A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain

https://doi.org/10.1016/j.ienj.2016.02.001Get rights and content

Highlights

  • The nurse-initiated pain protocol improved analgesic provision and administration.

  • A high percentage of patients refused to take analgesics.

  • Protocol implementation shortened time to analgesics, especially to first opioid.

  • Mean pain relief increased, with analgesic treatment even up to 2 NRS-points.

  • A high percentage of patients still suffered moderate to severe pain at ED discharge.

Abstract

While acute musculoskeletal pain is a frequent complaint, its management is often neglected. An implementation of a nurse-initiated pain protocol based on the algorithm of a Dutch pain management guideline in the emergency department might improve this. A pre–post intervention study was performed as part of the prospective PROTACT follow-up study. During the pre- (15 months, n = 504) and post-period (6 months, n = 156) patients' self-reported pain intensity and pain treatment were registered. Analgesic provision in patients with moderate to severe pain (NRS ≥4) improved from 46.8% to 68.0%. Over 10% of the patients refused analgesics, resulting into an actual analgesic administration increase from 36.3% to 46.1%. Median time to analgesic decreased from 10 to 7 min (P < 0.05), whereas time to opioids decreased from 37 to 15 min (P < 0.01). Mean pain relief significantly increased to 1.56 NRS-points, in patients who received analgesic treatment even up to 2.02 points. The protocol appeared to lead to an increase in analgesic administration, shorter time to analgesics and a higher clinically relevant pain relief. Despite improvements, suffering moderate to severe pain at ED discharge was still common. Protocol adherence needs to be studied in order to optimize pain management.

Section snippets

Background

While acute musculoskeletal pain is a frequent complaint among patients in the emergency department (ED), its management is often neglected, placing patients at risk of oligoanalgesia.

During the past decade, there has been an explosion of research on both acute and chronic pain, with significant advances in understanding its etiology, assessment, and treatment. Improvements in pain assessment and management have facilitated care improvements in the ED (Thomas, 2013). However, inadequate pain

Study design and setting

A pre–post intervention study was performed as part of the prospective “PROgnostic factors for the Transition from Acute to Chronic pain in Trauma patients” (PROTACT) follow-up study. Adult patients with musculoskeletal isolated extremity injury attending the ED of the level one trauma center Medisch Spectrum Twente in Enschede, The Netherlands, were invited to participate. The ED functions continuously 24 hours a day, 7 days a week (24/7 ED), has a catchment area of 264,000 individuals and

Results

In total 660 patients were included in this pre–post intervention study with the aim to evaluate the effect of the implementation of a nurse-initiated pain protocol on pain management in patients with acute musculoskeletal pain. Patients enrolled during the pre- (n = 504) and post- (n = 156) intervention period were similar with regard to pain intensity at admission (Table 1). The majority of patients suffered a fracture, most frequently in the ankle (n = 148) and wrist (n = 104). Almost 85% of

Discussion

This pre–post intervention study shows that the implementation of a nurse-initiated pain protocol in the ED appears to lead to an increase in analgesic provision, a shorter time to analgesics and a higher clinically relevant pain relief in acute musculoskeletal patients. However, adequate pain management remains a major challenge. Despite improvements in pain management, a high percentage of patients did not receive analgesics while in pain and a high percentage was still discharged with

Conclusion

The implementation of a nurse-initiated pain protocol in the ED appears to lead to an increase in analgesic provision, a shorter time to analgesics and a higher clinically relevant pain relief in acute musculoskeletal patients. Adequate pain management remains a major challenge for ED staff. Despite improvements in pain management, many patients did not receive analgesics. Moreover, the percentage of patients with moderate to severe pain at ED discharge is still high. The adherence to the

Conflict of interest

None declared.

Acknowledgments

We gratefully acknowledge nurses and staff, especially K. Waaijer-Wiefferink, A. Christenhusz and M. Poessé-Vennevertloo, of the emergency department of Medisch Spectrum Twente for their assistance, and patients for participating in the PROTACT study.

References (33)

Cited by (0)

View full text