Three years ago many best practices already were in place at LDS Hospital in Salt Lake City, Utah, USA. The hospital was providing bedside registration, advanced triage protocols, point of care testing and real time radiology. A robust and comprehensive continuous quality improvement program had been established and as a result, higher patient satisfaction scores, declining walkaway rates and shorter turnaround times had been realized.

Despite all of this, the hospital staff recognized a problem in the rapid treatment of painful conditions in the emergency department (ED). Alerted by a number of complaints from patients, the staff in the emergency department began a pain management initiative in 2002 to remedy the problem.

Pain is one of the major symptoms that cause patients to seek emergency medical care. Not surprisingly, studies have shown a correlation between pain relief and patient satisfaction. Numerous studies also have indicated that perceived waiting time is the most important variable contributing to patient satisfaction. Thus, while the complexities of pain management in the ED are only beginning to be unraveled, it is clear that timely alleviation of adverse symptoms deters patients from leaving before they have been seen by a doctor. This, along with the knowledge that feedback to caregivers through quality improvement data affects the behavior of healthcare providers, was utilized in tackling the defects in pain management in the LDS Hospital emergency department.

The Pain Reduction Project

With the goals of increasing the rate of administering pain treatment and reducing the time to administration, a quality improvement initiative was begun. It involved a chart audit, the formation of a work team, a root cause analysis, developing a new process and a second audit. The work team used the DMADV (Define, Measure, Analyze, Devise, Verify) roadmap to resolve the ED pain issue.

A version of the visual analog scale (VAS) is used routinely in the department to assess the patient’s perception of pain and is included in the nurses’ computerized charting. Moderate to severe pain was defined as VAS 4 or higher. A search was done of patients using the VAS criteria and 100 charts were randomly audited using a chart screening tool. Time to pain management was defined as the interval between triage (when the patient was recognized as an ED encounter) and the administration of a pain medication or other intervention as documented in the nursing record. The rate of pain treatment was defined as the number of patients who received a pain intervention divided by the number of patient encounters audited.

The chief complaint, the pain scale number and the type of treatment given were all recorded, as well as the documentation of pain relief. Other data recorded included patient demographics such as age and gender. Comfort measures – defined as ice packs, warm blankets, splints or pillows/positioning of patient – were noted in the audits as well.

Physicians were made aware of the first audit findings and in monthly staff meetings began working on the development of chief complaint-based patient care protocols for painful conditions. The work on these protocols kept the focus of the department on pain management issues for an extended period of time.

Nurses were in-serviced with an educational module on pain management in the ED. Quality goals were set to improve the rate of administering pain medication and the timeliness of administering the medication. The work team also developed other advanced triage protocols (Table 1) which allowed staff to begin pain management through adjunctive treatments like splints, ice, warm blankets, local anesthetics and non-narcotic medications.

Six months after the training module was complete and as the pain management initiative continued, a second chart audit was performed. One hundred charts were again randomly audited using the screening tool and the same criteria for moderate to severe pain. In addition, patient satisfaction surveys performed independently during the study period were incorporated into the study analysis.

Comparing Before and After Audits

The results of the two retrospective pain audits (Table 2) showed that the two groups of patients audited were closely matched in terms of age and gender. In both groups, the top two chief complaints of patients with moderate to severe pain were injuries and abdominal pain. Back pain, headache and flank pain also were fairly frequent. The average time to pain medication prior to the intervention was 67 minutes, while the average time to pain medication after the intervention was 46 minutes. Thirty-nine percent of the patients received no pain medicine in the first audit, while only 11 percent received no pain medication in the second audit.

Patient Satisfaction Scores Climb

In addition, the results of patient satisfaction surveys performed after the pain management education initiative and the implementation of the patient care protocols were analyzed in conjunction with the pain audit data. Between January and October of 2002, scores rose from 3.93 to 4.37 (see the figure below). Further, the number of patients who reported their pain control as “excellent” rose from 29.8 to 39.1 percent.

Conclusion: Project Achieves All Its Objectives

The initiative to improve the treatment of pain in the emergency department at LDS Hospital was successful. The goals of increasing the rate of administration of pain therapies and decreasing the time to pain management were met. And, this in turn had a positive effect on patient satisfaction.