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Copyright © eContent Management Pty Ltd. Contemporary Nurse (2012) 43 (1): 29–37.

Reducing time to analgesia in the emergency department using a nurse-initiated pain protocol: A before-and-after study

JUDITH C FINN* ,+,!,# , AMANDA RAE**, NICK GIBSON*, ROGER SWIFT ++ , TAMARA WATTERS !! AND IAN G JACOBS* ,#

*Discipline of Emergency Medicine (M516), The University of Western Australia, Crawley, WA, Australia; + School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; ! Centre for Nursing Research, Innovation and Quality, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; # St John Ambulance (Western Australia), Belmont, WA, Australia; **Nickol Bay Hospital, Karratha, WA, Australia; ++ Emergency Department, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; !! Fremantle Hospital and Health Service, Fremantle, WA, Australia

Abstract: Suboptimal management of pain in emergency departments (EDs) remains a problem, despite having been first described over two decades ago. A ‘before-and-after’ intervention study (with a historical control) was undertaken in one Western Australian tertiary hospital ED to test the effect of a ‘nurse-initiated pain protocol’ (NIPP) intervention. A total of 889 adult patients were included: 144 in the control group and 745 in the intervention group. Patients in the intervention group were: More likely to have a pain score recorded than those in the control group; have reduced median time to the first pain score; and reduced time to analgesia. The statistically significant reduction in both time to pain score and time to analgesia remained, even when adjusted by age and sex. Whilst we demonstrated the safety and efficacy of a NIPP in ED, an unacceptable proportion of patients continued to have inadequate pain relief.

Keywords: emergency nursing, pain relief

T here are over six million patient presenta- tions to emergency departments (EDs)

in Australia each year (Australian Institute of Health and Welfare, 2006) of which pain is the most frequent symptom; occurring in up to 80% of all presentations (National Institute of Clinical Studies, 2004). For several decades there has been evidence of the physiological and psy- chological adverse effects of acute (and chronic) pain (Macintyre et al., 2010) and yet subopti- mal management of pain remains a problem in EDs (Arendts & Fry, 2006; Karwowski-Soulie et al., 2006; Rupp & Delaney, 2004; Todd et al., 2007). A number of strategies have been pro- posed to increase the timely administration of analgesic medications for ED patients, includ- ing nurse-initiated (NI) analgesia (Fosnocht & Swanson, 2007; Fry, Ryan, & Alexander, 2004; Kelly, Brumby, & Barnes, 2005; Sando, Usher, & Buettner, 2009). Nurse-initiated analgesia is defined as ‘the ini- tiation of analgesia by nursing staff, using a pre- defined protocol, prior to the patient being seen by a medical officer’ (Kelly et al., 2005, p. 151). In Australia, all patients presenting to an ED

are assessed and ‘triaged’ by an experienced ED nurse, who allocates the patient to one of five Australasian triage scale (ATS) codes, reflect- ing that patient’s clinical urgency (Australasian College for Emergency Medicine, 2006). The tri-

age nurse is also in a position to initiate appropriate investigations or initial management, according to organisational guidelines (Australasian College for Emergency Medicine, 2006), although this

is less commonly undertaken. Despite the triage

nurse assessing pain, ED nurses do not routinely administer any analgesic medications until the patient has been assessed by the medical officer.

Depending on the workload of the ED, there can be considerable delay between the patient’s pre- sentation at ED and being seen by a doctor; and

even longer until pain relief is actually adminis- tered (Hoot & Aronsky, 2008). We sought to introduce and evaluate the prac- tice of ‘nurse-initiated analgesia’ in the ED of

a busy tertiary hospital, whereby the ED triage nurse (or other specifically trained ED nurse)

administered analgesic medications according to

a pre-defined protocol, without the patient being first assessed by a medical officer.

