Dilunga et al.

Safety in Health (2018) 4:12

https://doi.org/10.1186/s40886-018-0079-8

RESEARCH ARTICLE Open Access

Pain assessment and management

of trauma patients in an emergency
department of a tertiary hospital in
Tanzania
George D. Dilunga1, Hendry R. Sawe1,2* , Irene B. Kulola1,3, Juma A. Mfinanga1, Nanyori J. Lucumay1,
Elly M. Mulesi1 and Ellen J. Weber1

Abstract
Background: Proper pain assessment is a core component in management of trauma patients but prior literature
has suggested that pain management is inadequate in emergency settings. With the development of emergency
medicine in low-income countries (LIC), the procedures for pain assessment and management of trauma patients
have not been well studied and protocols have not been established. We aimed to describe practices of pain
assessment and management in an emergency department in Tanzania.
Methods: This was a prospective cohort study of consecutive adult trauma patients presenting to the Emergency
Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar es Salaam, Tanzania, from July 2017 to
December 2017. A case report form (CRF) was used to record demographics and clinical characteristics of participants,
whether or not pain was assessed at either triage or in the treatment area, and the administration of pain medications.
The assistant also assessed pain independently with the numeric rating scale (NRS) of (0–10). Outcomes were
proportions of patients who received pain assessment, patients who received pain medication, and types of
medications administered. Descriptive data is summarised using frequency, percentage, and median with interquartile
ranges as appropriate. Chi-square tests were used to determine association between pain assessments, receipt of pain
medication, and types of medications.
Results: We enrolled 311 (10.9%) trauma patients during the period of study. The median age was 32 years
(IQR 25–43 years), and 228 (73.3%) were male. The most common mechanism of injury was motor vehicle
crash 185 (59.4%), and of these, 87 (47%) involved motorcycles. Three hundred ten (99.6%) patients had pain
assessment documented arrival, and 285 (91.6%) had a second assessment. Pain scores obtained by the
research assistant were as follows: mild pain score (NRS 1–3) 154 (49.5%) patients, moderate pain (NRS 4–6)
68 (21.8%), and severe pain (NRS 7–10) 89 (28.7%). Pain medications were given to 144 (46.3%) patients, 29
(20.1%) of those with mild pain, 41 (28.7%) of those with moderate pain score, and 74 (51.4%) of those with
severe pain. The use of opiates increased with increased pain severity.
Conclusions: In this ED in LIC, the assessment of pain was well documented; however, less than half of patients with
documented pain received pain medication while at the ED. Future studies should focus on identification of factors
affecting the provision of pain medications to trauma patients in the ED.
Keywords: Pain assessment, Pain management, Trauma, And tertiary hospital

* Correspondence: hendry_sawe@yahoo.com
1
Emergency Medicine Department, Muhimbili University of Health and Allied
Science, P.O. Box 65001, Dar es salaam, Tanzania
2
Emergency Medicine Department, Muhimbili National Hospital, Dar es
Salaam, Tanzania
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Dilunga et al. Safety in Health (2018) 4:12 Page 2 of 6

