The TARGET Pain Trial

This trial will be undertaken in EDs across Australia under the auspices of the Clinical Trials Group of the Australasian College for Emergency Medicine.

This e-learning module

• This e-learning module will advise you of the background, nature and purpose of this trial

• Please read each information slide carefully

• Select an answer on each question slide

• Review the correct answer and explanation on the following slide

Background

• Pain is often poorly managed in EDs

• Initiatives attempting to improve pain management:• Staff education

• Time-to-analgesia KPIs

• Pain score recording

• Nurse-initiated analgesia

• These initiatives have had variable success

Arguably:Arguably:

The most important outcome is a

high level of patient satisfaction with their pain management

This is supported by:

‘Research will have to change its measured outcomes to terms like adequate pain relief and satisfaction with pain care’

James Ducharme EMA 2013; 25: 110-111

Q1. Q1. What is the most important outcome in pain management?

A. Short times to analgesia

B. High levels of patient satisfaction

C. Accurately recorded pain scores

D. Most patients receiving opioids

Q1. Q1. What is the most important outcome in pain management?

A. Short times to analgesia

B. High levels of patient satisfaction

C. Accurately recorded pain scores

D. Most patients receiving opioids

•Times to analgesia may be short but the analgesia may be inadequate in dose and/or frequency

•Pain scores are of little use unless they are acted upon and used to tailor the patient’s analgesia

•Opioid analgesia may be inadequate in dose and/or frequency

Intuitively:Intuitively:

A high level of satisfaction is achievable if

adequate analgesia is given

Also, intuitively:Also, intuitively:

Adequate analgesia should decrease pain by:

by a significant amount

and

to a level that is mild

Q2. Q2. What is the best way to manage a patient’s pain?

A. Administering opioid drugs

B. Administering analgesics intravenously

C. Providing adequate analgesia

D. Using combinations of analgesics

Q2. Q2. What is the best way to manage a patient’s pain?

A. Administering opioid drugs

B. Administering analgesics intravenously

C. Providing adequate analgesia

D. Using combinations of analgesics

•Opioids alone, drug combinations or the intravenous route may be inadequate in dose and/or frequency

•Adequate analgesia is provided if the patients pain is decreased by a significant amount and to a level that is mild

Research shows us that:

a significant decrease in

pain

a decrease in pain score of ≥ 2

(scale of 0-10)

=

=

Kelly AM. Emerg Med 2001; 13: 57-60Todd KH et al. J Pain 2007; 8: 460-6

a mild level of pain

pain score < 4(i.e. 0-3)

moderate-severe pain

↓ pain by ≥ 2 and

↓ pain until < 4

↑ satisfaction with pain management

Study hypothesis:

But does it work?

Our own research shows that:

Patients who get adequate analgesia (as defined) are significantly more likely to be very satisfied with their pain management (OR = 7.8)

Jao K et al. Emerg Med Australas 2011; 23, 195–201

Shill J et al. Acad Emerg Med October 2012

Q3. Q3. How is adequate analgesia provided?

A. Reducing the pain score by ≥ 2

B. Reducing the pain score to < 4

C. Either A or B

D. Both A and B

Q3. Q3. How is adequate analgesia provided?

A. Reducing the pain score by ≥ 2

B. Reducing the pain score to < 4

C. Either A or B

D. Both A and B

•Only decreasing a patient’s pain by only 2 may leave them in considerable pain e.g. 9 reduced to 7

•Even if pain is reduced to < 4 (mild), it may not have been reduced by a significant amount e.g. 4 reduced to 3

•Reducing the pain significantly and to a mild level is required

Aim of this trial

• Our ‘target’ in this trial is to provide adequate analgesia (as defined) to all patients with moderate-severe pain

• We will measure the effect on patient satisfaction

How can you help?

• ED staff can help by endeavouring to provide adequate analgesia

• This will be achieved by decreasing the pain score by ≥ 2 and to a level < 4

• This differs little from standard practice only now we have a target to aim for: ≥ 2 and to <4

Q4. Q4. What should be used to provide adequate analgesia?

A. any method or a combination

B. analgesic drugs

C. hot or cold packs

D. reassurance, support

Q4. Q4. What methods can be used to provide adequate analgesia?

A. any method or a combination

B. analgesic drugs

C. hot or cold packs

D. reassurance, support

•Many methods can be used to decrease a patient’s pain. The way will depend upon the patient, the pain severity and the cause.

e.g. splinting/elevation/ice may work best for a # wrist

•In this trial, any method(s) can be used so long as you provide adequate analgesia (i.e. decrease pain score ≥ 2 and to <4)

Summary

• Adequate analgesia is defined as a decrease in pain score by ≥ 2 and to < 4

• There is a strong association between receipt of adequate analgesia and a high level of patient satisfaction with pain management

• This trial will strive to provide adequate analgesia and so increase patient satisfaction

Q5. Q5. Which pain score change represents adequate analgesia?

A. 7 decreased to 4

B. 4 decreased to 3

C. 5 decreased to 3

D. 3 decreased to 1

Q5. Q5. Which pain score change represents adequate analgesia?

A. 7 decreased to 4

B. 4 decreased to 3

C. 5 decreased to 3

D. 3 decreased to 1

•7 to 4: score decreased by ≥ 2 but not to < 4

•4 to 3: score decreased to < 4 but not by ≥ 2

•5 to 3: score decreased by ≥ 2 and to < 4

•3 to 1: score decreased by ≥ 2 but was mild (< 4 ) to begin with

TARGET Pain by providing Adequate Analgesia

Pain Score:down by ≥ 2and to < 4

Acknowledgement

Thank you, in anticipation, for your support and co-operation in this study