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METHODS

A ‘before-and-after’ study with a historical control (National Health and Medical Research Council, 2009) was undertaken to test the null hypothesis that the ‘nurse-initiated pain protocol’ (NIPP) intervention had no effect on either the time to pain assessment or the time to analgesia. The study was undertaken in the ED of an urban tertiary teaching hospital, in Perth, Western Australia. In 2009, a total of 417,259 patients attended Perth metropolitan EDs, of which 54,740 attended the study hospital ED. The ED is medically staffed by a mix of consultant emergency physicians, senior registrars, resident medical officers and interns. The ED nurses are predominantly registered nurses, some of whom have completed a 12-month postgraduate emer- gency nursing certificate. The triage nurse posi- tion is filled on a shift-by-shift basis by a senior registered nurse. All adult patients (18 years) presenting to the ED with pain, during the study period from 4 April 2009 to 25 June 2009, were eligible for recruitment into the intervention arm of the study. Patients meeting the following conditions were excluded: presented with chest pain of pre- sumed cardiac origin or with headache; were tri- aged as emergency or urgent (Australasian Triage Score 1 and 2; Australasian College for Emergency Medicine, 2006); exhibited unstable vital signs; were pregnant or lactating; had known contra- indications to one of the study drugs; declined analgesia; or already had an analgesia related man- agement plan in place. Over the 12 months prior to the introduc- tion of the NIPP, baseline data about initial pain management in the ED had been collected as part of the (Australian) National Institute of Clinical Studies (NICS) National Emergency Care Pain Management Initiative (Yeoh & Huckson, 2007). These data were used as the convenience sample for the historical cohort, for comparison with the prospectively collected intervention data.

Intervention The ED NIPP was developed in consultation with hospital medical, nursing and pharmacy staff, resulting in guideline instructions, a flow

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chart depicting the decision path to be followed and single page information sheets for each of the protocol medications. These information sheets described the drug, dosage, route of administra- tion, indications, contraindications, potential adverse effects, required documentation and patient follow-up. Table 1 shows which medica- tions were to be administered depending on the patient’s initial pain score. The opioid analgesics [oral oxycodone and intravenous (IV) morphine] required medical approval prior to administration, whereas the other listed medications were ‘nurse- initiated’. The NIPP emphasised the importance of pain assessment using the ‘PAINED’ acronym, i.e., place, amount, intensifiers, nullifiers, effects of analgesics and description. Pain scores were to be recorded as soon as possible at triage, and again 60 minutes after oral analgesia or 30 minutes after oral oxycodone or IV morphine. Nurses were also advised to consider non-pharmacological meth- ods of pain relief, such as splinting, support or cold packs.

Education Prior to implementation of the NIPP, medical and nursing staff were encouraged to attend infor- mation sessions about the NIPP. Nurses were not permitted to administer analgesia per the NIPP until they had undertaken specific training and had demonstrated competence. In addition, all medical staff were advised of their responsibilities regarding the administration of Schedule 8 drugs by nurses (Department of Health and Ageing, 2010), phone ordering and written prescriptions. Hard copies of the summary protocol guidelines were laminated and displayed in strategic areas such as the triage desk, transit area and other common areas in the ED and complete protocol details were filed in the nursing practice guide- lines sited in the general ED area and the clinical nurse educator’s office.

Outcomes The primary outcomes were: (a) time to first pain score recorded; and (b) time to first analgesia administered. These were, respectively, defined as the time interval difference between the patient arrival in the ED; and (a) the time of the first pain

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TABLE 1: ED NURSE-INITIATED ANALGESIA PROTOCOL ACCORDING TO INITIAL PAIN SCORE

Pain score

Action

Mild

2 × paracetamol 500 mg (=1 g) or

1–3

× paracetamol 500 mg tabs if patient’s estimated weight is more than 100 kg or

3

2

× ibuprofen 200 mg (=400 mg) if paracetamol is

Moderate

contraindicated For further analgesia discuss with senior registrar 2 × paracetamol 500 mg/codeine 30 mg (‘Panadeine Forte’) or PO 3 × ibuprofen 200 mg/codeine 12.8 mg (‘Nurofen Plus’) For further analgesia discuss with senior registrar Patient to go through to ED assessment area ASAP, then

