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An emergency nurse’s pain management initiative: Mercy Hospital’s experience
Clinical Notebook An emergency nurse’s pain management initiative: Mercy Hospital’s experience Author: Patricia Spurlock, RN, BS, Ankeny, Iowa
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mergency nurses know that pain has been proven to have an impact on both clinical and patient satisfaction outcomes. The use of acetaminophen (Tylenol) and ibuprofen at triage; splinting; ice and elevation for extremity injuries; and morphine for chest pain and burns are standards of care in emergency departments. Is your emergency department addressing pain as a priority, or is pain addressed after diagnostic studies are performed? It has been said that up to 90% of patients who seek emergency care do so because of pain. Chest pain, trauma, fractures, migraine headaches, abdominal pain, extremity injuries, and earaches cover the broad spectrum of acuity where the focus is to diagnosis, treat, or stabilize. What percentage of those patients are being treated for their pain? Traditionally, pain management has had an inpatient focus, especially at the end of life or in the treatment of chronic pain or cancer. Why shouldn’t pain management be a focus in the emergency department, where treatment begins for up to 50% of hospital admissions and for the many patients discharged? At Mercy Hospital, many patients were telling us that we were not meeting their expectations with regard to addressing their pain, which led us to charter a performance improvement team. In early 1996, written comments returned with the patient surveys were bothersome. Although the survey did not include a specific question regarding pain or discomfort, the patterns of feedback were clear: “I was miserable and would have liked something for pain.” “Give pain medication, then do the tests. If the problem is severe, they will still find it.” Patricia Spurlock, Central Iowa Chapter, is Service Line Director, Emergency Services, Mercy Hospital Medical Center, Des Moines, Iowa. For reprints, write: Patricia Spurlock, RN, BS, 3001 NW 5th St, Ankeny, IA 50021. J Emerg Nurs 1999;25:383-5. Copyright © 1999 by the Emergency Nurses Association. 0099-1767/99 $8.00 + 0 18/9/101768
Two patients, both of whom were admitted to the hospital with back pain, did not receive anything for pain until after they were admitted to the inpatient unit. To patients who have pain significant enough to cause them to be hospitalized, it seems logical that they should receive analgesics in the emergency department.
Does it make sense to give a patient a prescription for pain, even a narcotic upon discharge, but give him or her nothing in the emergency department?
How could we as nurses begin to make an impact, when we could not prescribe medications? We elected first to go to our patients and ask them what one thing we could do better. Resoundingly, the response was to provide relief of pain. This response confirmed our theory that the issue was not anecdotal feedback. The next step was to determine where to begin to address this issue. Because not all the members of the team were convinced that every patient who said he or she had pain needed relief from his or her pain, we began by examining our own perceptions. We asked ourselves some hard questions. Does a fractured ankle hurt more before or after the radiographs are completed? Does it make sense to give a patient a prescription for pain, even a narcotic upon discharge, but give him or her nothing in the emergency department? Is a patient who has a migraine exhibiting drug-seeking behavior, or does he or she have legitimate pain? Should the nature of the source of the pain—whether it is from an injury or a disease—make a difference in determining whether medication should be provided for pain? After
October 1999 383
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spending much time examining our own perceptions of pain, we concurred that pain is subjective and that, in essence, we were asking patients to prove that they had pain before we considered it real enough to treat. In researching the barriers to addressing pain, we came up with the traditional responses. “We are too busy.” “The physicians don’t have the time to do more.” “Surgeons want to evaluate the pain to reach a definitive diagnosis.” “The patient didn’t complain of pain.” “There is a risk of respiratory depression.” And my personal favorite: “It only hurts when they are moved.” (Was the plan to keep the elderly woman with a hip fracture in the emergency department until the fracture healed?)
We revised the patient record to add a box to document the pain scale next to the vital signs as the fifth vital sign.
