PAIN MANAGEMENT IN A&E DEPARTMENT AT CNDRH lecture

PAIN MANAGEMENT IN A&E DEPARTMENT AT CNDRH
HOW GOOD ARE WE?

Results of a retrospective audit
May 2002

Dr K Shah, SHO A&E & Dr K Lendrum, Consultant A&E

Background

The British Association of A&E Medicine has produced guidelines for management of pain in the A&E department. According to these guidelines

Patients in severe pain (pain score 7 to 10) should receive appropriate analgesia within 20 minutes of arrival or triage whichever is the earliest.
Patients with moderate pain (pain score 4 to 6) should be offered analgesia at triage.
90% of patients with severe pain should have documented evidence of re-evaluation and action within 30 minutes of receiving the first dose of analgesic.
75% of patients with moderate pain should have documented evidence of re-evaluation and action within 60 minutes of receiving the first dose of analgesic.

Aim

The aim of this study was to compare our practice against the standards set by the BAAEM, and critically look at the results.

Methods

We decided to do a retrospective study of at least 25 sets of A&E notes bearing the title of either closed fractures or abdominal pain in the coding-bar. We selected the notes between the periods of Dec 2001 to Feb 2002

Exclusion: Compound fractures, fracture neck of femur, and all children were excluded from this study.

Results

The results were alarming. None of the notes had a documented pain score. Only 4 out of total 25 had a subjective pain assessment of patients having 'moderate' pain.

We carried on the study without having a pain score; assuming that patients who received parenteral analgesia (Diamorphine iv, Buscopan iv, or Pethidine im or iv) had severe pain, and those who received oral analgesia ( Co-codamol, Brufen, DF 118) had moderate pain.

According to these criteria, 13/25 had moderate pain and 12/25 had severe pain.

Moderate pain

3/13 received stat analgesia.
7/13 received first analgesia ranging from 10 to 90 minutes after arrival (mean time 35 minutes).
3/13 did not receive any analgesia.

Re-evaluation: Only 1/13 had a documented evidence of pain assessment (time not mentioned).

Action: Only 2/13 needed a second analgesic, but that was not given before 100 minutes of the first analgesic (mean time 150 minutes).

Severe pain

5/12 received first analgesic within 20 minutes (mean time 14 minutes).
7/12 received first analgesic ranging from 24 to 300 minutes (mean 136 minutes).

Re-evaluation: 5/12 had a documented pain assessment at times ranging from 15 to 65 minutes (mean 33 minutes).

Action: 4/12 needed a second analgesic, but none had it within 30 minutes of the first analgesic (mean 75 minutes).

Summary of the result

Moderate pain	1st analgesia at Triage/Arrival	Documented re-evaluation	Action in 60 minutes
Ideally	100%	75%	75%
CNDRH	24%	7%	0%

Severe pain	1st analgesia in 20 minutes	Documented re-evaluation	Action in 30 minutes
Ideally	100%	90%	90%
CNDRH	42%	42%	0%

Pain assessment tools

These help patients describe their pain. The pain scale is one tool commonly used to describe the intensity of the pain or how much pain the patient is feeling. The pain scales include the numerical rating scale, the visual analog scale, thecategorical scale, and the pain faces scale.

On the numerical rating scale, the person is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable).

The visual analog scale is a straight line with the left end of the line representing no pain and the right end of the line representing the worst pain. Patients are asked to mark on the line where they think their pain is.

The verbal rating scale has four categories:

none
mild
moderate
severe

Patients are asked to select the category that best describes their pain.

In the Numerical Rating Scale patients are asked to grade their pain between zero and 10, zero indicating no pain and 10 indicating the worst possible pain.

Discussion

Acute pain is one of the commonest symptoms of patients presenting in A&E. Management of acute pain is not just about fulfilling the guidelines, but more about the quality of care offered to the patient. Our management of pain, as realized from this audit, is inadequate. Two major loopholes are identified : documentation and implementation. Our documentation of pain intensity and pain relief is far far from ideal. There was no uniform method of documenting the intensity of pain (viz NRS, VAS, VRS), and documented reassessment of pain relief was erratic. In implementation we were slightly better in providing analgesia to patients with severe pain, although the number of patients receiving it was below 50% of the expected. Considering these two loopholes and the pattern of practice in the department, we suggest the following-

Documentation

All patients have a compulsory documented pain intensity score at triage. We suggest the Numerical Rating Score for this, as it is found to be a better mean for self-evaluation of acute pain in the emergency department compared to VRS, VAS.
Educating the patients and making them use the NRS for description of their pain, so that its use becomes routine practice and a day comes when A&E staff don't have to spend time to explain the NRS to the patient (which appears to be one of the barriers in its more extensive use).
Routine patient reporting of pain as part of the normal nursing observations, as they are going to be more in contact with the patient than the clinician.

Implementation

Training more nurses who can provide intravenous analgesia.
Education of A&E staff regarding pharmacology of various analgesics and their use, and remove some popular myths (pain killers mask abdominal signs, high rate of respiratory depression with opiods, etc).
Reiterating regularly to the staff that pain management is a high priority for patients.
Appropriate use of a wide spectrum of pain relieving methods including analgesic drugs, local anaesthesia, and non-pharmacological methods of pain relief.
Stressing the importance of the guidelines laid down by the BAAEM to the SHOs in their induction/ first departmental teaching.