3–6

Severe

7–10

2 × paracetamol 500 mg (=1 g)

PLUS 3 × ibuprofen 200 mg (=600 mg) PLUS IV morphine – 2.5 mg boluses up to 10 mg or If patient cannot proceed through to ED assessment area, then

2 × paracetamol 500 mg (=1 g)

PLUS 3 × ibuprofen 200 mg (=600 mg) PLUS 1–2 Endone 5 mg tabs (max 10 mg) For further analgesia discuss with senior registrar and get script for schedule 8 drugs

Any adverse events in the inter- vention group were recorded.

Data collection Data were initially extracted from clinical records on a study-specific form and then entered into an Excel database that had been specifically developed for the project by one of the three study research nurses. Data collected included: patient age, gender, data and time of ED presentation; triage category using the ATS (Australasian College for Emergency Medicine, 2006); time and value of first pain score; type of analgesia self-administered by patient prior to ED presentation; time and type of first analgesic medication administered in ED; and non-pharmacological pain management strategies used. ED diagnosis was manually catego- rised into one of the International Classification of Diseases (ICD- 10) Chapters (World Health Organisation, 2007).

score recorded, and (b) the first analgesic medica-

Sample size and power

tion administered.

A

sample size calculation was performed prior

A verbal numeric rating scale (VNRS) from

to

the implementation phase of the NIPP using

0–10 was used to assess (and re-assess) pain, where 0 represents ‘no pain’ and 10 represents

information gleaned from the N = 144 historical control group. With a baseline mean time to pain

‘worst pain imaginable’. The VNRS has been shown to be a sensitive (and practical) measure of acute pain in EDs (Holdgate, Asha, Craig, &

score of 61.5 minutes and a standard deviation (SD) of 56.3 minutes, a total of 144 cases in the intervention group would provide a power of 0.99

Thompson, 2003). Pain scores of ‘0–6’ were con-

to

detect a 50% relative difference in mean time

sidered to be ‘mild/moderate pain’ and pain scores

to

pain score between the experimental and con-

of ‘7–10’ were classed as ‘severe pain’.

trol arms of the study with a type 1 error of 0.05

For the initial severe pain cases who had both

(Dupont & Plummer, 1990). However, the intent

an initial and post-analgesia pain score recorded,

of

the study was to trial the implementation of the

adequacy of analgesic effect was calculated as per Jao, McD Taylor, Taylor, Khan, and Chae (2011) namely a reduction in the triage pain score of 2

NIPP intervention for up to 3 months and hence the actual number of cases in the experimental group was much larger than the 144 required.

and to a level <4. The NICS definition of ‘effec- tive pain management’, i.e., three-point or better reduction in severe pain scores, was also calculated (National Institute of Clinical Studies, 2008).

Statistical analysis Descriptive statistics were used to summarise the data, including means with SD and medians with

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interquartile range (IQR) for continuous variables. Denominators for the calculation of percentages varied because of missing values for some vari- ables, and in such cases the denominators used are reported. Comparisons between the ‘before’ and

‘after’ groups were made using Pearson’s Chi-squared test for nominal/ordinal data and the t-test or the non-parametric Mann–Whitney ‘U’-test for con- tinuous variables (depending on whether the data met the assumptions of normality). Multivariable regression (logistic/multiple regression depending on level of measurement of the outcome variable) was performed to adjust for potential confound- ers, with results reported as odds ratios (OR) and 95% confidence intervals (CI). Sub-group analysis by pain severity, i.e., ‘mild/moderate pain’ (pain score 0–6) and ‘severe pain’ (pain score 7–10),

was defined ‘a priori’. For the analysis of ‘time to analgesia’, only patients with a recorded initial pain score of at least ‘1’ were included. All analy- ses were performed using IBM SPSS Statistics v19.0 and statistical significance was accepted as p < 0.05.

