Defining the Painless Emergency Department

1. Defining the Painless Emergency Department Can it be done? James Ducharme MD CM, FRCP, DABEM Professor of Emergency Medicine Dalhousie University Clinical Director of Emergency Medicine Atlantic Health Sciences Corporation

2. Can we “make it so”? • Pathway • Guideline • Clinical Decision Rule • Protocol

3. Pathway • Evidence based discussion • Consensus of evaluation and care by all parties • Time demanding • Computer generated • Validated assessment criteria (PORT) • Limited (but mandatory) treatment options Not applicable: patient in pain may not wish pain relief, so cannot be mandatory

4. Guideline • Ignored • Hundreds available in National Guideline Clearinghouse • Medicolegal paranoia – “what if….?” • Routinely multiple steps • Often not evidence based “Give antibiotics for otitis media if high fever” Expert consensus in conflict with personal practice experience

5. Guidelines • Often drafted by physicians on payrolls of various companies • Update of ACR guidelines for osteoarthritis: role of the coxibs, Schnitzer,T.J. 2002 • Even when well done, massive ad campaigns overcome evidence and guidelines • #1 education source for physicians is Industry

6. Clinical Decision Rule • Ottawa Ankle Rule • What can doctors agree on? • Can it be standardized? • Can it be reduced to minimal steps? • Does it reduce system utilization? • Do I miss anything important? • Who defines what is important? Clinical rules not applicable to broad topic, very poorly accepted in USA

7. Protocol/Policy • Nurses & EMTs are protocol driven • Delegated responsibility • Perception of inflexibility • “If you want the patient with chest pain to get the ASA, take it out of the hands of the physician” • 85% compliance to > 97% compliance • < 30% compliance for beta blockers by MD

8. The hospital and conflicts of interest • Satisfaction scores more important than outcomes • The bottom line runs the system • Use of investigations and procedures as revenue generating, not necessarily because best for patient • Medicolegal concerns • “Don’t miss anything”

9. The patient • Expectation level • Too high (I want that test now!) • Too low (I expect to suffer) • Quality of Life • Functionality vs. pain relief • What has the Internet, or “Time” magazine said this week?

10. Canadian Experience • Mindset • What works best for the most number of people? • Very open to clinical rules and EB guidelines • Money • Maintain health care costs at a fixed percent of GNP • Establish provincial medication lists: companies lower prices to be included

11. Canadian battles fought • No specialty has a patent on patient care • Do what is right for the patient, not the specialty • P&T committee ensures medications available to all MDs who might need them and who demonstrate competency to their own Department Head • Specific patient care committees for issues that cross specialties (Code Blue)

12. CAEP Procedural Sedation Guideline • Attempt at consensus with Anesthesiology • Unable, as “double standard” • Production of CAEP document • Monitoring by own specialty • Assume medicolegal risk • Accreditation based on individual specialty standards

13. CAEP Asthma Guideline • Tremendous consensus • Canadian Respiratory Society • Canadian Pediatric Society • Canadian College of Family Practitioners • More widespread needs, continuity of care, buy-in required • You have to “make it so”

14. You cannot make a doctor provide pain relief. • You can ensure that once pain treatment is started that it achieves a standardized endpoint. • Nurse driven analgesic protocols • PCA

15. Nurse-driven protocols • Kelly 2000, long bone fractures • 1993: 53% of patients IM narcotic analgesia, 6% IV • 1997: 5% IM analgesia, 54% IV • Kelly 2000, renal colic • 1993: 76% of patients IM, 3% IV • 1997: 3% IM analgesia, 95% IV Physician allowed to say patient needed analgesia then protocol initiated by nurses

16. Nurse-driven protocols • Fry 2002 • Autonomous nurse-initiated IV morphine for patients in acute pain waiting for medical assessment • Time to analgesia: 18 minutes • Time to MD assessment: 52 minutes • Only additional treatment required: O2 • Average pain decrease: 8.5 cm to 4.0 cm within 60 minutes

17. Recognizing presence of pain • Jones 1999 • 4 hour educational program for residents on evaluating and treating pain • 65% of patients studied before the EP had significant reduction in their pain scores after 30 min in the ED • Afterwards, 92% had a significant reduction in their pain scores at 30 min. • Significant improvement was also seen in the patients' global evaluation of treatment

18. Recognizing presence of pain • Thomas 2004 • VAS 11 times over 2 hours • Either tabulated in chart or plotted on graph at head of bed or controls • If graphed at head of bed • Treating physicians more likely aware of initial and final VAS scores • Provided earlier analgesia • Patients and physicians perceived that VAS was useful

19. Recognizing presence of pain • Silka 2004 • Documentation of pain scores in trauma patients resulted in greater numbers of patients receiving analgesia • Only 73% documented – the more obvious ones, or the ones more in pain? • If you do not think about it, why would you treat it. • Need to make scoring mandatory and visible

20. Acceptance of presence of pain • “The patient rated their pain a 10/10 but I do not believe them” • Systemic miscalibration • Transferring patient’s past experience and filtering it through yours • Disbelief of patient • Patient does not understand scale • Patient manipulating to be seen more quickly

21. Acceptance of presence of pain • Weinstein 2000 Medical student beliefs on pain management • Unchanged from start to end of studies • The professionalization process may reinforce negative attitudes. • Psychologic characteristics, fears of patient addiction and drug regulatory agency sanctions were associated with reluctance to prescribe opioids. • Higher scores on reliance on high technology, external locus of control, and intolerance of clinical uncertainty were associated with higher levels of opiophobia

22. Painless ED? • Any plan for improving pain management in the ED must: • Include ongoing education • To overcome beliefs and barriers • To increase medication knowledge • Achieve buy-in from nurses and physicians • Establish nurse-driven protocols • Allow variability in medications and patient-chosen endpoints

23. Buy-in from other departments • Always start from “what’s best for the patient” position • Develop an evidence-based argument • Consequences of not treating pain • Patient comfort • Patient satisfaction • Demonstrate expertise and knowledge • Use neutral parties to mediate turf wars: your evidence should always win!

24. Make use of nursing involvement • When nurses are strong advocates, they influence nurses across hospital more than doctors ever can!