Improving Pain Management in

Australian Emergency Departments

Ruth CornishNational Institute of Clinical

Studies

National Institute of Clinical Studies

Established by the Federal government to improve health care

by closing gaps between best available evidence and current

clinical practice

National Institute of Clinical Studies

Key tasks:

– Identify important gaps

– Identify available, effective methods for changing practice

– Help increase uptake

National Institute of Clinical Studies

Challenges:

– Task is huge

– Making change happen is hard

– Poor measurement of clinical practice

– Diverse nature & type of evidence on behavior & organisational change

Stakeholder Initiated Clinical Projects

• Emergency Department Collaborative

• Heart Failure Program

• Pain Management Program

• Prevention of DVT in hospitalised patients

Who was involved

3

1

10

10

16

6

1

Collaborative Components

• Multi-organisational with common theme• Evidence of best practice and variation• Interdisciplinary teams• Information exchange • Close gaps by review & modification of work

processes & small scale test of change• Measurement to assess progress• System changes

Web based support system

Four Key Functions

• Data entry & graph results in real time

• Rapid exchange of protocols & documents

• News dissemination • Forum for emergency

care clinicians

FeaturesReal time graphing of results

Areas for improvement• Time to pain relief

• Time to thrombolysis

• Time to antibiotic for febrile neutropenia & pneumonia

• Time to X-Ray, pathology test results

• Referral to specialty units

• Fast track

Barriers to effective pain management in ED

• Inadequate pain assessment

• Misconception that analgesia impairs diagnosis

• Lines of authority

• Local process issues

“When I arrived I was in so

much pain I could barely

walk. They wouldn’t give

me anything because it was

‘undiagnosed abdominal

pain’ yet it took four hours

for someone to see me.”

Time to analgesia• Measurement to

recognise the problem

• Use of evidence to reduce barriers

• Local system changes

• Patient-centred approach

Median time to analgesia - all

0

10

20

30

40

50

60

70

6-M

ay-0

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20-M

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2

3-Ju

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17-J

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15-J

ul-02

29-J

ul-02

12-A

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26-A

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9/0

9/200

2

23-S

ep-0

2

7-Oct-0

2

22-O

ct-0

2

Minutes

Time to Analgesia – review of the data

• 34 of 41 sites improved time to analgesia

• 7 sites improved by more than 50%

• 9 sites improved by 30-50%

Time to analgesia – sustainable changes

• Identification and pain scoring at triage

• Pain protocols•Nurse-initiated analgesia• IV cannulation programs

Nurse-initiated narcotic analgesia: History

Prof AM Kelly mid 1990s

Recognition of poor pain management in ED process changes– Routine pain recording– Active change to IV narcotic analgesia

(away from IM)– Nurse-managed titration of analgesia

from standing orders

Nurse-initiated narcotic analgesia: History

• Proof of safety» Coman & Kelly (VIC) Emerg Med 1999

• "Accreditation" of nurses

• Internal hospital policy approval

• IM route dramatic decrease

Nurse-initiated narcotic analgesia: History

• Dissemination, spread

• Creep toward fully nurse-initiated

• Increasing ‘local’ evidence base» Fry & Holdgate (NSW) Emerg Med 2002

» Brumby (VIC) AMS project

• Improves time to analgesia by about 30 minutes

Nurse-initiatednarcotic analgesia

Victoria state ED Collaborative 2000

NICS national ED Collaborative 2002

• Focus on pain & time to analgesia

• Provided momentum & leverage for nurse-initiated analgesia

Nurse-initiatednarcotic analgesia

• Hospital approval processes

• NSW state support/policy

• Victoria - recently challenged along with standing-orders

Further Work

•Culture survey results and high and low performing sites

•Setting up a community of practice

Research Transfer Factors

Stakeholder drivers

• Political

• Organisational

• Clinicians

• Patients

Research Transfer Factors

Evidence based

• Existing evidence on pain management used as a driver for change

• Local evidence still needed

Research Transfer Factors

External leverage

• NICS Collaborative gave “time to analgesia” a national focus

• Transfer of “legitimacy”

• Increased speed of spread

Acknowledgements• Sue Huckson: EDC project manager

• Jan Davies: EDC project director

• Heather Buchan: CEO of NICS

• All the Emergency Departments

www.nicsl.com.au