Evaluating a medical directive for nurse-initiated analgesia in the Emergency Department

Dewhirst, Sebastian; Zhao, Yuan; MacKenzie, Taryn; Cwinn, A. Adam; Vaillancourt, Christian

doi:10.1016/j.ienj.2017.05.005

Cited by 12 publications

(31 citation statements)

References 14 publications

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“…Time to use of analgesics has also been shown to be reduced by using the NIPP (Barksdale, Hackman, Williams, & Gratton, 2016;Campbell, Dennie, Dougherty, Iwaskiw, & Rollo, 2004;Dewhirst, Zhao, MacKenzie, Cwinn, & Vaillancourt, 2017;Douma, Drake, O'Dochartaigh, & Smith, 2016;Fosnocht & Swanson, 2007;Fry & Holdgate, 2002;Kelly, Brumby, & Barnes, 2005;Muntlin et al, 2011).…”

Section: Nurse-initiated Pain Protocolmentioning

confidence: 99%

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management

Sturesson

Falk

Castrèn

et al. 2016

Scandinavian Journal of Pain

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AbstractBackgroundPain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients’ own experience regarding pain management in ED.ObjectiveThe aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED.MethodAn observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire.ResultsA total of 160 patients answered the questionnaire. In the pre- (n = 80) and post-intervention (n = 80) groups, 91/95% experienced pain in the ED. A significant difference (p < 0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p < 0.03) in patients’ own reported pain intensity at discharge was found between the groups. Patients’ reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly.ConclusionPatients’ satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain.Implication According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients’ satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients’ satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.

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Section: Nurse-initiated Pain Protocolmentioning

confidence: 99%

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management

Sturesson

Falk

Castrèn

et al. 2016

Scandinavian Journal of Pain

View full text Add to dashboard Cite

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“…Recommendations have been made to develop nurse-initiated analgesia (NIA) protocols to help expedite the treatment of acute pain in the ED 6. NIA is defined as medications administered by a nurse without a direct MRP order, based on a predefined set of criteria that is agreed on with the responsible medical leadership 14. NIA and pain protocols have been used in the ED with positive effects such as expedited analgesia administration and more timely reduction in pain score and with minimal negative effects such as adverse medication reactions such as nausea, vomiting, dizziness and/or change in vital signs 15…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…Studies that used NIA reduced the time to the first dose of analgesia and increased the proportion of patients receiving any analgesia 10 14 16. In one study, TTA was reduced from 76 min to 40 min with NIA at triage 10 14. Another example where NIA was used, first dose of analgesia was administered in less than 30 min versus 131 min when not used 10 14.…”

Section: Introductionmentioning

confidence: 99%

“…In one study, TTA was reduced from 76 min to 40 min with NIA at triage 10 14. Another example where NIA was used, first dose of analgesia was administered in less than 30 min versus 131 min when not used 10 14. Cabilan and Boyde15 conducted a systematic review of the impact of NIA in the ED based on the six domains of quality of care.…”

Section: Introductionmentioning

confidence: 99%

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Improving timely analgesia administration for musculoskeletal pain in the emergency department

et al. 2020

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Delays to adequate analgesia result in worse patient care, decreased patient and provider satisfaction and increased patient complaints. The leading presenting symptom to emergency departments (EDs) is pain, with approximately 34 000 such patients per year in our academic hospital ED and 3300 visits specific for musculoskeletal (MSK) injuries. Our aim was to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 min) in 9 months’ time (May 2018). Our outcome measures included mean TTA and ED length of stay (LOS). Process measures included rates of analgesia administration and of use of medical directives. We obtained weekly data capture for Statistical Process Control (SPC) charts, as well as Mann-Whitney U tests for before-and-after evaluation. We performed wide stakeholder engagement, root cause analyses and created a Pareto Diagram to inform Plan–Do–Study–Act (PDSA) cycles, which included: (1) nurse-initiated analgesia at triage; (2) a new triage documentation aid for medication administration; (3) a quick reference medical directive badge for nurses; and (4) weekly targeted feedback of the project’s progress at clinical team huddle. TTA decreased from 129 min (n=153) to 100 min (22.5%; n=87, p<0.05). Special cause variation was identified on the ED LOS SPC chart with nine values below the midline after the first PDSA. The number of patients that received any analgesia increased from 42% (n=372) to 47% (n=192; p=0.13) and those that received them via medical directives increased from 22% (n=154) to 44% (n=87; p<0.001). We achieved a significant reduction of TTA and an increased use of medical directives through front-line focused improvements.

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Assessment of Machine Learning–Based Medical Directives to Expedite Care in Pediatric Emergency Medicine

et al. 2022

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IMPORTANCEIncreased wait times and long lengths of stay in emergency departments (EDs) are associated with poor patient outcomes. Systems to improve ED efficiency would be useful. Specifically, minimizing the time to diagnosis by developing novel workflows that expedite test ordering can help accelerate clinical decision-making. OBJECTIVE To explore the use of machine learning-based medical directives (MLMDs) to automate diagnostic testing at triage for patients with common pediatric ED diagnoses. DESIGN, SETTING, AND PARTICIPANTS Machine learning models trained on retrospective electronic health record data were evaluated in a decision analytical model study conducted at the ED of the Hospital for Sick Children Toronto, Canada. Data were collected on all patients aged 0 to 18 years presenting to the ED from July 1, 2018, to June 30, 2019 (77 219 total patient visits). EXPOSURE Machine learning models were trained to predict the need for urinary dipstick testing, electrocardiogram, abdominal ultrasonography, testicular ultrasonography, bilirubin level testing, and forearm radiographs. MAIN OUTCOMES AND MEASURES Models were evaluated using area under the receiver operator curve, true-positive rate, false-positive rate, and positive predictive values. Model decision thresholds were determined to limit the total number of false-positive results and achieve high positive predictive values. The time difference between patient triage completion and test ordering was assessed for each use of MLMD. Error rates were analyzed to assess model bias. In addition, model explainability was determined using Shapley Additive Explanations values. RESULTS There was a total of 42 238 boys (54.7%) included in model development; mean (SD) age of the children was 5.4 (4.8) years. Models obtained high area under the receiver operator curve (0.89-0.99) and positive predictive values (0.77-0.94) across each of the use cases. The proposed implementation of MLMDs would streamline care for 22.3% of all patient visits and make test results available earlier by 165 minutes (weighted mean) per affected patient. Model explainability for each MLMD demonstrated clinically relevant features having the most influence on model predictions.Models also performed with minimal to no sex bias. CONCLUSIONS AND RELEVANCEThe findings of this study suggest the potential for clinical automation using MLMDs. When integrated into clinical workflows, MLMDs may have the potential to autonomously order common ED tests early in a patient's visit with explainability provided to patients and clinicians.

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Evaluating a medical directive for nurse-initiated analgesia in the Emergency Department

Cited by 12 publications

References 14 publications

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management

Improving timely analgesia administration for musculoskeletal pain in the emergency department

Assessment of Machine Learning–Based Medical Directives to Expedite Care in Pediatric Emergency Medicine

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