Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients' satisfaction of pain management

Effect of Pain Education Interventions on Registered Nurses' Pain Management: A Systematic Review and Meta-Analysis

OBJECTIVES

This review and meta-analysis aims to reveal how pain education interventions affect registered nurses' pain management.

DESIGN

A systematic review and meta-analysis DATA SOURCES: PubMed, Scopus, CINAHL (EBSCOhost), and ERIC REVIEW METHODS: A systematic search of four electronic databases was conducted to identify relevant peer-reviewed English or Finnish-language articles published between 2008 and 2021. The review included a quality appraisal and a meta-analysis of articles providing group-level data before and after the intervention (n = 12). The methods followed the PRISMA guidelines.

RESULTS

Overall, 23 articles met the inclusion criteria for the review, of which 15 were evaluated as good quality. Based on the articles on document audits (n = 10), pain education interventions reduced the risk of not receiving the best pain management by 40%, whereas based on the articles on patients' experiences (n = 4), they reduced the risk by 25%. The study quality and design of these articles were considerably heterogenous.

CONCLUSIONS

Pain education study strategies varied widely among the included articles. These articles used multivariate interventions without systematization or sufficient opportunity to transfer the study protocols. It can be concluded that versatile pain nursing education interventions, as well as auditing of pain nursing and its documentation combined with feedback, can be effective to nurses in adapting pain management and assessment practices and increasing patient satisfaction. However, further research is required in this regard. In addition, well-designed, implemented, and reproducible evidence-based pain education intervention is required in the future.

Nurses' Perceptions of the Management of Acute Pain in Emergency Departments: Cross-sectional Study

AIM

This study aimed to describe registered nurses' perceptions of acute pain management in emergency departments.

DESIGN

The study design was a cross-sectional survey carried out in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. One hundred one nurses from 5 different emergency departments participated in the survey.

METHODS

Data were analyzed using descriptive methods, nonparametric tests, and principal component analysis.

RESULTS

Continuing education was significantly related to pain management. Nurses who had received continuing pain management education thought more often that challenges in pain management impact patients' acute pain management than those who had not received education. Nurses reported that patients received inadequate pain medication. The most used nonpharmacological methods were ice therapy and postural care. The nurses reported that music and conversation with the patient ameliorated the patients' acute pain. Nurses stated that their lack of knowledge concerning pain management and workload affected their acute pain management.

CONCLUSION

Study results emphasize the need to develop ongoing pain management education for registered nurses and in addition to further research of nonpharmacological alleviation method in emergency departments.

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

Non-pharmacological interventions for acute pain management in adult trauma victims: a scoping review

OBJECTIVE

This scoping review aimed to map non-pharmacological interventions to reduce acute pain in adult trauma victims.

INTRODUCTION

Acute pain is a consequence of a pathological or traumatic event, and a result of invasive or non-invasive health care procedures. Acute trauma pain, as well as its treatment, is one of the least-studied areas of acute pain. Although non-pharmacological interventions are responsible for pain relief among a significant number of patients, only a small percentage of patients receive non-pharmacological interventions.

INCLUSION CRITERIA

This scoping review considered all studies conducted on adult victims of trauma, aged 18 years or over, in pre-hospital emergency care, emergency rooms, and trauma-center settings. Studies were considered if they focused on non-pharmacological interventions designed to reduce acute pain, and were implemented and evaluated by health professionals. Non-pharmacological interventions of any type, duration, frequency, and intensity were considered.

METHODS

A comprehensive search strategy across 11 bibliometric databases and gray literature sources was developed. Full texts of selected citations were assessed in detail for eligibility by two independent reviewers. No other relevant studies were identified by searching the references of the included articles. Data extraction was performed independently by two reviewers using an instrument previously developed, and those reviewers were later responsible for its validation. Findings were then extracted directly into tables that are accompanied by a narrative summary to show how they relate to the objectives of the review conducted.

RESULTS

This scoping review included nine studies: two retrospective cohort studies, five randomized controlled trials, one case report, and one literature review for five different countries. Non-pharmacological interventions identified and administered to trauma victims in pre-hospital settings, emergency services, and trauma centers were as follows: acupressure, auricular acupressure, auricular acupuncture, transcutaneous electrical nerve stimulation, repositioning, use of pressure relief devices, massage, heat therapy, music therapy, relaxation therapy, immobilization, ice therapy, compression, elevation, and bandage. Non-pharmacological interventions were mainly developed by nurses, physicians, and paramedics. They were, in most studies, poorly described in terms of their efficacy and were mostly reported in minor traumas, such as simple fractures or small wounds.