Background patients are referred to Muhimibili Orthopedic Institute

Trauma is among the leading cause of morbidity and where orthopaedics and neurosurgery are housed.
mortality around the globe with the highest frequency in
low-income countries (LICs) [1]. Pain is a prominent Participants
feature among trauma patients presenting at the EDs Adult patients 18 years of age and above who presented
worldwide. Pain assessment and management is a crucial with the complaint of pain as a result of trauma to the
aspect in management of patients presenting at the EMD were eligible. Patients were excluded if they were
emergency departments. Better pain management leads haemodynamically unstable with SBP < 90 mmHg or
to improved satisfaction of patients as well as decreased altered mental status GCS < 15.
length of stay in hospital [2].
Several pain assessment tools have been developed Procedures
over time. When these tools are used, they have proven A research assistant was present in the ED at various
to be helpful in helping the patients in their manage- times during the study period, both days and nights, and
ment of their pain [3]. There is also a pain assessment enrolled a convenience sample of patients meeting the
and documentation tool (PADT) that has been devel- inclusion criteria and who consented. Patients were
oped in order to better understand the effectiveness of approached in the treatment areas, after triage. Using a
treatment given to patients in pain [4]. case report form (CRF) (Additional file 1), the research
In high-income countries, there is still improper as- assistant collected information on the patient’s demo-
sessment and management of pain in trauma patients. graphics, clinical presentation, whether or not pain was
Pain relief is still more “rhetoric than a reality” despite assessed, administration of pain medication, ED diagno-
the advancements in acute pain teams [5]. In low- and ses, and disposition of based on both patient’s enrolled
middle-income countries, the management of pain in patients interview and review of the electronic medical
acute care settings has not been well studied. This is record (WELLSOFT Version 11 Corporation, Somerset,
particularly true in Sub Saharan Africa (SSA), where
Table 1 Characteristics of study patients
emergency medicine is still a developing speciality. An-
ecdotally, many acute receiving areas use subjective as- Demographics Number Percentage
sessment to determine levels of pain [6, 7]. (N) (%)
Tanzania opened its first full-capacity emergency de- Sex
partment, staffed by emergency medicine specialists in Male 227 73
2010 [8]. We aimed to describe the burden of traumatic Female 84 27
pain, frequency of its assessment, and subsequent man- Age group
agement among patients presenting with trauma to this
18–30 years 139 44.7
hospital’s ED. The information extrapolated from this
study will help us determine how well pain is managed 31–45 years 106 34.1
and lay a foundation for protocols for management of 46–60 years 43 13.8
acute traumatic pain. > 60 years 23 7.4
Referral status
Methods Referred 217 69.7
Study design
Self-referral 94 30.2
This was a prospective, descriptive study of consecutive
adult trauma patients presenting to Muhimbili National NRS pain score
Hospital Emergency Medicine Department (MNH-EMD) Mild (1–3) 154 49.5
between July 2017 and December 2017. Moderate (4–6) 68 21.8
Severe (7–10) 89 28.7
Study setting
Mechanism of injury
The MNH-EMD is located in Dar es Salaam, the busi-
Motor vehicle crash 185 59.5
ness capital of Tanzania. It is part of a tertiary referral
hospital with a total bed capacity of about 1500 [9]. The Fall 63 20.3
ED is at the forefront of the hospital and most of the pa- Assault 37 11.9
tients coming into the hospital pass through it. Burn 9 2.9
The ED sees about 1200 patients per week. The top five Gunshot wound 8 2.6
most commonly occurring complaints at the ED include Animal bite 7 2.3
trauma, infections, mental health cases, neoplasm, and is-
Stab wound 2 0.6
sues relating to pregnancy [8]. Most admitted trauma
Dilunga et al. Safety in Health (2018) 4:12 Page 3 of 6

NJ, USA). The research assistant independently assessed Results

pain for each patient using the validated numerical rat- During the study period, 2848 trauma patients presented
ing scale (NRS) and recorded it on the form. The treat- at the ED. We enrolled 311 patients. Of the 311 patients
ing physician was not told of the result on the NRS. enrolled, median age was 32 years (IQR 25–43 years)
and 227 (73%) were male. The majority 217 (69.7%) were
Outcomes referred from other hospitals. The most common identi-
Primary outcome of the study was the proportion of all fied mechanism of injury was motor vehicle crash in 185
patients who has a pain assessment performed (at triage (59.4%) of patients Table 1.
and/or the treatment room) and proportion who re-
ceived pain medication. Secondary outcomes were the Pain management in the ED
administration of pain medication according to the NRS Of the 311 patients enrolled in the study, 310 (99.6%) re-
level and the class of pain medication used. ceived pain assessment initially (Fig. 1). Of these, 285
(91.6%) had pain reassessment done to them. One pa-
Data analysis tient did not receive pain assessment at any point in the
Sample size estimate was based on the proportion of pa- ED. Pain medications were given to 144 (46.3%) of the
tients who received pain assessment (54%) in a study patients.
done in Ouagadougou [10]. To achieve a 95% confidence
interval with a width of 10%, a minimum number of 382 Pain assessment, NRS scores, and pain management
patients would be required. Overall, 285/311 (91.6%) patients received pain assess-
The data from the CRF was transferred into Excel ment by EMD Provider on arrival (Fig. 1). Among those
spreadsheet (Microsoft Corporation, Redmond, WA, who received assessment, 149 (52.2%) had mild pain, 59
USA) and then transferred to SPSS and analysed. Me- (20.7%) had moderate pain, and (27.0%) had severe pain.
dian with interquartile ranges and percentages were Overall, pain medications were given to 144 (46.3%) of
calculated for descriptive data. Chi-square tests were patients. The research assistant (RA) independently con-
used to determine relationship between NRS scores and ducted an assessment of all 311 patients using the NRS.
receipt of pain medication, and association of severity of The NRS pain scores were mild (1–3) 154 (49.5%), mod-
pain with pain assessment, and severity of pain with type erate (4–6) 68 (21.8%), and severe (7–10) 89 (28.6%).
of pain medication. Pain medication was given to 29/154 (18.8%) patients

