Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions

Abstract

Objectives: Traditionally, patients have to wait until assessed by a physician for opioid analgesia to be administered, which contributes to delays to analgesia. Western Hospital developed a protocol enabling nurses to initiate opioid analgesia prior to medical assessment for selected conditions. The aim of this study was to determine the impact of this protocol on time to first opioid dose in patients presenting to the emergency department (ED) with renal or biliary colic. Methods: This was an explicit medical record review of all adult patients with an ED discharge diagnosis of renal or biliary colic presenting to a metropolitan teaching hospital ED. Patients were identified via the ED data management system. Data collected included demographics, condition, triage category, time of presentation, whether analgesia was nurse-initiated or not, and interval from arrival to first opioid analgesic dose. The narcotic drug register for the relevant period was also searched to cross-check whether opiates were doctor-or nurse-initiated. Results: There were 58 presentations in the nurse-initiated opioid analgesia group and 99 in the non-nurse-initiated analgesia group. Groups were reasonably well matched for gender, triage category and time of presentation, but there was a higher proportion of biliary colic in the non-nurse-initiated analgesia group. Median time to first analgesic dose was 31 minutes in the nurse-initiated group and 57 minutes in the non-nurse-initiated analgesia group (effect size, 26 minutes; 95% confidence interval 16-36 min; p < 0.0001]. There were no major adverse events in either group. Conclusion: A nurse-initiated opioid analgesia protocol reduces delays to opioid analgesia for patients with renal and biliary colic. RÉSUMÉ Objectifs : Traditionnellement, les patients devaient attendre d'avoir été évalués par un médecin avant de recevoir une analgésie aux opiacés, ce qui contribuait à des délais avant l'analgésie. Le Western Hospital a mis sur pied un protocole autorisant les infirmières à commencer une anal- EM ADVANCES • INNOVATIONS EN MU

Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain

“…While these tests should theoretically not delay analgesia, patients who require more diagnostic evaluation have been shown to wait longer for their analgesia. 28 Similarly, there was no assessment made of the basis for the lower triage scores given to the women or whether these were born out by differences of severity in the final diagnosis. Arguing against this hypothesis in the current study is the fact that while the triage class is the basis for the urgency with which patients are brought back to the treatment area, the ED physician who determines the need for analgesia may not have this information.…”

“…29 Similarly, nurse-initiated analgesia for specific painful conditions has been shown to decrease time to analgesia by 50% compared to physician-initiated analgesia. 28 Although not specifically studied in our study, it is likely that determination of pregnancy status at triage and the placement of female patients in rooms, not hallways, in the treatment area would decrease patients' wait times before receiving analgesia. Similarly, triagedriven analgesic administration for patients with moderate pain (e.g., for pain scores >5) may further decrease treatment delays and also ensure that all patients receive analgesia.…”

Problems and barriers of pain management in the emergency department: Are we ever going to get better?

“…38 Kelly and colleagues showed that by enabling nurses to initiate opioid analgesia prior to medical assessment by physicians for selected painful conditions, the median time to fi rst analgesic dose decreased from 57 minutes to 31 minutes. 39 In 2007, Bijur and colleagues showed that intravenous morphine at 0.1 mg/kg was not effective for controlling severe acute pain in a majority of patients. The results showed that of 119 patients, 67% of the patients who received intravenous morphine at 0.1 mg/kg reported a less than 50% decrease in pain.…”

Introduction and general approach to pain

“…7 New frontiers, such as nurse-initiated analgesics while the patient is in triage or with the use of delegated acts, are growing rapidly. [8][9][10][11] Patients in many EDs are now routinely provided topical or local anesthesia for simple (yet painful)…”

“…Perhaps most importantly, the absence of such signs does not exclude the experience of pain. [6][7][8][9][10] The very idea of quantifying pain is somewhat controversial. Germaine to the debate is a nineteenth century contention made by William Thomson (Lord Kelvin) that worthy knowledge should be quantifiable in the form of…”