations to be inappropriate attendances. Previous studies have, however, identified a discrepancy between health professional and patient perspectives, and even between different health professionals, regarding ‘inappropriate’ attendances.2–4 Coleman et al. studied low-acuity ED patients to ascertain the likely usefulness of alternative immediate care services in reducing ED attendance in Sheffield, UK. They estimated that despite 55% of the study group being potentially manageable by providers other than ED, only 7% of those deemed suitable would be likely to go elsewhere for care, as a result of disparities between the professional view and the patient's perceptions of the seriousness of the health problem.5 Similarly, Masso et al. in New South Wales found that patients were significantly more likely to consider that their problem was serious or urgent than clinicians.6 On the other hand, a study from Wales of low-acuity attendees found that 27% were dissatisfied with their ED visit. Of these, 55% complained of dismissive attitudes of doctors.7

The present study, therefore, does not examine the appropriateness of the ED presentation, but instead asks what patients with minor injury hope to gain from their ED visit? And why have they not taken analgesia? A better understanding of why patients with minor injuries attend ED and what their expectations are of their visit will help us to better meet their needs, and might aid in planning ways to meet the needs of this patient group outside of the ED setting.


The primary objective of this prospective observational study was to examine patients' reasons for visiting the ED with minor injury, and to see whether these reasons are different for those who have self-medicated with analgesia before arrival compared with those who have not.

The secondary objectives were to quantify the proportion of patients with minor injury who present without having taken analgesia for their presenting complaint, to describe the reasons why these patients have not taken analgesia and to compare the pain scores of those who have taken analgesia with those who have not.



The study was performed in the ED of Palmerston North Hospital, Palmerston North, New Zealand. Palmerston North Hospital is a 350 bed regional base hospital, which services an urban population of 75 000 and a total population catchment of 160 000.8 The ED sees approximately 36 000 patients per year with an admission rate of 25%.

The study population

All patients 18 years and over presenting to the Palmerston North Hospital ED as the result of an injury between 2 December 2009 and 2 March 2010 who were assigned triage codes 4 or 5 (Using the Australasian Triage Scale9) were eligible for enrolment if they were triaged to be seen in the ambulatory care area. Patients who arrived by ambulance but were triaged to the waiting room to be seen in the ambulatory care area were also included.

Patients were excluded if they were unable to answer the questionnaire because of their injury or intoxication or because of language or comprehension barriers.

The study population was a convenience sample as it relied on the cooperation of reception staff to invite eligible patients to participate. When the reception staff were busy this task was sometimes overlooked.

Ethics approval

The study protocol was approved by the Central Regional Ethics Committee, and conforms to the provisions of the Declaration of Helsinki.


The study instrument was a written survey containing 13 questions (Appendix I). The list of possible reasons for not having taken prior analgesia (Question 4) was derived largely from a UK study in which patients were asked an open-ended question by an interviewer regarding why they had not taken analgesia.1 Further possible reasons were added based on the author's experience of reasons given by patients in Australasian EDs. In Question 6 participants were asked to numerically rank their reasons for coming from most important to least important. This list differed somewhat from similar questions in previous studies because reasons such as cost and poor access to primary care were not listed. This was deliberate as the focus of the present study was on what patients want from their ED visit once they are there, rather than on why they had not gone elsewhere.

The pain score assessment in question 11 used a standardized validated 100 mm non-hatched visual analogue scale.10,11

Sample size calculation

It was calculated that the study needed to recruit 459 patients, in order that a 15% true difference in primary reason for attending between the two groups (no prior analgesia vs prior analgesia) could be detected with 80% power. A 3:1 ratio of people taking no analgesia before attendance compared with people having taken analgesia was used for this calculation, based on Nichol and Ashton-Cleary's study in which 75% of participants had not taken analgesia before presentation.1 In another study 56% took analgesia and 44% didn't.12 In this case, a smaller sample size would have been sufficient to answer. A reported rate of 81% of patients presenting without prior analgesia was reported by Fullarton,13 but the patient group for that study included patients of all triage categories presenting to the ED, so as such it was less likely to predict analgesia usage for the current study group.

Sample size was calculated for the χ2-test outlined above. Other statistical analyses used in the present study (e.g. comparing pain scores between the two analgesia groups) were considered a priori to require a smaller sample size.