We began our mission to improve the management of pain in our emergency department with the recognition that we first have to ask the question about pain. We knew we did a good job with patients who had chest pain, because a question about pain was part of the initial assessment and the data were used to measure outcomes toward treatment goals. With that success in mind, we revised the patient record to add a box to document the pain scale next to the vital signs as the fifth vital sign. By raising the awareness of staff and patient expectations, physician awareness also was increased. We provided education regarding the use of the numeric pain scale and the pediatric Wong Baker scale at staff meetings and through a weekly newsletter. The next steps were focused on treatment options. When an emergency physician joined the team, we moved toward increased use of intravenous medications rather than parenteral routes of administration. Nitrous oxide, which had been used in the EMS arena, was now used as an alternative for specific patient populations. In pediatrics, the use of topical lidocaine, epinephrine, and tetracaine increased for pediatric patients with lacerations, and the use of eutectic mixture of local anesthetics (EMLA) topical anesthetic cream was initiated before insertion of peripheral lines when at all possible. Nurses began to inform elderly patients that they would probably experience pain upon being moved to the radiology department or to their room, and the nurses began to
384 Volume 25, Number 5
suggest that the patient might like to have something for pain before being moved. The use of meperidine (Demerol) has practically become obsolete in pain management in the emergency department. Staff members were educated about how to use patientcontrolled analgesia (PCA) pumps so that they could initiate the pump before patients went to the units to reduce the amount of time before pain was controlled and to put pain management in the patients’ hands. A member of the emergency performance improvement team became an active member of the hospital pain committee. The pain clinician welcomed us and served as a resource to assist with patients who had multiple visits to the emergency department for pain relief. We began to refer patients to the pain clinician, who provided options for the management of chronic pain that are facilitated by the case manager. The success was evident as patients experienced both access to the health care system and treatment options. The team established standards for triaging pain that relied on the patient’s self-report of the severity of pain. If the patient responds with a numeric pain scale of 7 or greater, he or she is triaged to a treatment room. In an audit, 31% of triaged patients who did not arrive by ambulance fell within these parameters, and all were triaged to a room for treatment. The presenting complaints ranged from fractures to kidney stones to back pain to migraine headache with vomiting. The pain scale is a good assessment tool to use in the triage setting to assist with screening stoic patients who previously may have received delayed treatment at a busy time in an emergency department. The emergency physicians and medical staff endorsed the initiative, and the nurses began reporting the pain scale to ED physicians and asking how they wished to address the pain. Nurses also turned to emergency physicians when a private physician did not provide an order for pain medication. The culture change had become integrated into clinical practice. How did the patients respond to the initiatives undertaken? Here are some of the comments that we received in the second half of the 1996 calendar year: “Because of my pain, I was taken immediately to a treatment room.” “They took great care in not hurting me and made me comfortable.” “I was in a great deal of pain and everyone was great.” “Everything was excellent. They knew I was in a great deal of pain and proceeded quickly.” Perhaps of greater significance is the absence of patient comments related to their pain not being taken care of.
Spurlock/JOURNAL OF EMERGENCY NURSING
The team wanted to inform patients that they should expect their pain to be addressed, and thus a statement was included in the patient brochure that is made available at the triage desk and in the public waiting areas. The evaluation of change needs to be measured periodically. One year later, in August 1997, 156 patients were asked, “Did you receive relief of your pain?,” and 142 responded yes; however, our sense is that patient satisfaction in this area is still not high. A telephone survey was conducted in the first half of 1998, and 83% of patients who were surveyed scored the staff’s responsiveness to pain and discomfort as “5” on a scale of 1 to 5. The survey tool now used at our organization includes a specific question related to pain and discomfort. Pain management is now integrated into orientation for new staff. We continue to feature periodic updates in the weekly newsletter as new information is learned and as a focus for staff. In fall 1998, the Health Care Advisory Board acknowledged the Mercy Hospital Emergency Department for its “Best Practice” in pain management.
Pain is an important clinical and ethical issue. The Joint Commission on Accreditation of Healthcare Organizations addresses pain under the patient rights standards. Science has demonstrated that severe pain can erode the will to live. The physiologic response in elderly patients with the release of epinephrine results in higher blood pressure. As emergency nurses, the management of pain is one of our most important responsibilities, especially in the young and old, those critically ill or injured, and those who have a history of substance abuse. A gap exists between the treatments that are available and what is practiced clinically. At our facility we have shown that emergency nurses can accept the challenge and move from data collecting to action. Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, EdD, RN, c/o Managing Editor; ENA, 915 Lee St, Des Plaines, IL 60016; phone (847) 4604044; E-mail: [email protected].
