pain management in the emergency department 2 ed pain mgt... · in a study of 525 patients from 2...
TRANSCRIPT
Pain Management in the Emergency Department
Prepared by Liz Hextall, Educator Critical Care; Shelley Yorke Clinical Resource Nurse Emergency; Seema Roberts, Manager
October 2005 Revised Oct 2007
The Current State
Up to 60-70% of patients presenting to the ED have pain as part of their presenting symptom
More than one third of all ED patients are reported to have moderate to severe pain
Health care providers consistently under estimate the severity of patient’s pain
The under use of analgesics or “oligoanalgesia” in the ED is an internationally recognized problem
The Current State cont’d
When analgesia is given, it is often given late
The paediatric population and elderly receive suboptimal analgesia
Organizations that have formal education programs on the treatment of pain demonstrate higher patient satisfaction with their pain management
In studies where nurse initiated analgesia protocols were used, the time to analgesia improved by half
In a study of 525 patients from 2 university affiliated hospitals (Atlanta and Chicago) subjects reported a high pain intensity level
Source: Todd, K.H., Sloan, E.P, Chen, C (2002) Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. Canadian Journal ofEmergency Medicine
Up to 60-70% of patients presenting to the ED have pain as part
of their presenting symptom…
More than one third of all ED patients are reported to have
moderate to severe pain…
Possible reasons for oligoanalgesia
Fear of masking symptoms of significant head or abdominal injury
Fear that opioids may precipitate hypotension in patients that are bleeding
The belief that acutely injured patients will not remember the painful events
Pain management is not the highest priority versus resus, diagnostics, OR
Groups at risk for Oligoanalgesia
Children
Elderly
Minorities
Those with abdominal pain
Those with a low Revised Trauma Score (RTS)
In studies where nurse initiated analgesia protocols were used, the time to analgesia
improved by half…
What is keeping you from providing good pain management all the time?
Surgeons who fail to order analgesics
EMO’s that hold narcotic for the surgeon to assess
Surgeons who fail to return your calls
Analgesics inappropriately listed as “allergies”
Not truthful patients
Concern re drug seeking
Not enough analgesia ordered, pain difficult to stabilize
Dosing schedules that are limiting e.g. q4-6h prn
Waiting for lab/diagnostic results
Underdosing or wrong drug for kind of pain
Not allowed in the PYXIS
? Function of pain control nurse
Staring at the Canad Inn spot light
Not allowed in the PYXIS
? Function of pain control nurse
Staring at the Canad Inn spot light
What do you suggest to improve?
Establishing an Emergency Department Pain Management System
Implications of the current state:
Pain is the most prevalent symptom in the ED
Patient expectations are quite high (23 minutes from arrival-Fosnocht)
Disparities amongst ethnic groups exist
Documentation of pain treatment is actually worse than treatment
-Richards, C.F. 2004
Setting Up the ProgramConsider:
Assessment
Acute vs chronic
Potential medication tolerance
Concurrent anxiety
Psychiatric issues
Communication with other members of the health care team
Assessment tools
Program monitoring
Treatment of Pain in the ED
Opiate analgesics
Non opioid analgesics
Adjuvants
Pain Audit Results at BRHC
Nurse Initiated Analgesia
0
10
20
30
40
50
60
charts audited patients not meetinginclusion criteria
patients receivinganalgesic
patients receivinganalgesic standing orders
patients receivinganalgesic physician
orders
Nu
mb
er o
f P
atie
nts
Pre implementation
Post Implementation
Reasons Analgesic Not Given
Patients Not Receiving Analgesia
0
5
10
15
20
25
Patients notrequiringanalgesia
Left without beingseen
Patients refusedanalgesia
Analgesic needsnot addressed
Nu
mb
er o
f p
atie
nts
Pre Implementation
Post Implementation
Post Implementation ResultsSept 2007
Time from Triage to Analgesia
010
2030
4050
6070
8090
100
Pre implementation Post implementation
Tim
e in
Min
ute
s
Physician Ordered
Standing Orders
Benefits of the ProtocolHas cut the time to pain medication by almost half
Where the nurse has not initiated the medication there is an increased awareness and pain is being addressed more rapidly by physicians
Decrease in patient complaints regarding pain
Increased staff satisfaction of being able to care for patients during triage waits
Increased comfort for patients awaiting physician assessment and diagnostic tests
Physicians are better able to examine patients in some cases
Tribulations of implementation
Surgeons particularly are a hard sell
Staff still need to do the paper work
Documentation reassessment still needs to be improved
Legal Issues in Pain Management
Pain is a symptom→there still remains an
expectation to treat the symptom
It can be argued that failure to properly manage pain may be professional negligence
Threat of malpractice suits for under treatment of pain is on the rise
Organizations that have formal education programs on the treatment of pain demonstrate
higher patient satisfaction with their pain management…
anda clear and definitive pain management protocol results in improved patient satisfaction and has a
positive effect on staff performance…
References:Bauman, B. H. & McManus, J.G (2005) Pediatric Pain Management in the Emergency Department.
