Improving Pain Management in
Australian Emergency Departments
Ruth CornishNational Institute of Clinical
Studies
National Institute of Clinical Studies
Established by the Federal government to improve health care
by closing gaps between best available evidence and current
clinical practice
National Institute of Clinical Studies
Key tasks:
– Identify important gaps
– Identify available, effective methods for changing practice
– Help increase uptake
National Institute of Clinical Studies
Challenges:
– Task is huge
– Making change happen is hard
– Poor measurement of clinical practice
– Diverse nature & type of evidence on behavior & organisational change
Stakeholder Initiated Clinical Projects
• Emergency Department Collaborative
• Heart Failure Program
• Pain Management Program
• Prevention of DVT in hospitalised patients
Collaborative Components
• Multi-organisational with common theme• Evidence of best practice and variation• Interdisciplinary teams• Information exchange • Close gaps by review & modification of work
processes & small scale test of change• Measurement to assess progress• System changes
Web based support system
Four Key Functions
• Data entry & graph results in real time
• Rapid exchange of protocols & documents
• News dissemination • Forum for emergency
care clinicians
Areas for improvement• Time to pain relief
• Time to thrombolysis
• Time to antibiotic for febrile neutropenia & pneumonia
• Time to X-Ray, pathology test results
• Referral to specialty units
• Fast track
Barriers to effective pain management in ED
• Inadequate pain assessment
• Misconception that analgesia impairs diagnosis
• Lines of authority
• Local process issues
“When I arrived I was in so
much pain I could barely
walk. They wouldn’t give
me anything because it was
‘undiagnosed abdominal
pain’ yet it took four hours
for someone to see me.”
Time to analgesia• Measurement to
recognise the problem
• Use of evidence to reduce barriers
• Local system changes
• Patient-centred approach
Median time to analgesia - all
0
10
20
30
40
50
60
70
6-M
ay-0
2
20-M
ay-0
2
3-Ju
n-02
17-J
un-02
1-Ju
l-02
15-J
ul-02
29-J
ul-02
12-A
ug-02
26-A
ug-02
9/0
9/200
2
23-S
ep-0
2
7-Oct-0
2
22-O
ct-0
2
Minutes
Time to Analgesia – review of the data
• 34 of 41 sites improved time to analgesia
• 7 sites improved by more than 50%
• 9 sites improved by 30-50%
Time to analgesia – sustainable changes
• Identification and pain scoring at triage
• Pain protocols•Nurse-initiated analgesia• IV cannulation programs
Nurse-initiated narcotic analgesia: History
Prof AM Kelly mid 1990s
Recognition of poor pain management in ED process changes– Routine pain recording– Active change to IV narcotic analgesia
(away from IM)– Nurse-managed titration of analgesia
from standing orders
Nurse-initiated narcotic analgesia: History
• Proof of safety» Coman & Kelly (VIC) Emerg Med 1999
• "Accreditation" of nurses
• Internal hospital policy approval
• IM route dramatic decrease
Nurse-initiated narcotic analgesia: History
• Dissemination, spread
• Creep toward fully nurse-initiated
• Increasing ‘local’ evidence base» Fry & Holdgate (NSW) Emerg Med 2002
» Brumby (VIC) AMS project
• Improves time to analgesia by about 30 minutes
Nurse-initiatednarcotic analgesia
Victoria state ED Collaborative 2000
NICS national ED Collaborative 2002
• Focus on pain & time to analgesia
• Provided momentum & leverage for nurse-initiated analgesia
Nurse-initiatednarcotic analgesia
• Hospital approval processes
• NSW state support/policy
• Victoria - recently challenged along with standing-orders
Further Work
•Culture survey results and high and low performing sites
•Setting up a community of practice
Research Transfer Factors
Evidence based
• Existing evidence on pain management used as a driver for change
• Local evidence still needed
Research Transfer Factors
External leverage
• NICS Collaborative gave “time to analgesia” a national focus
• Transfer of “legitimacy”
• Increased speed of spread