Do you mistreat patients who arrive at ED in pain?
Do you mistreat patients who arrive at ED in pain?
ED nurses may be a patient’s only advocate
When patients with an acute exacerbation of chronic pain from pancreatitis, migraines, cancer, fibromalgia, or other conditions go to an ED for help, pain management often is delayed or inadequate, says Elena Clifford, RN, an ED nurse at Massachusetts General Hospital in Boston.
"Research has shown that increased pain can cause increased tissue damage and possible psychological damage," Clifford adds.
Pain is better controlled with less medication if it can be handled before it gets out of control, says Theresa McKee, RN, an ED nurse at San Antonio Community Hospital in Upland, CA. "So don’t waste time battling about it," she says. "Get the med on board stat, as ordered by the physician."
The No. 1 rule is to believe the patient’s self-report of pain, says Clifford. "The patient’s pain is subjective, and we have to take their word for what it is," she says.
To improve care of patients with chronic pain, do the following:
• Form a pain task force.
At Massachusetts General, an interdisciplinary task force was formed to develop pain assessment and management protocols, with the goal of improving pain management, says Clifford. "A lot of education with ED nurses was done to improve the way we manage pain," she says.
Nurses were inserviced in groups, and updates on Joint Commission requirements and new medications are given verbally and via e-mail. "We recently reminded nurses that if you don’t document the pain scale on a patient and you have given a pain medication, then insurance can deny reimbursement," adds Clifford.
• Offer alternatives.
Pain management doesn’t always mean giving narcotics; distraction and other alternatives often are effective, says Clifford. She suggests offering a cool cloth for headaches, turning down the lights, noise reduction, distraction, and therapeutic touch or massage if nurses are certified.
Alternatives are very effective with pediatric patients, adds Clifford. "We use children’s videos, video games, and books for older children. For babies and neonates, we dip their pacifier into sucrose water and use swaddling," she says.
• Avoid use of the term "drug seeking" or "frequent flier."
Start with a "clean slate" each time you see the patient, and don’t prejudge, McKee suggests. "We need to look at each patient as though it were the first time we have met," she says. "We would not want to miss something new that could be going on and must still do appropriate testing when necessary."
Every patient should be treated the same, urges McKee. "This means VIPs, homeless patients, drug abusers, and patients with chronic pain," she says. Don’t discuss the patient with anyone except those involved in their immediate care, adds McKee.
"How many times has a negatively preconceived picture gone through the ED like wildfire before the patient even arrives? These patients are doomed before they even get into a bed, with nurses begging not to care for that’ patient," says McKee.
Meet the basic needs of every patient, and make them as comfortable as you can with pillows, blankets, and prompt responses to call lights, says McKee.
• Give appropriate dosages for individual patients.
The amount of medication needed can vary widely depending on the patient, says Clifford. "Every person is an individual, and we administer medications on an individual basis," she says.
One 24-year-old patient with severe pelvic pain became nauseous from only 1 mg of morphine, whereas a patient with a history of drug abuse might not get relief from even 5mg-10 mg of morphine, notes Clifford.
Clifford also has had trauma patients with a history of drug abuse who refuse to take any pain medication because they fear they will become addicted again. "No matter how much teaching you do, they are deathly afraid of becoming addicted and may even suffer nerve damage because they won’t take pain medication," she says.
• Keep a log of pain medications.
Nurses can refer to a patient’s medication history when patients report pain at triage, says Clifford.
"We can see what has been dispensed to them in the past, such as two days worth of [acetaminophen and oxycodone]," she says. "If they are back two days later asking for more, that raises a red flag," she says.
In this case, nurses would offer other forms of pain management or give the patient a referral to a primary care physician or outpatient pain center, she says. "We are not obligated to give a narcotic," Clifford says. "We are obligated to assess and manage their pain appropriately."
• Document what you’ve done.
Charts are audited to check for assessment and reassessment of the patient’s pain and to verify that it was managed appropriately, says Clifford. The Joint Commission on Accreditation of Healthcare Organizations is looking for documentation of pain assessment and management, preferably with a plan of care, she says. "They will want to see what happened to this patient as soon as they stepped in the door at triage," Clifford says.
Sources
For more information on chronic pain management in the ED, contact:
- Elena Clifford, RN, BSN, Emergency Department, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Telephone: (617) 724-4100. E-mail: [email protected].
- Theresa McKee, RN, Emergency Department, San Antonio Community Hospital, 999 San Bernardino Road, Upland, CA 91786. Telephone: (909) 985-2811. E-mail: [email protected].
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