ENA Special Interest Groups—Our Way of Meeting Your Needs ENA offers you the opportunity to network with members in your speciality. If you would like more information about ENA’s Special Interest Group in your area of interest, please check the appropriate box below and return this form to: Emergency Nurses Association Professional Services 915 Lee St Des Plaines, IL 60016 ■ Forensic nursing
■ Telephone triage
■ Uniformed services
Name __________________________________________________________________ Address ________________________________________________________________ City/State/Zip Code ______________________________________________________ __________________ ENA Member number
October 1999 385
E
mergency nurses know that pain has been proven to have an impact on both clinical and patient satisfaction outcomes. The use of acetaminophen (Tylenol) and ibuprofen at triage; splinting; ice and elevation for extremity injuries; and morphine for chest pain and burns are standards of care in emergency departments. Is your emergency department addressing pain as a priority, or is pain addressed after diagnostic studies are performed? It has been said that up to 90% of patients who seek emergency care do so because of pain. Chest pain, trauma, fractures, migraine headaches, abdominal pain, extremity injuries, and earaches cover the broad spectrum of acuity where the focus is to diagnosis, treat, or stabilize. What percentage of those patients are being treated for their pain? Traditionally, pain management has had an inpatient focus, especially at the end of life or in the treatment of chronic pain or cancer. Why shouldn’t pain management be a focus in the emergency department, where treatment begins for up to 50% of hospital admissions and for the many patients discharged? At Mercy Hospital, many patients were telling us that we were not meeting their expectations with regard to addressing their pain, which led us to charter a performance improvement team. In early 1996, written comments returned with the patient surveys were bothersome. Although the survey did not include a specific question regarding pain or discomfort, the patterns of feedback were clear: “I was miserable and would have liked something for pain.” “Give pain medication, then do the tests. If the problem is severe, they will still find it.” Patricia Spurlock, Central Iowa Chapter, is Service Line Director, Emergency Services, Mercy Hospital Medical Center, Des Moines, Iowa. For reprints, write: Patricia Spurlock, RN, BS, 3001 NW 5th St, Ankeny, IA 50021. J Emerg Nurs 1999;25:383-5. Copyright © 1999 by the Emergency Nurses Association. 0099-1767/99 $8.00 + 0 18/9/101768
Two patients, both of whom were admitted to the hospital with back pain, did not receive anything for pain until after they were admitted to the inpatient unit. To patients who have pain significant enough to cause them to be hospitalized, it seems logical that they should receive analgesics in the emergency department.
Does it make sense to give a patient a prescription for pain, even a narcotic upon discharge, but give him or her nothing in the emergency department?
How could we as nurses begin to make an impact, when we could not prescribe medications? We elected first to go to our patients and ask them what one thing we could do better. Resoundingly, the response was to provide relief of pain. This response confirmed our theory that the issue was not anecdotal feedback. The next step was to determine where to begin to address this issue. Because not all the members of the team were convinced that every patient who said he or she had pain needed relief from his or her pain, we began by examining our own perceptions. We asked ourselves some hard questions. Does a fractured ankle hurt more before or after the radiographs are completed? Does it make sense to give a patient a prescription for pain, even a narcotic upon discharge, but give him or her nothing in the emergency department? Is a patient who has a migraine exhibiting drug-seeking behavior, or does he or she have legitimate pain? Should the nature of the source of the pain—whether it is from an injury or a disease—make a difference in determining whether medication should be provided for pain? After
October 1999 383
JOURNAL OF EMERGENCY NURSING/Spurlock
spending much time examining our own perceptions of pain, we concurred that pain is subjective and that, in essence, we were asking patients to prove that they had pain before we considered it real enough to treat. In researching the barriers to addressing pain, we came up with the traditional responses. “We are too busy.” “The physicians don’t have the time to do more.” “Surgeons want to evaluate the pain to reach a definitive diagnosis.” “The patient didn’t complain of pain.” “There is a risk of respiratory depression.” And my personal favorite: “It only hurts when they are moved.” (Was the plan to keep the elderly woman with a hip fracture in the emergency department until the fracture healed?)
We revised the patient record to add a box to document the pain scale next to the vital signs as the fifth vital sign.
