Outcomes of a nurse-initiated intravenous analgesic protocol for abdominal pain in an emergency department: A quasi-experimental study

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Abstract

Background

Abdominal pain is one of the most frequent reasons for seeking care in an emergency department. Surveys have shown that patients are not satisfied with the pain management they receive. Reasons for giving inadequate pain management may include poor knowledge about pain assessment, myths concerning pain, lack of communication between the patient and healthcare professional, and organizational limitations.

Objectives

The aim of the study was to investigate the outcome of nursing assessment, pain assessment and nurse-initiated intravenous opioid analgesic compared to standard procedure for patients seeking emergency care for abdominal pain. Outcome measures were: (a) pain intensity, (b) frequency of received analgesic, (c) time to analgesic, (d) transit time, and (e) patients’ perceptions of the quality of care in pain management.

Design

A quasi-experimental design with ABA phases was used.

Setting

The study was conducted in an emergency department at a Swedish university hospital.

Participants

Patients with abdominal pain seeking care in the emergency department were invited to participate. A total of 50, 100 and 50 patients, respectively, were included for the three phases of the study. The inclusion criteria were: ongoing abdominal pain not lasting for more than 2 days, ≥18 years of age and oriented to person, place and time. Exclusion criteria were: abdominal pain due to trauma, in need of immediate care and pain intensity scored as 9–10.

Methods

The patients’ perceptions of the quality of care in pain management in the emergency department were evaluated by means of a patient questionnaire carried out in the three study phases. The intervention phase included education, nursing assessment protocol and a range order for analgesic.

Results

The nursing assessment and the nurse-initiated intravenous opioid analgesic resulted in significant improvement in frequency of receiving analgesic and a reduction in time to analgesic. Patients perceived lower pain intensity and improved quality of care in pain management.

Conclusions

The intervention improved the pain management in the emergency department. A structured nursing assessment could also affect the patients’ perceptions of the quality of care in pain management in the emergency department.

Introduction

Abdominal pain is one of the most frequent reasons for seeking care at an emergency department (ED) (Bayley et al., 2004, Uppsala University Hospital, 2008). Several studies in Sweden and internationally have shown that patients are not satisfied with the pain management they receive in the emergency department (Muntlin et al., 2006, Marinsek et al., 2007, Todd et al., 2007). Reasons for giving insufficient pain management have been reported as being multifactorial, such as, for example, poor knowledge about pain assessment and pain management, myths and misunderstandings concerning pain and opioids, lack of communication between the patient and healthcare professional, and organizational limitations (Klopfenstein et al., 2000, Dihle et al., 2006, Layman Young et al., 2006). The International Association for the Study of Pain (IASP) has defined pain as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP, 1979). Studies carried out in EDs have shown that emergency nurses and emergency physicians assess pain as being of lower intensity than the patients do (Puntillo et al., 2006, Marinsek et al., 2007). Another problem is that pain is seldom re-assessed during the ED visit (Todd et al., 2007). Studies have also shown that patients do not always receive analgesic in the emergency department. For example, Yanuka et al. (2008) found that only 30% of the patients with urgent pain received analgesic in an Israeli emergency department. An American study (Todd et al., 2007) showed that 60% of patients received analgesics, however, with lengthy delays.

Another problem is the time to analgesic. Mean time to received analgesic can vary between 53 and 90 min, with a range of 0–962 min (Fry and Holdgate, 2002, Arendts and Fry, 2006, Todd et al., 2007). Studies investigating analgesic administration in the emergency department are, however, scarce. An Australian study (Fry and Holdgate, 2002) showed that patients who had analgesic administered by a nurse, before examination by a physician, received analgesic on average 26 min earlier than patients who were seen by a physician before analgesic was given. Similar results were found by another Australian study (Kelly et al., 2005). But nursing intervention studies investigating nurse-initiated intravenous (IV) opioid analgesic administration in other countries are sparse in the literature. This should be further investigated in other contexts, to find out the possible implications for evidence-based practice.

By tradition, analgesic in the emergency department has been limited, to avoid negative effects on the diagnosis process or the further treatment (Thomas et al., 2003, Neighbor et al., 2004). Several recent studies (Thomas et al., 2003, Gallagher et al., 2006, Amoli et al., 2008) have shown that it is safe to give analgesic to patients with abdominal pain and that it does not delay diagnosis. A policy for pain management might facilitate the possibilities of giving adequate analgesic and pain relief (Marinsek et al., 2007).

