Pain Management in the Emergency Department Gabrielle Dunne RGN, RANP, MSc., FFNMRCS I

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

Aim Improving the management of pain in the emergency department. Action Learning sets as an interdisciplinary practice development strategy

15/10/2015 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 analgesia for patients attending the ED are clearly outlined in the literatureProblems related to ineffective or delayed analgesia for patients attending the ED are clearly outlined in the literature A structured, economical & sustainable approach to improving this fundamental aspect of the service to patients was introduced.A structured, economical & sustainable approach to improving this fundamental aspect of the service to patients was introduced.

Two specific Issues had to be addressed 1.Failure to treat pain promptly 2. The introduction of action learning sets as a means of using an interdisciplinary approach to improve the time to treatment for patients with moderate pain

Action Learning Is described as “ a dynamic process that involves a small group or ‘set’ of people solving real problems..” (Schwandt & Marquardt 2000)Is described as “ a dynamic process that involves a small group or ‘set’ of people solving real problems..” (Schwandt & Marquardt 2000) Used to solve complex problems & to significantly increase the quality of the team /organisational learning (soffe et al 2011)Used to solve complex problems & to significantly increase the quality of the team /organisational learning (soffe et al 2011) In this project action learning facilitated a reflective & critical assessment of practice related to pain management by focusing on the collective experience of the relevant ED staffIn this project action learning facilitated a reflective & critical assessment of practice related to pain management by focusing on the collective experience of the relevant ED staff

Action learning is traditionally associated with non health care settings i.e. Industry but is becoming increasing common in health but is becoming increasing common in health care as a means of achieving collaborative & consistent practice development (Bell et al 2007)

Audit and Result As part of quality initiative in our ED a detailed analysis of pain management for patients presenting with severe & moderate pain was undertaken. This review of pain was inline with the Clinical Effectiveness Committee of the CEM developed Best Practice Guidelines for the Management of Pain in Adults (June 2010)As part of quality initiative in our ED a detailed analysis of pain management for patients presenting with severe & moderate pain was undertaken. This review of pain was inline with the Clinical Effectiveness Committee of the CEM developed Best Practice Guidelines for the 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) an audit over 24hours period of 137 patients presenting with pain was undertaken in large teaching hospital in the republic of Ireland using the Manchester triage pain assessment tool.As recommended by the CEM (2010) an audit over 24hours period of 137 patients presenting with pain was undertaken in large teaching hospital in the republic of Ireland using the Manchester triage pain assessment tool. 25% (n=34) reported moderate pain25% (n=34) reported moderate pain

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

The outcome & planned action 1.Agreement to review / revise general department pain guideline based on the CEM (2010) 2.Paracetamol administration protocol for triage nurses 3.Place clearly visible laminated information cards at triage stations 4.Place guideline / protocol on the desktops of all computers in the department

The outcome & planned action (2) 5. Provide education programme to all nurses and doctors on the revised ED pain management guideline / protocol (outcome of audit / CEM clinical standards / pain assessment / pain management – pharmacological and non pharmacological and evaluation) 6. Re-audit 3 months later

2nd Audit and Result Re audit after 3 months over 24 hours period was undertaken of a further 258 patients with a specific focus on moderate pain.Re audit after 3 months over 24 hours period was undertaken of a further 258 patients with a specific focus on moderate pain. 27%(n=24) of patients reported moderate pain received analgesia within 30 minutes and 52% (n=46) received analgesia with in 60 minutes.27%(n=24) of patients reported moderate pain received analgesia within 30 minutes and 52% (n=46) received analgesia with in 60 minutes.

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

Table 1 Chi-square Tests Pearson Chi-Square a Likelihood Ratio Linear-by-Linear Association N of Valid Cases 123

Discussion Pain management is an important quality indicator for emergency care.Pain management is an important quality indicator for emergency care. Using action learning methodology we achieved an improvement in the management of pain in our ED.Using action learning methodology we achieved an improvement in the management of pain in our ED. One of the key changes that contributed to this improvement was administration of analgesia by triage nurse. One of the key changes that contributed to this improvement was administration of analgesia by triage nurse.

Auditing of practice is an important quality initiativeAuditing of practice is an important quality initiative Appropriate modifications of systems that contribute to poor performancesAppropriate modifications of systems that contribute to poor performances Regular feedback to all members of the multidisciplinary team.Regular feedback to all members of the multidisciplinary team. The use of Action learning as a framework --identifies realistic ways of what works in practiceThe use of Action learning as a framework --identifies realistic ways of what works in practice Trehan and Pedler (2011) describe action learning as also having a ‘moral’ philosophyTrehan and Pedler (2011) describe action learning as also having a ‘moral’ philosophy

Conclusion This presentation has outlined how action learning sets can be used to provide a framework that facilitates engagement by facilitating staff to reflect, critique their own practice and learn new ways of practice.This presentation has outlined how action learning sets can be used to provide a framework that facilitates engagement by facilitating staff to reflect, critique their own practice and learn new ways of practice. Provide a feasible, flexible, economical and sustainable process by which to effect changeProvide a feasible, flexible, economical and sustainable process by which to effect change

References: 1.Macway-Jones K, Marsden J, Windle J (2006) Emergency Triage Manchester Triage Group 2 nd Edn. Blackwell Publishing Ltd. 2.College of Emergency Medicine (2010) Clinical Standards Guidelines: Guidelines for the Management of Pain in Adults. Accessed 4 th January 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); Soffe, S. M., Marquardt, M. J., & Hale, E. (2011). Action learning and critical thinking: A synthesis of two models. Action Leaning, 8(3),

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