CONCLUSIONS

Currently, there is no consensus for the implementation of non-pharmacological interventions in the treatment of acute trauma pain. Their application is primarily used for minor traumas, and their potential for the treatment of major traumas is yet unknown. No studies on the use of non-pharmacological interventions aimed at reducing the impact of traumatic adverse environments were identified. Further investigation on the effects of these interventions should be encouraged so that robust decisions and recommendations can be made.

A prospective study to compare serial changes in pain scores for patients with and without a history of frequent ED utilization

Background

In the face of the opiate addiction epidemic, there is a paucity of research that evaluates limitations for our current pain rating methodologies for patient populations at risk for drug seeking behavior.

Objective

We hypothesized that VAS scores would be higher and show less serial improvement for patients with a history of frequent ED use.

Methods

This was a prospective, observational cohort study of a convenience sample of adult ED patients with chief complaint of pain. Initial VAS scores were recorded. Pain scores were subsequently updated 30–45 min after pain medication administration. ED frequenter defined as having >4 ED visits over a 1-year time period. Categorical data analyzed by chi-square; continuous data analyzed by t-tests. A multiple linear regression performed to control for confounding.

Results

125 patients were enrolled; 51% ED frequenters. ED frequenters were similar to non-ED frequenters with respect to gender, mean age, Hispanic race, educational level, chief complaint type, and initial pain medication narcotic. ED frequenters more likely to have higher initial VAS score (9.17+/-1.25 vs. 8.51+/-1.68; p = 0.01) and higher second VAS scores (7.48+/-2.56 vs. 5.00+/-3.28; p <0.001) and significantly lower mean change in first to second VAS scores (1.69+/-2.17 vs. 3.51+/-3.25; p <0.001). Within our multiple linear regression model, only ED frequenter group (p < 0.001) and private insurance status (0.04) were associated with differences in mean reduction in pain scores.

Conclusion

We found that ED frequenters had significantly less improvement between first and second VAS measurements.

Evaluation and treatment of pain in the pre-hospital setting. A comparison between patients with a hip injury, chest pain and abdominal pain

BACKGROUND

A large proportion of patients who call 112 in Sweden do so because of pain. The purpose of this study was to compare three of the most common types of pain presented by the patients: chest pain, abdominal pain and hip injury, in terms of initial assessment, intensity, treatment and effect of treatment. The overall rationale was to evaluate whether the early assessment and treatment of pain in the pre-hospital setting is optimal or whether there is room for improvement.

METHODS

Observational study during 2016 including 1234 patients triaged to chest pain, abdominal pain and hip injury by the Emergency Medical Services (EMS) in Gothenburg, Sweden.

RESULTS

Severe pain on the arrival of the EMS was described by 39% of patients with a hip injury, 27% with abdominal pain and 15% with chest pain. Analgesics were given to 58% of patients with a hip injury, 35% with chest pain and 34% with abdominal pain. A lower intensity of pain at re-evaluation was observed in 80% of patients with a hip injury, 57% with chest pain and 43% with abdominal pain. Administration of analgesics increased with the duration of pre-hospital care time in all three groups.

CONCLUSIONS

Patients with a hip injury had the most severe pain and they received most pain-relieving medication. Overall, a relatively small proportion of patients with pain received pain-relieving medication and there appears to be an extensive room for improvement.

Modified Delphi Method Derivation of the FAMILY (Family Assessment of Medical Interventions & Liaisons with the Young) EMS Instrument

BACKGROUND

Though family satisfaction with prehospital care is a surrogate for quality and patient outcomes, there are no tools available to measure family satisfaction.

OBJECTIVE

To develop the EMS Family Assessment of Medical Interventions & Liaisons with the Young (FAMILY) instrument.

METHODS

Components of family experiences with pediatric prehospital care were identified with a modified Delphi method. The expert panel included Emergency Medical Technicians, paramedics, family representatives, and EMS leaders from Colorado, Connecticut, and Rhode Island. An online survey was used to assess proposed questions from each of five candidate domains from national guidelines, including Safety, Communication, Family Presence, Cultural Awareness, Children with Special Healthcare Needs and Overall Satisfaction. Round-1 items were scored on a five-point Likert scale. Inclusion in the final instrument required 70% agreement ranking items as "include" or "definitely include." In Round-2, participants assessed proposed refinements. This resulted in FAMILY Version-1, with sections for family members and EMS care providers. EMSC Family Action Network (FAN) representatives evaluated the FAMILY, leading to Version-2. Suggestions from the national FAN about content, clarity, and whether the instrument captured their experiences with pediatric EMS care led to the final FAMILY version. Bilingual speakers translated the instrument into Spanish, while assessing the content for semantic, idiomatic, experiential, and conceptual equivalence between the English and Spanish versions.

