Transcript Defining the Painless Emergency Department

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
Can we “make it so”?
► Pathway
► Guideline
► Clinical
Decision Rule
► Protocol
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
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
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
Clinical Decision Rule
► Ottawa
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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
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
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”
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?
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
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)
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
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”
► 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
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
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
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
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
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
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
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
Painless ED?
►
Any plan for improving pain management
in the ED must:
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Include ongoing education
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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 patientchosen endpoints
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!
► Make
use of nursing involvement
 When nurses are strong advocates, they
influence nurses across hospital more than
doctors ever can!