Emergency Medicine Clinics of North America: Elsevier Saunders: USA
Blackburn, P. & Vissers R.(2000) Pharmacology of Emergency Department Pain Management and Conscious Sedation Emergency Medicine Clinics of North America Vol. 18 No.4: ElsevierSaunders: USA
Blyth, F.M., March, L.M.M., Brnabic, A.J. et al (2004) Chronic pain and frequent use of health care. Pain 111 (2004): Elselvier B.V.
Dillard, J.N. & Knapp, S. (2005) Complementary and Alternative Pain Therapy in the Emergency Department. Vol 18 No. 1 pp7-12. The Journal of Emergency Medicine: Elselvier Science Inc., USA
Gru, V., & Dubinsky I (1999) The Patient versus Cargiver Perception of Acute Pain in the Emergency Department Emergency Medicine Clinics of North America: Elsevier Saunders: USA
Kelly, A.M., Brumby, C. & Bar, C. (2004) Nurse-initiated, titrated intravenous opiod analgesia reduces time to analgesia for selected painful conditions. Canadian Journal of Emergency Medicine (CJEM). Vol. 7 2005: Canadian Association of Emergency physicians (CAEP)
Lawrence, L.L., (2005) Legal Issues in Pain Management: Striking the Balance Emergency Medicine Clinics of North America pp573-584: Elselvier saunders USA
McIntosh, S.E. & Lefler, S. (2004) Pain Management After Discharge From the ED American Journal of Emergency Medicine Vol 22 No. 2 Reprint.Petrak, E. & Christopher, N.C. (1997) Pain Management in the Emergency Department: Patterns of Analgesic Utilization. Vol 99 Issue 5. Reprint.
Neighbour, M.L., Honner, S. & Kohn M.A. (2004) Factors Affecting Emergency Department Opiod Administration to Severly Injured Patients ACAD Emer. Med Vol. 11 No. 12 Reprint.Puntillo, K. Nieghbour, M., O’Neil, N. et al (2003) Accuracy Of Emergency Nurses in Assessmenr of Patient’s Pain. Pain Management Nursing Vol.4 No. 4 Reprint.
Cont’d
References cont’d:
Ralferty, K. A, Smith,-Coggons, R & Chen, A. (1995) Gender-Associated Differences in Emergency Department Pain Management Annals of Emergency Medicine. 26:4 Reprint.
Rupp, T. & Delaney, K.A. (2004) Inadequate Analgesia in Emergency Medicine. Annals of Emergency Medicine 43:4 pp494-503 Reprint
Seguin, D. ((2004) A Nurse –initiated Pain Management Advanced Triage Protocol for ED Patients With an Extremity Injury at a Level I Trauma Center Journal of Emergency Nursing 30:4 pp330-335: Emergency Nurses Association USA
Todd, K.H. (2001) Influence of ethnicity on emergency department pain management. Emergency medicine pp274-278. Reprint
Todd, K.H., Sloan, E.P., Chen, C. et al. (2001) Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. Canadian Journal of Emergency Medicine (CJEM). Vol. 4 2002: Canadian Association of Emergency physicians (CAEP)
Stalinkowicz, R., Mahamid, R., Kaspi, S. et al (2005) Undertreatmewnt of acute pain in the emergency department: a challenge International Journal for Quality in Health Care Vol 17. No. 2. Pp173-176: Advance Access publication Oxford University.
Zohar, Z., Eitan, A., Halperin, P. et al (2001) Pain Relief in Major Trauma Patients: An Israeli Perspective. The Journal of Trauma. Vol. 51 No. 4. Reprint