Pain Management in the Emergency Department

Gabrielle DunneRGN, RANP, MSc., FFNMRCSI

Introduction

• This presentation discusses the use of This presentation discusses the use of action learning to improve the action learning to improve the management of pain in the Emergency management of pain in the Emergency Department (ED).Department (ED).

Aim

Improving the management of pain in the

emergency department.

Action Learning sets as an interdisciplinary

practice development strategy

20/04/23

Why Audit Pain

Key Performance Indicators (KPIs) such as pain management provides a comprehensive

examination of the care provided to patients attending the ED

The reported prevalence of pain in Emergency patients is approx. 78%.

Pain is one of the most important components of patient care and is therefore given a high priority in the CEM Clinical Standards for Emergency Departments'

Pain is one of the six discriminators of the Manchester Triage System (MTS)

Background

• Problems related to ineffective or delayed Problems related to ineffective or delayed analgesia for patients attending the ED are analgesia for patients attending the ED are clearly outlined in the literatureclearly outlined in the literature

• A structured, economical & sustainable A structured, economical & sustainable approach to improving this fundamental approach to improving this fundamental aspect of the service to patients was aspect of the service to patients was introduced.introduced.

Two specific Issues had to be Two specific Issues had to be addressedaddressed

1.1.Failure to treat pain promptlyFailure to treat pain promptly

2.2. The introduction of action learning sets The introduction of action learning sets as a means of using an interdisciplinary as a means of using an interdisciplinary approach to improve the time to approach to improve the time to treatment for patients with moderate treatment for patients with moderate painpain

Action Learning• Is described as “ a dynamic process that Is described as “ a dynamic process that

involves a small group or ‘set’ of people involves a small group or ‘set’ of people solving real problems..” solving real problems..” (Schwandt & Marquardt 2000)(Schwandt & Marquardt 2000)

• Used to solve complex problems & to Used to solve complex problems & to significantly increase the quality of the team significantly increase the quality of the team /organisational learning /organisational learning (soffe et al 2011)(soffe et al 2011)

• In this project action learning facilitated a In this project action learning facilitated a reflective & critical assessment of practice reflective & critical assessment of practice related to pain management by focusing on related to pain management by focusing on the collective experience of the relevant ED the collective experience of the relevant ED staffstaff

Action learning is traditionally associated Action learning is traditionally associated

with non health care settings i.e. Industrywith non health care settings i.e. Industry

but is becoming increasing common in but is becoming increasing common in health health

care as a means of achieving care as a means of achieving collaborative & collaborative &

consistent practice development consistent practice development (Bell et al 2007)(Bell et al 2007)

Audit and Result

• As part of quality initiative in our ED a As part of quality initiative in our ED a detailed analysis of pain management for detailed analysis of pain management for patients presenting with severe & patients presenting with severe & moderate pain was undertaken. This moderate pain was undertaken. This review of pain was inline with the Clinical review of pain was inline with the Clinical Effectiveness Committee Effectiveness Committee of the CEM of the CEM developed Best Practice Guidelines for the developed Best Practice Guidelines for the Management of Pain in Adults (June 2010)Management of Pain in Adults (June 2010)

•

CEM CLINICAL STANDARDS(Severe Pain)

90% of Patients with Severe Pain should have documented evidence of re-evaluation and action

within 60 minutes of receiving the first dose of analgesic

If analgesia is not prescribed and the patient has moderate or severe pain the reason should be

documented in the notes

CEM CLINICAL STANDARDS(Moderate Pain)

75% Patients with moderate pain should have documented evidence of re-evaluation and

action within 60 minutes of receiving the first dose of analgesia

If analgesia is not prescribed and the patient has moderate or severe pain the reason

should be documented in the notes

Audit of Moderate pain

• As recommended by the CEM (2010) As recommended by the CEM (2010) an audit over 24hours period of 137 an audit over 24hours period of 137 patients presenting with pain was patients presenting with pain was undertaken in large teaching hospital in undertaken in large teaching hospital in the republic of Ireland using the the republic of Ireland using the Manchester triage pain assessment Manchester triage pain assessment tool.tool.