Of a total of 1452 eligible patients presenting to the ED during the study period, 473 patients (32.6%) were enrolled.

Of these, 36.1% (171/473) (95% CI 31.9–40.5) had taken analgesia before arriving at the ED and 63.9% (302/473) (95% CI 59.4–68.0) had not.

Primary reason for coming

The analysis of primary reason for coming was based on the reason that was ranked most important by each participant – if only one reason was marked, this was counted as the primary reason. If multiple reasons were indicated but not ranked, no primary reason could be assigned. In all, 115 respondents indicated multiple reasons without ranking their answers. These were excluded from this analysis.

A further 23 participants who ranked ‘other’ as their main reason for coming were excluded from this analysis because their responses did not answer the question of what they wanted from their ED visit. The reasons given for their attendance can be summarized as difficulty with accessing primary health care, advised to attend ED by other health professionals, or advised to attend by friends or family.

The remaining 335 respondents had indicated a primary reason for coming and were included in this analysis.

The percentage of patients in each group (analgesia vs no analgesia) who selected each reason as their main reason for coming is shown in Figure 1, along with the total percentage of patients who selected each reason as their main reason.

Figure 1.

Effect of self-administration of analgesia on main reason for ED attendance. (inline image) no analgesia; (inline image) analgesia; (inline image) all patients.

In all, 116/335 (49.6%) (95% CI 45.1–54.1) indicated that their main reason for attending was ‘to find out how serious my injury is, or to get a diagnosis’. The next most frequently selected main reason was ‘for treatment of my injury (e.g. Stitches, wound dressing, plaster cast)’ (105/335 [31.3%][95% CI 27.1–35.5]), then ‘for an X-ray’ (23/335 [6.9%][95% CI 4.6–9.2]). Only 13/335 (3.9%) (95% CI 1.2–5.6) indicated that their main reason for coming was ‘for pain relief’.

The responses of the two groups (analgesia vs no analgesia) were then compared for each possible main reason using χ2-tests. Where the number of responses was small the Fisher's exact test was performed. Those who had not taken analgesia were significantly less likely to come primarily for analgesia (1.8% [4/218][CI 0.5–4.8]vs 7.7% [9/117][CI 3.9–14.1]P= 0.008), and significantly more likely to select ‘treatment’ (35.8% [78/218][CI 29.7–42.3]vs 23.1% [27/117][CI 16.3–31.5]P= 0.017) or ‘my employer told me to come’ (5.0% [11/218) [CI 2.7–8.9]vs 0% [0/117][CI 0.0–3.8]P= 0.016) as primary reason for coming. Analgesia, treatment and being told to by an employer were the only main reasons that occurred with significantly different frequencies in the two groups.

All reasons for coming

Analysis of all reasons indicated as contributing to the patients' ED attendance, including those who ticked multiple reasons rather than ranking answers, revealed that 70.6% (334/473) (CI 66.3–74.7) of all respondents came ‘to find out how serious my injury is, or to get a diagnosis’. 59.8% (283/473) (CI 55.3–64.3) sought treatment, 37.2% (176/473) (CI 32.8–41.7) wanted an X-ray and 29.4% (139/473) (CI 25.3–33.7) sought advice on how to care for their injury. 28.8% (136/473) (CI 24.7–33.1) gave ‘analgesia’ as a reason for coming. 17.1% (81/473) (CI 13.8–20.8) came for paperwork, 10.8% (51/473) (CI 8.1–13.9) came because their employer told them to, 9.1% (43/473) (CI 6.7–12.0) came for a prescription and 3.4% (16/473) (CI 1.9–5.4) because advised to by a doctor elsewhere.

Those who had taken prehospital analgesia selected ‘analgesia’ as a reason for coming significantly more frequently than the no prior analgesia group (39.2% (67/171) (CI 31.8–46.9) vs 22.8% (69/302 [CI 18.2–28.0][P < 0.001]). They were also more likely to indicate that they had come for an X-ray (46.8% [80/171][CI 39.1–54.6]vs 31.8% [96/302][CI 26.6–37.4][P= 0.001]).

There were no statistically significant differences between the two groups in terms of other reasons for coming.