Fig. 1 Pain assessment and management of study participants in the emergency department
Dilunga et al. Safety in Health (2018) 4:12 Page 4 of 6

Table 2 Pain assessment and management of adult trauma patients by pain level
NRS pain score Mild Moderate Severe P value
Provider pain assessment (aN = 285) 149 (52.2%) 59 (20.7%) 77 (30.1%) 0.008
RA NRS pain assessment (bN = 311) 154 (49.5%) 68 (21.8%) 89 (28.6%) < 0.00001
Pain medications given in EMD (n/N) 29/154 (18.8%) 41/68 (60.3%) 74/ 89 (83.1%) < 0.00001
a
26 patients did not receive pain reassessment
b
Research assistant (RA) performed NRS pain assessment

with mild pain, 41/68 (60.3%) with moderate pain, and prompted providers to manage the pain without docu-
74/89 (83.1%) with severe pain. Patients with more se- mentation of pain assessment.
vere pain on the NRS were more likely to receive pain Muhimbili National hospital is a tertiary referral hos-
medications (p < 0.00001) Table 2. pital that receives patients from various parts of the
country [9]. Of patients, 70% were referred and may
Types of pain medications according to pain scores have been given pain medication prior to arrival, result-
Opioids were the most prescribed medications given to ing in overall lower pain levels. Nevertheless, half of the
97 (68%) out of 144 patients who received pain medica- patients had moderate or severe pain. In most previous
tions. Patients with severe pain were more likely to re- studies in HICs as well as LMICs, most patients had
ceive opioids than those with lower pain scores, whereas moderate to severe pain scores [4] (Fig. 2).
patients with mild pain were more likely to receive acet- In our study, 144 (46.3%) of trauma patients received
aminophen or non-steroidal anti-inflammatory medica- pain medications. The percentages of those receiving
tions Table 3. pain medications increased with increasing pain score
while the percentages of those not receiving pain medi-
Discussion cations decreased with increasing pain score. This tallies
Pain assessment has been shown to improve the out- with the WHO recommendation of pain management
comes of patients who present to the ED with pain as a which involves the provision of pain medications to pa-
result of trauma [2, 3]. In our study, we found that tients with the score of 6 or higher [14]. Importantly,
nearly all patients received pain assessment on arrival, less than half of all patients who had pain assessment
and most were reassessed. However, only half of the pa- documented received any pain medications. Some pa-
tients received pain medications. tients who had low pain scores still received pain medi-
The frequency of pain assessment found in our study cations while some who had a high pain score did not
is higher than in most studies in other parts of the receive pain medications. While we did not inquire
world. In a study in Morocco, only 14% of the patients exact reasons for low rate of provision of anti-pain
were assessed for pain while in a study in Ouagadougou medications, we believe number of factors might con-
about 54% of the trauma patients received pain assess- tribute towards this, including access to medications,
ment [10, 11]. A study in Norway found that 77% of pa- underassessment, and poor documentation.
tients were evaluated for pain on arrival at the ED [5]. In The type of medication given in general varied
a multi-centre study in the USA and Canada, 83% of pa- according to the degree of pain. Opioids were given
tients with pain intensity of 4 or more received pain as- more frequently to patients with a higher pain score
sessment, and 31% had a repeat assessment [12]. compared to those with mild pain score. Less strong
This suggests that pain has become the “fifth vital medications for pain like acetaminophen were given to
sign” in the developing specialty of emergency medicine patients with lower pain scores compared to those with
in Tanzania [13]. However, there were some patients higher pain scores. In a previous study done at Muhim-
who had a high pain score as determined by the research bili Orthopaedic Institute, opioids were not used at all
assistant but did not receive pain assessment by pro- to treat severe pain in long bone fractures [15]. Thus,
viders in the treatment and resuscitation rooms. This our findings suggest improved compliance with recom-
could have been due to their severity of pain that mendations of the World Health Organization on man-
agement of pain [16].
Table 3 Types of pain medications according to pain scores Although we saw a greater level of assessment than in
NRS pain Score Mild Moderate Severe P value many other studies, our study shows similar problems
N = 29 N = 41 N = 74 with regard to delivery of pain medication. The reasons
Opioids 3 (3.1%) 25 (60.9%) 69 (93.2%) 0.0001 for receiving pain medications and the barriers for not
Acetaminophen 7 (24.1%) 4 (9.7%) 2 (2.7%) 0.003
receiving pain medications at Muhimbili may however
be different compared to HICs [17]. Patients with low
NSAIDs 19 (65.5%) 12 (29.3%) 3 (4.1%) 0.0001
pain scores may have sometimes asked for pain
Dilunga et al. Safety in Health (2018) 4:12 Page 5 of 6