We began our mission to improve the management of pain in our emergency department with the recognition that we first have to ask the question about pain. We knew we did a good job with patients who had chest pain, because a question about pain was part of the initial assessment and the data were used to measure outcomes toward treatment goals. With that success in mind, we revised the patient record to add a box to document the pain scale next to the vital signs as the fifth vital sign. By raising the awareness of staff and patient expectations, physician awareness also was increased. We provided education regarding the use of the numeric pain scale and the pediatric Wong Baker scale at staff meetings and through a weekly newsletter. The next steps were focused on treatment options. When an emergency physician joined the team, we moved toward increased use of intravenous medications rather than parenteral routes of administration. Nitrous oxide, which had been used in the EMS arena, was now used as an alternative for specific patient populations. In pediatrics, the use of topical lidocaine, epinephrine, and tetracaine increased for pediatric patients with lacerations, and the use of eutectic mixture of local anesthetics (EMLA) topical anesthetic cream was initiated before insertion of peripheral lines when at all possible. Nurses began to inform elderly patients that they would probably experience pain upon being moved to the radiology department or to their room, and the nurses began to
384 Volume 25, Number 5
suggest that the patient might like to have something for pain before being moved. The use of meperidine (Demerol) has practically become obsolete in pain management in the emergency department. Staff members were educated about how to use patientcontrolled analgesia (PCA) pumps so that they could initiate the pump before patients went to the units to reduce the amount of time before pain was controlled and to put pain management in the patients’ hands. A member of the emergency performance improvement team became an active member of the hospital pain committee. The pain clinician welcomed us and served as a resource to assist with patients who had multiple visits to the emergency department for pain relief. We began to refer patients to the pain clinician, who provided options for the management of chronic pain that are facilitated by the case manager. The success was evident as patients experienced both access to the health care system and treatment options. The team established standards for triaging pain that relied on the patient’s self-report of the severity of pain. If the patient responds with a numeric pain scale of 7 or greater, he or she is triaged to a treatment room. In an audit, 31% of triaged patients who did not arrive by ambulance fell within these parameters, and all were triaged to a room for treatment. The presenting complaints ranged from fractures to kidney stones to back pain to migraine headache with vomiting. The pain scale is a good assessment tool to use in the triage setting to assist with screening stoic patients who previously may have received delayed treatment at a busy time in an emergency department. The emergency physicians and medical staff endorsed the initiative, and the nurses began reporting the pain scale to ED physicians and asking how they wished to address the pain. Nurses also turned to emergency physicians when a private physician did not provide an order for pain medication. The culture change had become integrated into clinical practice. How did the patients respond to the initiatives undertaken? Here are some of the comments that we received in the second half of the 1996 calendar year: “Because of my pain, I was taken immediately to a treatment room.” “They took great care in not hurting me and made me comfortable.” “I was in a great deal of pain and everyone was great.” “Everything was excellent. They knew I was in a great deal of pain and proceeded quickly.” Perhaps of greater significance is the absence of patient comments related to their pain not being taken care of.
Spurlock/JOURNAL OF EMERGENCY NURSING
The team wanted to inform patients that they should expect their pain to be addressed, and thus a statement was included in the patient brochure that is made available at the triage desk and in the public waiting areas. The evaluation of change needs to be measured periodically. One year later, in August 1997, 156 patients were asked, “Did you receive relief of your pain?,” and 142 responded yes; however, our sense is that patient satisfaction in this area is still not high. A telephone survey was conducted in the first half of 1998, and 83% of patients who were surveyed scored the staff’s responsiveness to pain and discomfort as “5” on a scale of 1 to 5. The survey tool now used at our organization includes a specific question related to pain and discomfort. Pain management is now integrated into orientation for new staff. We continue to feature periodic updates in the weekly newsletter as new information is learned and as a focus for staff. In fall 1998, the Health Care Advisory Board acknowledged the Mercy Hospital Emergency Department for its “Best Practice” in pain management.
Pain is an important clinical and ethical issue. The Joint Commission on Accreditation of Healthcare Organizations addresses pain under the patient rights standards. Science has demonstrated that severe pain can erode the will to live. The physiologic response in elderly patients with the release of epinephrine results in higher blood pressure. As emergency nurses, the management of pain is one of our most important responsibilities, especially in the young and old, those critically ill or injured, and those who have a history of substance abuse. A gap exists between the treatments that are available and what is practiced clinically. At our facility we have shown that emergency nurses can accept the challenge and move from data collecting to action. Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, EdD, RN, c/o Managing Editor; ENA, 915 Lee St, Des Plaines, IL 60016; phone (847) 4604044; E-mail: [email protected].
ENA Special Interest Groups—Our Way of Meeting Your Needs ENA offers you the opportunity to network with members in your speciality. If you would like more information about ENA’s Special Interest Group in your area of interest, please check the appropriate box below and return this form to: Emergency Nurses Association Professional Services 915 Lee St Des Plaines, IL 60016 ■ Forensic nursing
■ Telephone triage
■ Uniformed services
Name __________________________________________________________________ Address ________________________________________________________________ City/State/Zip Code ______________________________________________________ __________________ ENA Member number
October 1999 385