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Implications for practice and research
▪ With appropriate training and safeguards, nurse-initiated analgesia should be more broadly adopted for treatment of emergency department (ED) patients with abdominal pain. Further research is warranted investigating barriers to early analgesia administration in ED.
▪ Research is warranted comparing different analgesia protocols for safety and effectiveness.
▪ Research should investigate the safety and effectiveness of analgesia initiated at triage.
Pain is a very common problem in EDs. There is convincing evidence that treatment of pain in the ED is suboptimal, in timeliness and adequacy of pain control.1 Contributors to this failure include myths regarding masking of symptoms, historical models of care where analgesia can only be initiated by a doctor, staff attitudes and systems issues such as ED crowding. There is a growing body of evidence that nurse-initiated opiate analgesia results in reduced delays to analgesia and is safe.2 3
Muntlin and colleagues used a quasi-experimental design. The intervention was education, nursing assessment and nurse-initiated opiate analgesia for ED patients with abdominal pain. Data were collected in three periods: before the intervention, when the intervention was available and after the intervention had been withdrawn. Main outcomes of interest were pain intensity, time to analgesia, ED transit time and patients' perception of quality of pain management care. The data were collected from electronic medical records and from a questionnaire administered before discharge. Methods of analysis included non-parametric comparisons.
Data from 200 patients were analysed (50 preintervention, 100 during intervention and 50 after intervention withdrawal). Documentation of pain intensity was much higher in the intervention phase (96% vs 35%). Time to analgesia was significantly reduced in the intervention phase (1.3 vs 2.5 h preintervention). During the intervention phase, patients perceived a higher quality of pain management. Pain intensity scores showed a reduction in least pain from preintervention to during the intervention, but worst pain and pain now showed no significant differences. ED transit time did not differ significantly. Improvements were not sustained once the intervention was withdrawn.
This study adds to the growing body of evidence that nurse-initiated opiate analgesia improves pain management for ED patients. However, effects on pain intensity were less convincing. The weight of that evidence is becomingsuch that historical models of care should be challenged and appropriate-accelerated analgesia protocols should be developed and implemented. It also adds to the evidence that processes incorporating structured pain assessment linked to analgesia administration result in more timely analgesia.3,–,5
Muntlin and colleagues were brave to study the difficult patient group with abdominal pain. This is a group where historical practice, influenced by unfounded myths of analgesia masking diagnosis, has been entrenched.6 This makes their findings important.
Unfortunately, time to analgesia was still quite long in the intervention group (1.3 h). Other studies of nurse-initiated opiates have reported much shorter treatment times (31 min in a study of patients with biliary colic3 and 18 min in a study of patients with fractured neck of femur2). The reason for this difference is unclear and worthy of further work.
Regarding methodology, the authors acknowledge that a quasi-experimental design is inferior to a randomised controlled trial in terms of quality of evidence of effectiveness. This means there is a risk of bias, and staff were aware of the change and that it was being evaluated. Patients with a pain score of 9 or 10 not included in the study, and thus the effect of this intervention of those with the severest pain is not known.
The administration of the quality of care questionnaire by the nursetreating the patient is a potential weakness. There is evidence that patient satisfaction with analgesia is not necessarily related to effective pain management.6 Staff communication, attention and empathy are thought to be major influences on satisfaction perceptions.7 Thus, the administration of the survey by the treating nurse may well have confounded the findings.
Competing interests A-MK has conducted and published research in the area of pain management and nurse-initiated analgesia protocols. She has also been a member of NHMRC working group on analgesia in ED. She has contributed to three books on acute pain management. She has no commercial or funding conflicts of interest to declare.
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