RESULTS

The study cohort comprised 889 patients (51% males), with 144 in the pre-intervention (his- torical sample) group and 745 post-intervention group. Overall, most of the patients fell within ATS category 3 or 4 (see Table 2; ATS category 1 and 2 were excluded) and two-thirds had an initial pain score of ‘0–6’.Overall, 88.8% of all cases attending ED for pain fell into four main diagnostic categories (based on ICD-10 Chapters; World Health Organisation, 2007), namely: (1) disorders of the musculoskeletal sys- tem and connective tissue (60.4%); (2) disorders of the digestive system (13.4%); (3) infectious and parasitic diseases (9.7%); and (4) disorders of the genitourinary system (5.3%). Of those

TABLE 2: DIFFERENCES IN BASELINE CHARACTERISTICS OF THE PRE- AND POST-INTERVENTION GROUPS

Gender: male (%) Age Mean (SD) Median ATS

3

4

5

Musculoskeletal system related ED diagnosis Analgesia prior to ED presentation yes (%) Pain score recorded yes (%) Initial pain score Mean (SD) Median Initial pain score category N (%)

Mild–moderate

(0–6)

Severe (7–10)

Non-

pharmacological

pain interventions

N

PRE N = 144

144

144

144

144

74

144

83

83

144

78 (54.2%)

38.9 (20.0)

32.1

(52.1%)

(45.8%)

3 (2.1%)

103 (71.5%)

75

66

36

(48%)

83

(57.6%)

4.75 (3.2)

5.00

53

(63.9%)

30 (36.1%)

(28.5%)

41

N

POST (N = 745)

745

740

744

745

745

745

708

708

745

380 (51%)

41.9 (19.7)

37.5

349 (46.9%)

382 (51.3%)

13 (1.7%)

434 (58.3%)

180 (24.3%)

708 (95%)

5.67 (2.4)

6.00

443 (62.6%)

265 (37.4%)

90 (12.1%)

Difference

0.49

0.38

a

b

0.48

a

0.003

<0.001

<0.001

0.03

0.82

b

b

a

a

a

Ethics approval Ethics approval for this study was obtained from the Hospital’s Human Research Ethics Commit- tee, QIA#2226. Given that the intervention was deemed to be a quality improvement activity and the data required for the study was already col- lected as part of normal clinical practice, a waiver of consent was granted. The data collected were initially identifiable, but only de-identified data were used for data manip- ulation and analysis.

<0.001 a

a Pearson’s Chi-squared test; b Mann–Whitney ‘U’-test.

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patients in the diagnostic category of the ‘mus- culoskeletal system and connective tissue’, 81% (435/537) were related to injury. The majority of cases (76%) were recruited during the morn- ing and afternoon nursing shifts at ED, which corresponded to the period when the research nurses were present. As shown in Table 2, the two groups did not differ with respect to age, gender, ATS category or initial pain score category. However, the his- torical control group had a lower proportion of patients with a pain score recorded; a lower median initial pain score; and a higher propor- tion of patients who received non-pharmacolog- ical pain relieving interventions. Patients in the intervention group were much more likely to have a pain score recorded than those in the con- trol group (95 vs. 58%, p < 0.001), even when adjusted for age and sex (OR = 13.9, 95% CI 8.6, 22.4).

Primary outcomes The time to the first pain score was reduced from a median of 47 (IQR 20–93) minutes in the ‘control’ group to a median of less than 1 minute (IQR 0–26) in the NIPP intervention group (p < 0.001). The comparison of time to analgesia administration only included patients who had an initial pain score of greater than or equal to ‘1’, i.e., N = 67 in the control group and N = 689 in the intervention group. The time to analgesia in the intervention group was significantly reduced from a median of 98 (IQR 44–137) minutes to 28 (IQR 8–58) minutes (p < 0.001). The statisti- cally significant reduction in both median time to pain score and median time to analgesia remained, even when adjusted for age and sex. Both the time to initial pain score and the time to analgesia administration were reduced in the NIPP intervention group compared to the pre-intervention group in both the mild/mod- erate and severe pain sub-groups, as shown in Table 3. Patients in the NIPP group with severe pain were more likely to receive analgesia within 30 minutes, as per the NICS recommendations (National Institute of Clinical Studies, 2008), than patients in the control group (47.3% vs. 20%, p = 0.009).