• 25% (n=34) reported moderate pain25% (n=34) reported moderate pain

Results

• Management of pain in moderate group Management of pain in moderate group was poor, no patients had analgesia was poor, no patients had analgesia administered within 30 minutes and only administered within 30 minutes and only 9% received analgesia within 60 9% received analgesia within 60 minutesminutes

The outcome & planned action

1.1. Agreement to review / revise general Agreement to review / revise general department pain guideline based on the department pain guideline based on the CEM (2010)CEM (2010)

2.2. Paracetamol administration protocol for Paracetamol administration protocol for triage nursestriage nurses

3.3. Place clearly visible laminated information Place clearly visible laminated information cards at triage stationscards at triage stations

4.4. Place guideline / protocol on the desktops Place guideline / protocol on the desktops of all computers in the departmentof all computers in the department

The outcome & planned action (2)

5. 5. Provide education programme to all Provide education programme to all nurses and doctors on the revised ED nurses and doctors on the revised ED pain management guideline / protocol pain management guideline / protocol

(outcome of audit / CEM clinical standards / pain (outcome of audit / CEM clinical standards / pain

assessment / pain management –assessment / pain management –pharmacological and pharmacological and

non pharmacological and evaluation)non pharmacological and evaluation)

6. 6. Re-audit 3 months laterRe-audit 3 months later

2nd Audit and Result

• Re audit after 3 months over 24 hours Re audit after 3 months over 24 hours period was undertaken of a further 258 period was undertaken of a further 258 patients with a specific focus on patients with a specific focus on moderate pain.moderate pain.

• 27%(n=24) of patients reported 27%(n=24) of patients reported moderate pain received analgesia within moderate pain received analgesia within 30 minutes and 52% (n=46) received 30 minutes and 52% (n=46) received analgesia with in 60 minutes. analgesia with in 60 minutes.

Results

• This demonstrated a substantial This demonstrated a substantial improvement with 27% more patients improvement with 27% more patients receiving analgesia within 30 minutes and receiving analgesia within 30 minutes and 43% more patients within 60 minutes 43% more patients within 60 minutes between the 1between the 1stst and 2 and 2nd nd audit. audit.

Table 1 Chi-square Tests

Pearson Chi-Square 27.023a 2 .000

Likelihood Ratio 27.493 2 .000

Linear-by-Linear Association 1.465 1 .226

N of Valid Cases 123

Discussion• Pain management is an important Pain management is an important

quality indicator for emergency care. quality indicator for emergency care.

• Using action learning methodology we Using action learning methodology we achieved an improvement in the achieved an improvement in the management of pain in our ED.management of pain in our ED.

• One of the key changes that One of the key changes that contributed to this improvement was contributed to this improvement was administration of analgesia by triage administration of analgesia by triage nurse.nurse.

• Auditing of practice is an important quality Auditing of practice is an important quality initiative initiative

• Appropriate modifications of systems that Appropriate modifications of systems that contribute to poor performances contribute to poor performances

• Regular feedback to all members of the Regular feedback to all members of the multidisciplinary team. multidisciplinary team.

• The use of Action learning as a framework The use of Action learning as a framework --identifies realistic ways of what works in --identifies realistic ways of what works in practice practice

• Trehan and Pedler (2011) describe action Trehan and Pedler (2011) describe action learning as also having a ‘moral’ learning as also having a ‘moral’ philosophy philosophy

Conclusion

• This presentation has outlined how This presentation has outlined how action learning sets can be used to action learning sets can be used to provide a framework that facilitates provide a framework that facilitates engagement by facilitating staff to engagement by facilitating staff to reflect, critique their own practice and reflect, critique their own practice and learn new ways of practice. learn new ways of practice.

• Provide a feasible, flexible, economical Provide a feasible, flexible, economical and sustainable process by which to and sustainable process by which to effect changeeffect change

References:

1. Macway-Jones K, Marsden J, Windle J (2006) Emergency Triage Manchester Triage Group 2nd Edn. Blackwell Publishing Ltd.

2. College of Emergency Medicine (2010) Clinical Standards Guidelines: Guidelines for the Management of Pain in Adults. Accessed 4th January 2013.

3. Mills A, Shofer F, Chen E, Hollander J, Pines J. The Association between Emergency Department Crowding and Analgesia Administration in Acute Abdominal Pain Patients. Academic Emergency Medicine 2009: 16(7); 603-608.

4. Soffe, S. M., Marquardt, M. J., & Hale, E. (2011). Action learning and critical thinking: A synthesis of two models. Action Leaning, 8(3), 211-230.

 

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