Is your ED as pain-free as possible? Pay attention to patient complaints

Many ED nurses are improving pain management at their facilities by targeting specific patient populations, adding pain resource nurse roles, and revising clinical pathways.

Patients who arrive at your ED are usually in some amount of pain, but many of them may not be getting enough pain relief. "In the ED, we are usually focused on diagnosis and treatment, and look at pain as a symptom, instead of something we need to treat,"emphasizes Paula Tanabe, RN, PhD, CEN, CCRN, clinical nurse specialist and trauma coordinator for the ED at Northwest Community Hospital in Arlington Heights, IL.

ED nurses need to add a "D" for discomfort to their ABCs, Tanabe stresses. "Unless someone specifically requests pain medication, we often don't even think of treating it," she says.

Failure to provide adequate pain relief is a major cause of patient dissatisfaction. "Treating for pain is a real patient satisfier," says Tanabe. "If a patient is waiting in the ED for four or five hours, at least you can make them comfortable."

A study done by Tanabe showed that 79% of patients arrived with a complaint related to pain, but only 58% were treated, either pharmacologically or with ice. "That is justification that we should be looking at this," she says. "Pain is a high-frequency complaint, but it's not treated with frequency."

Of the patients who were treated for pain, fewer than half received an analgesic, and the average waiting time for the medication was 73 minutes. Only 15% of the patients received an opioid, although the average pain rating was 6 on a scale of 0-10.

While chest pain patients tended to be treated for pain, other patient populations were routinely not treated. "The only factor that predicted treatment was chest pain," says Tanabe. "We identified that chest pain had negative physiologic effects, but we stopped there."

Many ED nurses are uncomfortable with giving drugs, or they are afraid they will addict patients. When 300 Illinois ENA members completed a 52-item survey about pharmacologic treatment, responses revealed a lack of knowledge, Tanabe reports. "There is a severe deficit of knowledge in this area," she says. "Many ED nurses don't understand addiction, dependence, and tolerance."

Survey responses indicated that many of the nurses were reluctant to give patients narcotics. "We need to educate ourselves, so we are not afraid to treat patients," says Tanabe. Addiction occurs in less than 1% of patients in the hospital, she notes.

Task force improves pain management

At Harborview Medical Center in Seattle, WA, a task force was formed to review pain management after a patient satisfaction survey detected problems in this area. "Some patients felt that the staff wasn't doing everything possible to control their pain," says Carol Metcalf, RN, the hospital's pain management clinical nurse specialist.

In order to identify problems, the nursing staff was surveyed. (See nursing satisfaction with pain management survey, opposite page.)

Availability of patient-controlled analgesia (PCA) machines was one problem area. "Sometimes we would run out unexpectedly, and by the time we tracked one down, an unacceptable amount of time had gone by," says Carolyn Hoover, RN, chair of the pain management task force. "We ordered additional machines and did daily checks to make sure there were always two machines stocked."

Inconsistent charting between the different hospital departments was another problem. "We standardized our method of flagging charts," says Hoover. "This ensures that an order won't sit there for an hour and a half because someone doesn't use the same color code in their unit."

Nurses also responded that orders often needed clarification. "If you have an analgesic prescription that needs clarification, that causes a time delay," Metcalf explains.

The task force began monthly chart reviews to audit the pain management of individual patients. "Sometimes it was obvious that patients' pain levels remained high, but nurses still reported that the pain management regimen was giving the patient fair relief," says Metcalf. "For a patient to go from a pain level of 8 to a 7.5 is not fair relief."

The chart reviews assess the steps taken for patients who report a high pain level. "We look for evidence that further orders were pursued," Metcalf notes. "Then we determine whether those orders resulted in a change in the patient's pain levels."

Clinical pathways should contain a pain management component, urges Metcalf. "Pain management should be threaded though the individual pathways not separated out as an entity of its own," she says.

Pediatric trauma patients were a major focus of the task force. "It hit us that a lot of these kids weren't getting any pain medicine, yet they had significant injuries," says Mary Royce, RN, BSN, CEN, nursing educator in the hospital's ED. "We also looked at whether the pain medication they received was appropriate."

When the task force began its work in February of 1996, it was determined that only 42% of trauma patients received pain medication. As of January 1998, the percentage has increased to 94%. "Treatment of pain has become second nature," Royce reports. "Now, one of the first things nurses ask is, 'Can I give this patient pain medicine, and if so, what can I give and how much?'"

Pain management tips

Don't fail to treat patients' pain because of informed consent issues. "Some people feel that if you give a narcotic, you can't get informed consent from a patient," says Tanabe. "But, if you have a patient writhing in pain because you haven't medicated them, how informed are they, really? Those patients are more likely to say, `Fine, just put it in front of me, I'll sign anything.'" When the patient's pain is under control, they can better comprehend what you're telling them, she notes.

Establish policies in advance. "You need to work with surgeons individually to establish a policy for pain management," says Tanabe. "One possible approach is to give the surgeons a limited time frame to respond to the ED before going ahead and treating the patient."

Don't ignore minor injuries. Although patients with significant trauma such as fractures are generally managed well, less serious injuries are often overlooked. "There is a tendency to fall behind in the minor injuries, such as patients who have twisted their ankle or have minor head injuries," Royce acknowledges.

Be an advocate for pain management. "Educate yourself enough so you can approach a physician and bring up this issue," says Tanabe. "If you bring literature to them, what you say is much more difficult to refute."

However, disagreements about pain management shouldn't be a showdown between an individual nurse and physician, Tanabe stresses. "You need to go to a nurse manager and get support for the issue on a unit level, so you don't have a one-on-one confrontation," she explains.

Improve patient assessment. It helps to have more than one pain assessment tool available. "We use a 0-10 numerical scale, but some patients don't feel comfortable with that, so we also give them the choice of using a verbal descriptive scale," says Tanabe.

Be aware of all your options. Even if some pain interventions are not appropriate, you should consider other options. "If a patient is going upstairs to the OR, and you don't want to give them a narcotic, that doesn't mean you shouldn't give them anything-there are other things you can use," Royce emphasizes.

Remain with patients in severe pain. Even if there is nothing else that can be done, patients may perceive that you are not doing anything if they are left stranded. "Patients can have a pain level of 8 and still feel like you are doing everything possible to help them," says Metcalf. "It's difficult when you have many other patients to attend to, and it can be uncomfortable remaining with that patient if they are in a lot of pain, but it can be very comforting for them."

Consider other methods. Pain management doesn't have to mean medication. "Certainly with a fractured femur, you would need medication, but there are complementary things you can do in addition to that," says Metcalf. "Even in a chaotic environment, slow rhythmic breathing or relaxation techniques can be effective." Distraction is another method easy to use in the ED, she adds.

Instructions for these techniques can be put on a laminated card that nurses can refer to. "This kind of thing won't work for every patient in every situation, so if patient isn't receptive, you can just stop," says Metcalf. "But for the patients it does work for, they won't care if you are reading from a card. You can stand behind them at the head of the bed and they won't even notice."

Use dosage charts. Preprinted dosage charts can facilitate pediatric medication. "We have calculated dosages for a variety of pain and sedation meds, which are in our treatment rooms," says Metcalf. "We also developed guidelines for use of PCA in pediatric patients, because nurses are often unfamiliar with how much morphine to give per kilo in what interval."