Adequacy of analgesic effect Only around 50% of patients overall had their second pain score within 1 hour of administra- tion of analgesia and this was no different when only the severe pain group was considered. For patients with an initial pain score of ‘7–10’ (i.e., ‘severe pain’), and both an initial and post-anal- gesia pain score recorded (N = 238), a three-point or better reduction in pain score was achieved for a significantly higher proportion of patients in the post-intervention group (115/216 = 53.2%) compared to the baseline period (4/22 = 18.2%; χ 2 = 9.82, 1df, p = 0.003). Using the Jao et al. (2011) definition of ‘adequate analgesia’ pro- duced similar (but not identical results), with 2/22(9.1%) in the pre-intervention group and 70/216 (32.4%) in the post-intervention group achieving ‘adequate’ analgesia (χ 2 = 5.44, 1df, p = 0.03).

Adverse events (NIPP group only) Of the 548 (74%) of the NIPP patients who received an analgesic medication in ED, 22 (4%) had an ‘adverse event’ flagged; 10 (45.5%) in the patients with mild/moderate pain (PS 0–6) and 12 (54.5%) in the severe pain group (PS 7–10). Only 15 of these ‘events’ were described – of these half as ‘nausea’ and the other half as feel- ing ‘light headed/dizzy’. The medications that had been given in these 22 cases were as follows:

paracetamol (N = 7); paracetamol + codeine (N = 5); morphine (N = 4); ibuprofen (N = 3); oxycodone (N = 3). There were no serious adverse events recorded.

DISCUSSION

We demonstrated that a NIPP resulted in dra- matic improvements in each of the indicators commonly used to gauge the quality of pain man- agement in EDs. When compared to a historical control group, the NIPP patients were more likely to have an initial pain score recorded (95% vs. 58%, p < 0.001); have a reduced median time to initial pain score (<1 min vs. 47 min, p < 0.001) and a reduced median time to first analgesia (28 min vs. 98 min, p < 0.001). Whilst the adequacy of analgesic effect for patients with severe pain, as defined by Jao et al. (2011), substantially increased

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TABLE 3: DIFFERENCES IN PRIMARY AND SECONDARY OUTCOMES PRE- AND POST-INTERVENTION, BY SEVERITY OF PAIN

N

N

Initial pain score = 0–6 (N = 496)

 

Time to 1st pain score (min) Range Mean (SD) Median (IQR) Time to analgesia (min) c Range Mean (SD) Median (IQR) Initial pain score = 7–10 (N = 295)

53

21

30

Time to 1st pain score (min) Range Mean (SD) Median (IQR) Time to analgesia (min) c Range Mean (SD) Median (IQR) Analgesia within 30 min Three-point reduction in pain score d Adequate analgesic effect d,e

25

25

22

22

PRE (N = 53)

N

POST (N = 443)

Difference

 

443

<0.001 a

0–197

0–289

55.6 (50.5)

20.9 (39.6)

43 (14–88)

0 (0–27)

 

283

<0.001 a

0–366

0–315

108.4 (90)

44.2 (57.5)

88 (48.5–152)

22 (5–64)

PRE (N = 30)

POST (N = 265)

0–259

264

0–284

73.5 (65.0)

17.3 (35.9)

49 (25–126)

0 (0–22)

2–386

220

0–284

105.4 (85.9)

44.6 (46.4)

105 (43–134)

32 (13–56)

5 (20.0%)

220

104 (47.4%)

4(18.2%)

216

115 (53.2%)

2(9.1%)

216

70 (32.4%)

