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