Pain score

The pain scores of the two groups (analgesia vs no analgesia) were compared. The group that had not taken prehospital analgesia (n= 277), had a mean pain score of 47.2 (95% CI 44.6–49.9), which was significantly lower than the pain scores for the group that had taken prehospital analgesia (n= 163), who had a mean pain score of 59.8 (95% CI 56.3–62.2) – unpaired t-test t(438) = 5.67, P < 0.001.

There were 33 study participants who did not indicate a pain score. They were excluded from this analysis.

Reasons given for not having taken analgesia

The 302 patients who had not self-administered analgesia before arrival in ED were asked to indicate all the applicable reasons why they had not done so. The most commonly cited reason was ‘I didn't have any painkillers handy’ (86/302, 28.5% [CI 23.4–33.6]), followed by ‘I didn't have time – I came straight here’ (75/302, 24.8% [20.0–29.7]). The third most cited reason was ‘It isn't painful enough to bother me’ (61/302, 20.2% [15.7–24.7]). Percentages of participants who cited each possible reason for not taking analgesia before arrival in ED are summarized in Table 1. Reasons given by more than one respondent as ‘other’ were ‘already on pain relief for an unrelated condition’ (n= 3), ‘thought pain would go away’ (n= 2) and ‘didn't know what to take for an eye injury’ (n= 2).

Table 1.  Reasons given for not self-medicating analgesia
ReasonNumber of patients% (95% CI)
Didn't have any painkillers handy8628.5 (23.4–33.6)
Didn't have time – I came straight here7524.8 (20.0–29.7)
It isn't painful enough to bother me6120.2 (15.7–24.7)
Didn't think it would work for my injury4314.2 (10.3–18.2)
Didn't think of it3712.3 (8.6–16.0)
The pain will be better once injury is treated258.3 (5.2–11.4)
Wanted the doctor to see how painful it was186.0 (3.3–8.6)
Didn't want to block pain – it's there for a reason186.0 (3.3–8.6)
Can't afford to buy medicines175.6 (3.0–8.2)
Don't like taking medicines – not healthy/natural144.6 (2.3–7.0)
Concerned about drug interactions134.3 (2.0–6.6)
Concerned about side-effects31.0 (0.0–2.1)
Other165.3 (2.8–7.8)


The present study provides new information about the priorities of patients presenting to an Australasian ED with minor injury. It clearly shows that diagnosis and treatment are the main concerns of these patients, with pain relief being a side issue for most. In many cases patients have not taken analgesia because the pain is not bothering them, or because the pain is overshadowed by concern about the perceived urgency of their condition.

These results are similar to those of a UK study of low acuity ED patients who were asked what they expected the ED to do for them. In that study the top three expectations of patients were that the ED would provide treatment, assess or examine, and diagnose. Provision of advice and reassurance ranked higher than pain relief.14

Patients who present to the ED with minor injury are therefore likely to feel dissatisfied with their visit if all they receive is analgesia. It is important to them to receive a diagnosis and to receive appropriate treatment. This is the case whether or not they have self-medicated analgesia before their arrival.

Diagnosis should therefore be explained clearly, in plain language. This was well illustrated in a large Canadian study of the expectations of ED attenders, in which 96.5% of respondents considered it ‘very’ or ‘extremely’ important that ‘staff explain the test results in a way you can understand’.15

Although children were excluded from the present study, paediatric presentations are also known to be related to the perceived seriousness of their injury. A recent study of Triage 4 and 5 presentations to the Paediatric ED at Royal Children's Hospital, Brisbane found that perceived seriousness of the child's injury or illness was cited as a major reason for presenting to the ED, with 11% of parents/carers rating their child's condition as very serious, and 57% rating the child's condition moderately serious.16

The significantly lower pain scores in the group who had not taken analgesia are in keeping with the finding that many in this group did not feel that they required analgesia.


A major limitation of the present study is that it was carried out at a single centre in a rural region of New Zealand. This significant bias should lead to caution extrapolating the results to larger urban EDs across Australasia.

In addition, the convenience sampling of the study population was open to bias. Although the reception staff were asked to give surveys to all eligible patients, they might nonetheless have favoured certain patient types over others, either consciously or unconsciously. It is possible that some patient subgroups with different needs (e.g. the intoxicated patients) have been underrepresented in the present study.