Difference

<0.001

a

<0.001 a

0.009

0.003

b

b

0.02 b

a Mann–Whitney ‘U’-test; b Pearson’s Chi-squared test; c Only patients with initial pain scores > ‘0’; d Only patients with initial and post-analgesia pain scores; e As defined by Jao et al. (2011)

in the NIPP group, there were still two-thirds of patients with inadequate pain relief. Thus we have shown that whilst NIPP can improve pain man- agement in EDs, there is still scope for further improvement. Provision of effective pain management in EDs requires systems to ensure adequate assess- ment of pain, provision of timely and appro- priate analgesia, with frequent monitoring and reassessment of pain (Macintyre et al., 2010). Enabling an ED nurse to assess a patient’s pain at the point of presentation to ED and then administer analgesia according to a pre-approved protocol simply makes sense, given the goal to reduce time to analgesia. The evidence for the efficacy of NI analgesia in EDs is persuasive, albeit mostly based on before and after studies, in single centres.

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For example, a before–after study conducted in an urban university ED in Utah (USA; Fosnocht & Swanson, 2007), showed a reduction in the mean time to pain medication administra- tion from 76 to 40 minutes (p < 0.001) after the introduction of a triage pain protocol initiated by nurses, for patients presenting with isolated extremity or back pain. However, individual ED nurse compliance with the pain protocol varied between 8–96% and the protocol was not used in 30% of the eligible 800 patients (Fosnocht & Swanson, 2007). At a Swedish university hos- pital ED, Muntlin, Carlsson, Säfwenberg, and Gunningberg (2011) implemented a NI intra- venous analgesic protocol (IV morphine) for abdominal pain, and measured time to analge- sia at three time points: before (A1); during (B); and after (A2) the intervention. The mean time

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to

analgesia was reduced from 2.5 hours (A1)

These crude estimates of protocol adherence

LIMITATIONS

This was a single centre study, based on a non-

to

1.3 hours (B), but reverted back to 2.1 hours

are consistent with results reported elsewhere. In

during the A2 phase, highlighting the challenges

a recent study (Stephan et al., 2010) conducted

in sustaining changes in clinical practice. In Australia, it has been shown that NI anal- gesia is safe and efficacious (Fry & Holdgate, 2002; Kelly et al., 2005). A decade ago, at a uni- versity teaching hospital in Sydney (Australia), Fry and Holdgate (2002) demonstrated that an

in a university hospital in Switzerland it was found that their locally developed pain manage- ment protocol for ED was only correctly applied in 42% of patients, with the protocol incorrectly or only partially applied in 30% of patients and 28% of patients refused any analgesia at the

IV

morphine pain protocol could be safely and

time of presentation. Similarly, in a study of

effectively implemented in the ED for patients

NI oral paracetamol for ED patients present-

with acute severe pain. The median time from triage to administration of NI morphine (‘time

ing with minor musculoskeletal injury at a uni- versity hospital in Hong Kong, whilst the mean

to

narcotic’) was 18 minutes. Whilst there was

time to analgesia in the NI-Paracetamol group

no concurrent comparison group, a previous audit at the same hospital had found median time of 58 minutes between triage and admin-

was dramatically reduced compared to the non NI-Paracetamol groups (9 min vs. 93 min) and pain scores were significantly lower at 60 minutes,

istration of analgesia (Fry, Holdgate, Baird, Silk, & Ahern, 1999). Similarly, Kelly et al. (2005) in

only 22% of eligible patients actually received paracetamol by the triage nurse (Wong, Chan,

an

urban public teaching hospital in Melbourne

Rainer, & Ying, 2007). As astutely concluded by

(Australia), showed that specially trained and cre-

the authors ‘protocols and standing orders offer

dentialed ED nurses could safely and effectively initiate and manage titrated IV opioid analgesia for selected painful conditions. Unfortunately the study was suspended early when an exter-

options for nurses, however, the translation of the concept into clinical reality is multidimensional and highly complex’ (Wong et al., 2007, p. 69). In our study, anecdotal feedback indicated

nal

government body apparently challenged the

that NIPP implementation was less likely when

‘legality’ of what they perceived to be ‘nurse pre- scribing’ (Kelly et al., 2005). That this should occur is fascinating, given that out-of-hospital paramedic practice around the world relies on non-physicians administering analgesia (and a suite of other medications) on the basis of pre- approved protocols.

