Improving Pain Management in Australian Emergency Departments Ruth Cornish National Institute of Clinical Studies

Established by the Federal government to improve health care by closing gaps between best available evidence and current clinical practice

National Institute of Clinical Studies Key tasks: –Identify important gaps –Identify available, effective methods for changing practice –Help increase uptake

National Institute of Clinical Studies Challenges: –Task is huge –Making change happen is hard –Poor measurement of clinical practice –Diverse nature & type of evidence on behavior & organisational change

Stakeholder Initiated Clinical Projects Emergency Department Collaborative Heart Failure Program Pain Management Program Prevention of DVT in hospitalised patients

Who was involved

Collaborative Components Multi-organisational with common theme Evidence of best practice and variation Interdisciplinary teams Information exchange Close gaps by review & modification of work processes & small scale test of change Measurement to assess progress System changes

Web based support system Four Key Functions Data entry & graph results in real time Rapid exchange of protocols & documents News dissemination Forum for emergency care clinicians

Features Real time graphing of results

Areas for improvement Time to pain relief Time to thrombolysis Time to antibiotic for febrile neutropenia & pneumonia Time to X-Ray, pathology test results Referral to specialty units Fast track

Barriers to effective pain management in ED Inadequate pain assessment Misconception that analgesia impairs diagnosis Lines of authority Local process issues

“When I arrived I was in so much pain I could barely walk. They wouldn’t give me anything because it was ‘undiagnosed abdominal pain’ yet it took four hours for someone to see me.”

Time to analgesia Measurement to recognise the problem Use of evidence to reduce barriers Local system changes Patient-centred approach

Median time to analgesia - all

Time to Analgesia – review of the data 34 of 41 sites improved time to analgesia 7 sites improved by more than 50% 9 sites improved by 30-50%

Time to analgesia – sustainable changes Identification and pain scoring at triage Pain protocols Nurse-initiated analgesia IV cannulation programs

Nurse-initiated narcotic analgesia: History Prof AM Kelly mid 1990s Recognition of poor pain management in ED  process changes –Routine pain recording –Active change to IV narcotic analgesia (away from IM) –Nurse-managed titration of analgesia from standing orders

Nurse-initiated narcotic analgesia: History Proof of safety »Coman & Kelly (VIC) Emerg Med 1999 "Accreditation" of nurses Internal hospital policy approval IM route dramatic decrease

Nurse-initiated narcotic analgesia: History Dissemination, spread Creep toward fully nurse-initiated Increasing ‘local’ evidence base »Fry & Holdgate (NSW) Emerg Med 2002 »Brumby (VIC) AMS project Improves time to analgesia by about 30 minutes

Nurse-initiated narcotic analgesia Victoria state ED Collaborative 2000 NICS national ED Collaborative 2002 Focus on pain & time to analgesia Provided momentum & leverage for nurse-initiated analgesia

Nurse-initiated narcotic analgesia Hospital approval processes NSW state support/policy Victoria - recently challenged along with standing-orders

Further Work Culture survey results and high and low performing sites Setting up a community of practice

Research Transfer Factors Stakeholder drivers Political Organisational Clinicians Patients

Research Transfer Factors Evidence based Existing evidence on pain management used as a driver for change Local evidence still needed

Research Transfer Factors External leverage NICS Collaborative gave “time to analgesia” a national focus Transfer of “legitimacy” Increased speed of spread

Acknowledgements Sue Huckson: EDC project manager Jan Davies: EDC project director Heather Buchan: CEO of NICS All the Emergency Departments