It is also well known that questionnaire design can lead to bias. An attempt was made to reduce this bias by ensuring that ‘pain relief’ was not at the top of the list of possible reasons for coming. However, the two most commonly selected reasons for coming, ‘diagnosis’ and ‘treatment’ were the first on the list of possible responses. This raises the question of whether these reasons for coming would have been less highly scored if they appeared further down the list. Given that they were scored so far above other reasons though, the removal of this bias would be unlikely to change the ranking to the extent that another reason would rank higher.

Because the questionnaire was anonymous, there was no way of knowing whether the patients' perception of what they wanted from their ED visit was in fact what they received, or indeed whether it differed from the treating doctor's perception of what was required. Also, it is not known whether there was any difference between the two groups (analgesia vs no analgesia) in nature of injury.


Clearly, patients who attend the ED with minor injury come primarily for diagnosis and treatment. If they have not self-medicated analgesia, it is most likely because pain is not their main concern. This raises the interesting question of whether we might be dispensing more analgesia than required at triage.

Although continuing to offer our patients with minor injury analgesia, we need to understand that they have probably not come just to get analgesia that they could have gotten elsewhere.

Remembering that most of these patients primarily want diagnosis and/or treatment of their injury, we need to ensure that we communicate clearly with them regarding the nature of their condition, and offer them appropriate treatment.


The author would like to thank the reception staff at Palmerston North Hospital ED, without whose assistance the present study would not have been possible. Also thanks to James Stanley of the University of Otago, Wellington, for assistance with statistical planning and analysis, and Drs Ian Martin and Paul Quigley for providing encouragement and advice at various stages.

Competing interests

None declared.


Appendix I

Study questionnaire



The answers you give on this form will not influence the care you receive today in any way. Your answers are anonymous and optional.


1. How long ago did your injury occur? (tick one)

( ) Less than 1 h

( ) 1–4 h

( ) 4–24 h

( ) more than 24 h

2. Have you taken any pain relief medication (pain killers) for your injury before coming to the Emergency Department?

( ) Yes

( ) No

3. If you have taken pain relief medication as a result of your injury, what did you take?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. If you have not taken any pain relief medication, please indicate why by ticking the reasons that apply to you in the list below: (you may tick more than one)

( ) I didn't think it would work for my injury

( ) I don't like taking medicines because they are not healthy/natural

( ) I don't know if it's okay to have them with my other pills (or drugs/alcohol)

( ) It isn't painful enough to bother me

( ) I was concerned about side effects

( ) I didn't think of it

( ) I didn't have time – I came straight here

( ) I didn't have any painkillers handy

( ) I can't afford to buy medicines

( ) I wanted the doctor to see how painful it was

( ) I didn't want to block the pain – it's there for a reason

( ) I knew the pain would be better once I got my injury treated anyway

( ) Other – Please state: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Have you done anything else to reduce the pain? (eg. Ice, sling, bandage, wound dressing, herbal preparations) If so, what?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. Why have you come to the Emergency Department today?

Please mark the number 1 beside the most important reason

  2 beside the second most important reason

  3 for the next

and so on for all the reasons that apply to you

(Leave blank the reasons that do not apply to you)

[] to find out how serious my injury is, or to get a diagnosis

[] For treatment of my injury (eg. Stitches, wound dressing, plaster cast)

[] For advice on how to care for my injury

[] For pain relief

[] for an xray

[] for a prescription for medicine

[] For an ACC form or other paperwork

[] My employer told me to come

[] I saw a doctor elsewhere who told me to come here

[] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Do you think you may need to be admitted to hospital (stay overnight)?

( ) Yes

( ) No

( ) Not sure

8. Do you expect to be offered pain relief medication in the Emergency Department?

( ) Yes

( ) No

9. If offered pain relief medication in the Emergency Department will you (or did you) want it?

( ) Yes

( ) No

10. Do you expect to be painfree when you leave the Emergency Department?

( ) Yes

( ) No

11. Please mark an X on the line below to indicate how painful your injury has been:


 No pain  Worst pain ever

12. What is your age?

( ) 18–30 years

( ) 31–45 years

( ) 46–60 years

( ) 61–75 years

( ) over 75 years

13. What gender are you?

( ) male

( ) female

Thank you for your timeinline image