Can a nurse initiated pain protocol (NIPP) improve pain management in the ED? Janice Muir RN MSc(N) CNS1 Anne Dewar RN PhD2 , Pat Munro RN BSN1 Julian Marsden MDCCFP(EM) 1 , Eric Grafstein MD FRCPC1 ,\ Beena Parappilly RN MSN1 , Angus Kinkade PharmD1 , Gisha Ashly RN BSN2 1, Providence Health Care—St. Paul’s Hospital; 2 UBC-- School of Nursing INTRODUCTION & BACKGROUND In the Emergency Department (ED) pain is a significant problem, yet not all patients receive analgesics and for those who do, it is often after a considerable wait.1,2 An audit (2009) of 325 patient charts of nine Lower Mainland Emergency Departments (EDs) using a tool based on the Canadian Accreditation Pain Management standards indicated that: •74% patients with pain as chief complaint •0nly 43 % receive analgesics with median wait-time of 1. 7 hours (103 minutes). At St. Paul’s Hospital -76% of patient’s had pain as a chief complaint and only 45 % received analgesics with a mean wait time of 110 minutes. 3 The results of this audit motivated the team to initiate a Nurse Initiated Pain Protocol (NIPP) to improve pain management. A NIPP is a decision-making support system designed to enable nurses to initiate analgesics.
RESEARCH QUESTIONS 1.Does the implementation of a NIPP improve documented wait time for analgesics & percentage of patients who receive analgesics? 2. What are the ED nurses perceptions of the impact of a NIPP on patient care & nursing practice?
METHODS – The design incorporated mixed methods: 3 phased before and after comparison retrospective chart audit with a post NIPP implementation qualitative focus group interview. Phase I & II: Developed the NIPP, educated the RN’s & physicians & implemented the NIPP. Phase III: Evaluated the NIPP using the previously piloted tool to audit 300 patient charts pre and post NIPP (in progress). Conducted focus group interview with 4 ED nurses.
DATA ANALYSIS •Focus group used open-ended questions about challenges implementing the NIPP & providing pain care for ED patients. •Interview was audio-tape recorded & transcribed verbatim. •Themes were identified about pain management issues faced by ED nurses. •Chart audit will use quantitative analysis to determine if time to first analgesic decreased. Preliminary results indicate that pain assessments are not always done and there is a lack of re-assessment following analgesics in ED.
CONCLUSIONS: Systems issues including medication dose limitations, combined with resistance to change have impacted upon the use of a NIPP in this setting. Pain is still not seen as a priority and there is a great need for further education to assist nurses to meet the minimum Canadian Pain Accreditation Standards. Acknowledgement to 2012-13 PHC Based Research challenge fund for helping to fund this project
FINDINGS Focus group themes : • Lack of confidence of nurses in pain assessment and initiating analgesics. • Systems issues-protocol accessibility & limited number of ED RN’s in some areas. • Change-resistance to change. • NIPP limitations: nurses unable to administer higher dose of ibuprophen & opioids without a physician’s order. • Culture of ED - use an IV for meds -“get patients in & out” • Trust relationships-needed between patient & nurse and RN & physician. • Re-assessment of pain is not always done- not enough time or not a priority. • Non-pharmacological-heat/cold, warm blankets.
Discussion and Implications: • Nurses need to understand balanced analgesia & importance of pain assessment & re-assessment. • Patients & families – need to understand the value of acetaminophen & ibuprofen, in lessening the need for stronger analgesics. • Involving nurse managers/educators in the research process has increased awareness of pain care issues.
References: 1.Todd, K.L. et al. (2007). Pain in the Emergency Department: results of the pain and emergency medicine initiative (PEMI) multicenter study. The Journal of Pain, 8(2), 460-466. 2.Fry, M. & Holgate, A. (2002). Nurse initiated intravenous morphine in the emergency department: efficacy, rate of adverse events & impacts on time to analgesics. Emergency Medicine, 14, 249-254. 3. BC Ministry of Health the Lower Mainland Integration and Innovation Funded (LMIIF) (2009) .Integrated Pain Strategy Project—Emergency chart audit (unpublished data).