Standardising analgesic administration for nurses: a prospective intervention study

Abstract

Background Uncontrolled pain reduces quality of life, delays recovery from surgery and can potentially contribute to the development of chronic pain. Strategies to improve pain management are desirable in view of these detrimental outcomes, yet frequently they are predominately medically based despite nurses playing key roles in pain assessment and analgesic administration. Objective To develop an algorithm-based guidance addressing nurses' pain assessment and analgesic administration and investigating its impact on quality of pain management. Setting Two orthopaedic units in a university hospital. Method An interdisciplinary expert panel consisting of physicians, nurses and clinical pharmacists developed an algorithm-based guidance in analgesic administration for nurses. The guidance was based on current guidelines addressing the appropriate use of analgesics. In a prospective intervention study, clinical pharmacists acted as independent monitors who assessed nurses' pain assessment and analgesic administration before (control period: usual care without any further support) and after implementation of the algorithm-based guidance (intervention period). We evaluated patient-nurse contacts for guideline adherence. We predefined guideline adherence (main outcome) as fulfilling all three of the following criteria: (A) nurses' pain intensity assessment, (B) their assessment of the patients' need for analgesics, and (C) analgesic administration depending on patients' individual pain intensity (including choice of prescribed analgesics). Main outcome measure Adherence to pain management guidelines. Results We analysed 706 patient-nurse contacts with 162 patients in the control and 748 contacts with 168 patients in the intervention period. Without support, guidelines were followed in 6 % of the patient contacts. We achieved an increase to 54 % (p < 0.001) after guidance implementation (main outcome). Guideline adherence decreased with rising pain intensity (slope coefficient -0.763, p < 0.001). Conclusion Especially in patients suffering from severe pain, current guidelines were not strictly followed by nurses when administering analgesics. Guideline adherence improved eightfold by implementing an algorithm-based guidance.

Reviewing opioid use, monitoring, and legislature: Nursing perspectives

“…The pre/post-pain assessment includes monitoring pain quality, intensity, and duration before and after administration of pain medication. Nurses need to balance the evaluation with direct observations of the level of consciousness, behavior, and vital signs that we learn to use to assess various situations including pain during our nursing education [55]. These are the essential core competencies that nurses possess that are useful when providing care to patients.…”

“…These are the essential core competencies that nurses possess that are useful when providing care to patients. The knowledge and skill set, in addition to others, should be evident in nursing curricula and continuing education activities [55]. Findings related to increased requests for pain medication, inadequate pain relief, or unacceptable behaviors from patients related to an inability to receive requests or demands need to be addressed by an interdisciplinary team.…”

“…This approach should help to assure that a more comprehensive and complete course of action will dominate the decision-making process. The use of evidence-based guidelines should be followed, and all members of the team ought to serve as monitors of the process to more closely align with medicine guidelines related to opioid use and prescribing [55]. Nurses are well positioned to collaborate on the developing and standardizing analgesic administration guidelines and presenting the outcomes of their practice through research [55].…”

“…Although prescribers may initially provide a prescription for opioids correctly, they may further re-prescribe or renew a prescription without conducting a re-evaluation of the patient's condition which could further the opioid abuse epidemic. It is important to recall that practitioners must be educated about and monitored with the use of national standards set forth by the U.S. Food and Drug Administration [50], [55].…”

“…Consistent with the Food and Drug Administration (FDA) guidance for the pharmaceutical industry regarding abuse-deterrent opioids, work is being done to reformulate opioid analgesics making them difficult to tamper with or abuse by nasal and intravenous routes when prescribed orally. Also, in April of 2017, the FDA announced the restriction of codeine and tramadol in children under the age of 12 years [55]. Consistent with government efforts, a clear federal policy that guides prescription practice is sorely needed to direct the care given to patients and their families.…”