RESULTS

There were 22 experts in Round-1, and 20 continued into Round-2 .The Delphi process yielded 12 questions in six domains with 14 recommended modifications. Two questions were excluded. Five domains reached 70% agreement in Round-1. Cultural Awareness reached 75% agreement after Round-2. Six FAN representatives evaluated Version-1, leading to changes for clarity, content and cultural sensitivity. Seventeen FAN representatives evaluated Version-2 leading to additional refinement. The assessment of the equivalence between the English and Spanish survey versions resulted in changes in the Spanish language content for equivalent meaning.

CONCLUSION

A panel of EMS and family stakeholders successfully developed an instrument to assess family satisfaction with pediatric EMS care. Further validation is required in a large respondent population. Assessing family satisfaction with pediatric EMS encounters is an important step toward improving prehospital care.

Non-pharmacological interventions for pain management in adult victims of trauma: a scoping review protocol

OBJECTIVE

This scoping review aims to map non-pharmacological interventions for reducing acute pain for adult victims of trauma.

INTRODUCTION

Acute pain, as a consequence of either a pathological or traumatic event or even due to invasive and non-invasive healthcare procedures, is highly prevalent in critically ill patients. However, specific acute pain as a direct consequence of trauma is one of the least studied areas of acute pain.

INCLUSION CRITERIA

This scoping review will consider studies on adult victims of trauma, aged 18 years or over, in prehospital emergency care, emergency departments and trauma centers. All studies that focus on non-pharmacological interventions designed to reduce acute pain, implemented and evaluated by health professionals in any form, duration, frequency and intensity, will be considered.

METHODS

An initial search of PubMed and CINAHL will be undertaken, followed by a second search for published and unpublished studies from 2000 to the present in major healthcare related electronic databases. Studies in English, French, Spanish and Portuguese will be included. Data extraction will be performed independently by two reviewers in tabular form and include details about the interventions, populations, study methods and outcomes of interest. A narrative synthesis will accompany the results and will describe how they relate to the review objectives.

Assessment of Acute Pain Management and Associated Factors among Emergency Surgical Patients in Gondar University Specialized Hospital Emergency Department, Northwest Ethiopia, 2018: Institutional Based Cross-Sectional Study

Background

Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients.

Patients and Methods

After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department.

Results

A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery.

Conclusion

The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice.

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection

BACKGROUND

Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients.

METHODS

This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA).

RESULTS

There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03-3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA.

CONCLUSION

Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.

Registered nurses' own experience of using a nurse-initiated pain protocol based on their working experience

AIMS AND OBJECTIVES

To explore registered nurses' (RNs) own experience of using the nurse-initiated pain protocol (NIPP) in the emergency department (ED) based on their working experience.

BACKGROUND

Pain is known to be one of the most common symptoms among adult patients seeking care at the ED. Several strategies aiming to improve pain management have been developed. Despite some improvements in pain management using NIPP, a large number of patients continue to have inadequate pain treatment when cared for in EDs.

DESIGN AND METHOD

A cross-sectional study design based on a questionnaire was used. The variable working experience was based on a theory that experience will make a change in RNs' knowledge. Descriptive statistics and Pearson's chi-square tests were used for analysing quantative data. Qualitative data were analysed by summative content analysis.

RESULTS

Seventy RNs answered the questionnaire (response rate 42%) and 61% considered the NIPP adequate to relieve patients' acute pain at the ED. No significant difference was found on how the RNs used the NIPP. However, qualitative data showed that more experienced RNs adapt the NIPP according to the patients' needs in a higher extent.

CONCLUSION

A majority of the RNs consider the NIPP to be adequate to relieve patients' acute pain in the ED. An increase in working experience showed an impact on how the NIPP was used, with an increase in pain management that is personalised depending on individual patients' needs. The RNs used several alternatives to both dosage and type of medication when the ED becomes crowded.

RELEVANCE TO CLINICAL PRACTICE

Registered nurses' working experience should be considered when planning nursing schedules to be better able to meet patients' needs. Guidelines should be developed and evaluated by both healthcare professionals and patients.