Patients’ perceptions of the care they receive are often seen as an indicator for quality (Donabedian, 1998, Elder et al., 2004). Adequate doses of analgetica and time to analgetica administration should be seen as important quality indicators for pain management in emergency departments (Arendts and Fry, 2006). To improve the pain management, it is necessary to listen to the patients who receive the actual care and the healthcare professionals who perform that care. In addition, in recent years, in Sweden as well as internationally the health and medical care systems have experienced economic constraints and organizational and political changes are common. This highlights the importance of quality improvements that are not only evidence-based but also cost-effective. The emergency department can stand for a large part of a hospital's total patient visits. Improved throughput times and patient satisfaction could thus be essential factors for the hospital's economy (Karpiel, 2000).

This intervention study was the outcome of a previous patient questionnaire in the emergency department (Muntlin et al., 2006), where the following five areas for improvement were identified: (1) information, respect and empathy, (2) pain relief, (3) nutrition, (4) waiting time, and (5) general atmosphere. Following the patient survey, interviews were conducted with healthcare professionals working at the emergency department, about their perceptions and the prerequisites for quality improvement with respect to the identified areas for improvement (Muntlin et al., 2010). The interviewed physicians thought that pain relief was not a problem to be prioritized in the quality improvement work. In contrast, the registered nurses’ (RNs) interviewed were concerned about the inadequate pain management in the emergency department, and requested more education in pain management and range orders for analgesics.

Furthermore, to evaluate the quality of care in pain management, both the clinical practice and the patients’ perception of the quality of pain management care should be taken into consideration. Our hypothesis was that focus on nursing assessment, pain assessment and nurse-initiated analgesic could improve the pain management in the emergency department. The aim of the current study was to investigate the outcome of nursing assessment, pain assessment and nurse-initiated IV opioid analgesic, compared to standard procedure for patients seeking emergency care for abdominal pain. Outcome measures were: (a) pain intensity, (b) frequency of received analgesic, (c) time to analgesic, (d) transit time in the emergency department, and (e) patients’ perceptions of the quality of care in pain management.

Section snippets

Design

This study had a quasi-experimental design, with ABA phases. The ABA phases represent baseline (A1), intervention (B) and return to baseline (A2) (Kazdin, 2003). Fig. 1 describes the different phases in detail.

Setting

The study was conducted in 2009 in the main emergency department of a Swedish university hospital. In 2008, the emergency department treated more than 52,000 patients, with a mean age of 55 years (49% men; 51% women). The emergency department is divided into three main specialties:

Results

In total, 200 patients were included. Of these patients, 81 were men (40%) and 119 women (60%), with a mean age of 44.9 years (range 18–85; SD = 16.7) and 38.9 years (range 18–78; SD = 16.1), respectively. A total of 278 patients were approached, but there were a number of dropouts (n = 78). Of the 78 dropouts, 27 were men, 45 women, and 6 unknown. The mean age for dropouts was 42.3 years (n = 71; range 17–84; SD = 18.4). No significant differences in age and gender between the included and the excluded

Discussion

The results of our study demonstrate how a nursing intervention, uncomplicated to learn and administrate, can improve pain management and the patients’ perceptions of the quality of care in pain management. The intervention has probably also clarified the RNs’ work and did not generated new costs for the emergency department.

The patients’ descriptions of their pain indicate that abdominal pain is complex, and confirms that the perception of pain is subjective (McCafferey, 1979). The presented

Conclusion

The intervention improved pain management in the emergency department. Pain management is not only about receiving analgesics. A structured nursing assessment could affect patients’ perceptions of the quality of care in pain management in the emergency department.

Acknowledgements

We would like to thank the Head of Surgery Division Staffan Wollert, and Associate Professor Peter Ståhlberg (Surgery Division) for their support and creative discussions regarding the study design and the intervention's educational session. We would also like to thank Garrett Chan, Assistant Clinical Professor at the University of California San Francisco School of Nursing, for his fruitful contribution regarding the intervention.

Conflicts of interest: None declared.
Funding: None declared.

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