Fig. 2 Plot of pain level and provision of pain medication at the EMD

treatment while some with high pain scores might have Additional file
refused pain treatment. Certain pain medications are
sometimes not available. Therefore, further studies are Additional file 1: S1. Case report form (CRF). (PDF 153 kb)
needed in order to identify the reasons for lack of
provision of medications to trauma patients in the ED Acknowledgements
The author would like to thank Prof. Mwafongo, Dr. Said Kilindimo, Dr. Upendo
and also create a clear protocol in our setting. George, and Dr. Bernard Kepha for their unwavering support, also to the
research assistants and all who made the study possible.

Limitations Funding
The major limitation in our study was that this was a This was a non-funded project. The principal investigators used their own
funds for logistics, data collection, and analysis.
single-site descriptive study over a short duration of
time. We did not have seasonal variations of trauma pa- Availability of data and materials
tients especially the ones who present during the busy The datasets used and/or analysed during the current study are available from
the corresponding author on request.
travelling and holiday seasons. Therefore, our findings
may not necessarily reflect the general picture of a busy Author’s contributions
ED. Due to the limited nature of the study time, we did GDD contributed to the conceptualization, data curation, formal analysis,
funding acquisition, methodology, project administration, validation, writing
collect the required sample size and not all patients with
the original draft and writing review, and editing. HRS was involved in the
trauma were enrolled in the study, and thus, it is not conceptualization, data curation, formal analysis, methodology, and
clear that the patients are representative. However, the supervision as well as in the revision of the manuscript and writing review
and editing. IBK contributed to the design, formal analysis, supervision,
characteristics of our patients are similar to those in
writing review, and editing as well as to the review of the manuscript. JAM
other studies [7, 18, 19]. We collected NRS pain scores contributed design, formal analysis, supervision, writing review and editing
and used these to compare treatment with scores; it is as well as review of manuscript. NJL contributed to the design, formal
analysis, supervision, writing review, and editing as well as to the review of
possible the locally used system resulted in different re-
manuscript, EMM contributed to the conceptualization and analysis, as well
sponses. However, we did not use this as it is not a stan- as to the review of manuscript. EJW contributed to the conceptualization,
dardised scale with external validity. data curation, formal analysis, methodology, supervision, validation, and
critical review of the manuscript. All authors read and approved the final
manuscript.
Conclusion
Ethics approval and consent to participate
The assessment of pain in our setting was well docu- The study protocol was reviewed and approved by the Institutional Review
mented in contrast with findings of prior studies in Board of the Muhimbili University of Health and Allied Sciences and
HICs. However, less than half of patients with docu- permission to conduct the study was obtained from Muhimbili National
Hospital administration. All patients enrolled provided written consent.
mented pain received pain medications while at the
EMD. Our study lays a foundation for upcoming studies Consent for publication
focusing on identification of factors affecting the Not applicable

provision of pain medications to trauma patients and Competing interests

improving management of pain in these patients. The authors declare that they have no competing interests.
Dilunga et al. Safety in Health (2018) 4:12 Page 6 of 6

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.

