Emergency department pathway for pain management using DELPHI approach and criticality analysis

Pain management remains inadequate despite numerous studies on undertreatment. Addressing this issue in the emergency department (ED) requires an organizational perspective. This expert-consensus case study aimed to model the pain journey in the ED (DELPHI-based), and perform a risk analysis using a failure modes, effects, and criticality analysis (FMECA). Seven experts participated to a six-step process. A care pathway was provided, structured by five management phases, including 17 situations and four repetitive mechanisms at risk for oligoanalgesia. Then, situations were classified into three criticality levels and incorporated into a risk map, with six high-risk situations throughout the care pathway. A root cause analysis finally highlighted redundant contributing factor themes and key failure factors in pain management, such as "communication", "decision support and protocolization", and "pain education". These management issues are relatively accessible, do not require complex or costly resources and can be optimized through concrete actions. Despite numerous high-risk situations, only a few required prioritizations, underscoring the challenge of ED pain assessment, beyond improving pain-intensity scoring at triage, and the need to individualize treatments. In high-pressure care environments, FMECA provides a framework for identifying failures and informing action plans alongside protocol development, adaptable to pain management.