the ED was ‘busy’ or when no research nurse was present in ED. Moreover, we were aware that there were some triage nurses who refused to par- ticipate in the study. We did not formally survey the staff (or patients) re their experiences/attitudes about NIPP, which on reflection was an unfortu- nate omission. As identified by Fry, Bennetts, and

Because medication dosage was not reliably entered into the study database, our capacity to ascertain compliance with the protocol was lim- ited. However we were able to report that the type of analgesic medication(s) administered was con- sistent with the NIPP for the specific pain score in 61.1% of patients who received an analgesic agent. This congruence with the protocol was higher for patients with mild–moderate pain than

Huckson (2011, p. 273), ‘further investigation is needed into emergency nurses’ attitudes towards the enablers and barriers to NI policies’.

consecutive convenience sample of patients. As such the results may not be generalisable to other EDs with different staffing profiles and/or case-

for

patients with severe pain (83.4 vs. 30.6%).

mix. The data for the pre-intervention historical

One might assume that patients with ‘severe pain’ were more likely to have been assessed by an ED physician and have had their pain management individually adjusted, although this was not cap- tured in the database.

cohort that was used as the comparison group were collected as part of an audit process, up to 1 year prior to the intervention study. It is there- fore not surprising that differences between the groups were identified, thereby increasing the risk

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of confounding of the result. However, adjust- ment for potential confounders through the use of multivariable statistics did not alter the strong effect of the NIPP on time to initial pain score and time to analgesia. Despite the study inclusion criteria being ‘patients presenting to ED with pain’, a small number of patients (3.9% overall) had an ini- tial pain score recorded as ‘0’. This could mean that these patients were incorrectly included in the study, or it could indicate that patients can still nominate their initial pain score as ‘0’ even if their reason for presenting to ED is related to pain (for instance, patients with pain on move- ment but no pain at rest). We were not able to discern which of these alternatives applied. There were also 11% (N = 98/889) of cases without a recorded initial pain score. It cannot be certain whether this reflects pain not being assessed or simply not recorded.

CONCLUSION

This study has demonstrated that a NIPP in the ED increased the likelihood of pain scores being recorded, reduced the time from ED presen- tation to the initial pain score and reduced the time to analgesia. Whilst the adequacy of analge- sic effect more than tripled, almost two-thirds of all patients still had inadequate pain relief. Thus whilst we have demonstrated the potential effi- cacy of a NIPP, a system-wide multidisciplinary approach is likely to be required to address the persistent problem of ‘oligoanalgesia’ (Wilson & Pendleton, 1989) in the ED.

ACKNOWLEDGEMENTS

This study was funded by a research grant from The Sir Charles Gairdner Hospital Research Advisory Committee. The research team acknowledges this financial and other support provided by the nursing and medical staff of the emergency department. In particular, we acknowledge and thank the following research nurses for their assistance with implementation of the protocol and data collection: Grainne Mallen, Susan Greyling and Michelle Lucking. Australian New Zealand Clinical Trials Registry number:

ACTRN12611000953932.

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Received 09 April 2012

Accepted 17 August 2012

ANNOUNCING

Cross-cultural pedagogies: The interface between Islamic and Western pedagogies and epistemologies

A special issue of International Journal of Pedagogies & Learning – Volume 7 Issue 3 – 112 pages – December 2012

Guest Editors: Ibrahima Diallo (University of South Australia) and Shirley O’Neill (University of Southern Queensland)

Cross-cultural pedagogies and teaching focusing on Islamic pedagogies and epistemologies in a western context and the transfer of western pedagogies and epistemologies within an Islamic setting.

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