Author details
1
Emergency Medicine Department, Muhimbili University of Health and Allied
Science, P.O. Box 65001, Dar es salaam, Tanzania. 2Emergency Medicine
Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
3
Department of Emergency Medicine, University California San Francisco, San
Francisco, CA, USA.

Received: 20 August 2018 Accepted: 25 October 2018

Referrences
1. Addressing the Growing Burden of Trauma and Injury in Low- and Middle-
Income Countries | AJPH | Vol. 95 Issue 1 [Internet]. [cited 2017 Jun 9].
Available from: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2004.
039354
2. Silka PA, Roth MM, Moreno G, Merrill L, Geiderman JM. Pain scores improve
analgesic administration patterns for trauma patients in the emergency
department. Acad Emerg Med. 2004;11(3):264–70.
3. Assessment of pain | BJA: British Journal of Anaesthesia | Oxford Academic
[Internet]. [cited 2017 Jun 9]. Available from: https://academic.oup.com/bja/
article-lookup/doi/10.1093/bja/aen103
4. Singer AJ, Garra G, Chohan JK, Dalmedo C, Thode HC. Triage pain scores and
the desire for and use of analgesics. Ann Emerg Med. 2008;52(6):689–95.
5. Dale J, Bjørnsen LP. Assessment of pain in a Norwegian Emergency
Department. Scand J Trauma Resusc Emerg Med. [Internet]. 2015 Oct 29
[cited 2017 Feb 17];23. Available from: http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC4625614/.
6. Awolola AM, Campbell L, Ross A. Pain management in patients with long-
bone fractures in a district hospital in KwaZulu-Natal South Africa. Afr J Prim
Health Care Fam Med. 2015;7(1):818.
7. Size M, Soyannwo OA, Justins DM. Pain management in developing
countries. Anaesthesia. 2007;62:38–43.
8. Muhimbili Emergency Medicine Program [Internet]. [cited 2015 Jan 16].
Available from: https://emd.muhas.ac.tz.
9. Our Profile - MUHIMBILI NATIONAL HOSPITAL [Internet]. [cited 2015 Jan 16].
Available from: http://www.mnh.or.tz/index.php/our-profile.
10. Assessment of the Care of Acute Pain at the Trauma Center of
Ouagadougou [Internet]. [cited 2017 Feb 17]. Available from: https://www.
jscimedcentral.com/Anesthesiology/anesthesiology-1-1016.php
11. Damghi N, et al. Patient satisfaction in a Moroccan emergency department.
Int Arch Med. 2013;6:20.
12. Paula Tanabe KHT. Pain in the Emergency Department: results of the Pain
and Emergency Medicine Initiative (PEMI) multicenter study. J Pain. 2007;
8(6):460–6.
13. Kelly A-M. A process approach to improving pain management in the
emergency department: development and evaluation. J Accid Emerg Med.
2000;17(3):185–7.
14. Stephan F-P, Nickel CH, Martin JS, Grether D, Delport-Lehnen K, Bingisser R.
Pain in the emergency department: adherence to an implemented
treatment protocol. Swiss Med Wkly. 2010;140(23–24):341–7.
15. Haonga BT, Makupa JE, Muhina RI, Nungu KS. Pain management among
adult patients with fractures of long bones at Muhimbili Orthopaedic
Institute in Dar es Salaam Tanzania Tanzan. J Health Res. 2011;13(4):107–11.
16. Undertreatment of acute pain (oligoanalgesia) and medical practice
variation in prehospital analgesia of adult trauma patients: a 10 yr.
retrospecti... - PubMed - NCBI [Internet]. [cited 2017 Feb 17]. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/23059961
17. Patrick PA, Rosenthal BM, Iezzi CA, Brand DA. Timely pain management in
the emergency department. J Emerg Med. 2015;48(3):267–73.
18. Herr K, Titler M. Acute pain assessment and pharmacological management
practices for the older adult with a hip fracture: review of ED trends. J
Emerg Nurs. 2009;35(4):312–20.
19. Huang KTL, Owino C, Gramelspacher GP, Monahan PO, Tabbey R, Hagembe
M, et al. Prevalence and correlates of pain and pain treatment in a western
Kenya referral hospital. J Palliat Med. 2013;16(10):1260–7.