Defining the Painless Defining the Painless Emergency Emergency DepartmentDepartment

Can it be done?Can it be done?

James Ducharme MD CM, FRCP, DABEMProfessor of Emergency MedicineDalhousie UniversityClinical Director of Emergency MedicineAtlantic Health Sciences Corporation

Can we “make it so”?Can we “make it so”?

► PathwayPathway► GuidelineGuideline► Clinical Decision Clinical Decision

RuleRule► ProtocolProtocol

PathwayPathway

►Evidence based discussionEvidence based discussion►Consensus of evaluation and care by Consensus of evaluation and care by

all partiesall parties►Time demandingTime demanding►Computer generatedComputer generated►Validated assessment criteria (PORT)Validated assessment criteria (PORT)►Limited (but mandatory) treatment Limited (but mandatory) treatment

optionsoptionsNot applicable: patient in pain may not wish pain relief, so cannot be mandatory

GuidelineGuideline

► IgnoredIgnored Hundreds available in National Guideline Hundreds available in National Guideline

ClearinghouseClearinghouse Medicolegal paranoia – “what if….?”Medicolegal paranoia – “what if….?” Routinely multiple stepsRoutinely multiple steps Often not evidence basedOften not evidence based

““Give antibiotics for otitis media if high fever”Give antibiotics for otitis media if high fever”

Expert consensus in conflict with personal Expert consensus in conflict with personal practice experiencepractice experience

GuidelinesGuidelines

► Often drafted by physicians on payrolls of Often drafted by physicians on payrolls of various companiesvarious companies

► Update of ACR guidelines for osteoarthritis: Update of ACR guidelines for osteoarthritis: role of the coxibs, Schnitzer,T.J. 2002role of the coxibs, Schnitzer,T.J. 2002 Even when well done, massive ad Even when well done, massive ad

campaigns overcome evidence and campaigns overcome evidence and guidelinesguidelines

►#1 education source for physicians is Industry#1 education source for physicians is Industry

Clinical Decision RuleClinical Decision Rule

►Ottawa Ankle RuleOttawa Ankle Rule What can doctors agree on?What can doctors agree on? Can it be standardized?Can it be standardized? Can it be reduced to minimal steps?Can it be reduced to minimal steps? Does it reduce system utilization?Does it reduce system utilization? Do I miss anything important?Do I miss anything important?

►Who defines what is important? Who defines what is important?

Clinical rules not applicable to broad topic, very poorly accepted in USA

Protocol/PolicyProtocol/Policy

►Nurses & EMTs are protocol drivenNurses & EMTs are protocol driven►Delegated responsibilityDelegated responsibility►Perception of inflexibilityPerception of inflexibility►““If you want the patient with chest pain If you want the patient with chest pain

to get the ASA, take it out of the hands to get the ASA, take it out of the hands of the physician”of the physician” 85% compliance to > 97% compliance85% compliance to > 97% compliance < 30% compliance for beta blockers by MD< 30% compliance for beta blockers by MD

The hospital and conflicts of The hospital and conflicts of interestinterest

►Satisfaction scores more important Satisfaction scores more important than outcomesthan outcomes

►The bottom line runs the systemThe bottom line runs the system Use of investigations and procedures as Use of investigations and procedures as

revenue generating, not necessarily revenue generating, not necessarily because best for patientbecause best for patient

►Medicolegal concernsMedicolegal concerns ““Don’t miss anything”Don’t miss anything”

The patientThe patient

►Expectation levelExpectation level Too high (I want that test now!)Too high (I want that test now!) Too low (I expect to suffer)Too low (I expect to suffer)

►Quality of LifeQuality of Life Functionality vs. pain reliefFunctionality vs. pain relief

►What has the Internet, or “Time” What has the Internet, or “Time” magazine said this week?magazine said this week?

Canadian ExperienceCanadian Experience

►MindsetMindset What works best for the most number of What works best for the most number of

people?people? Very open to clinical rules and EB guidelinesVery open to clinical rules and EB guidelines

►MoneyMoney Maintain health care costs at a fixed percent Maintain health care costs at a fixed percent

of GNPof GNP Establish provincial medication lists: Establish provincial medication lists:

companies lower prices to be includedcompanies lower prices to be included

Canadian battles foughtCanadian battles fought

►No specialty has a patent on patient No specialty has a patent on patient carecare Do what is right for the patient, not the Do what is right for the patient, not the

specialtyspecialty P&T committee ensures medications P&T committee ensures medications

available to all MDs who might need them available to all MDs who might need them andand who demonstrate competency to their who demonstrate competency to their ownown Department Head Department Head

Specific patient care committees for issues Specific patient care committees for issues that cross specialties (Code Blue)that cross specialties (Code Blue)

CAEP Procedural Sedation CAEP Procedural Sedation GuidelineGuideline

►Attempt at consensus with Attempt at consensus with AnesthesiologyAnesthesiology Unable, as “double standard”Unable, as “double standard”

►Production of CAEP documentProduction of CAEP document Monitoring by own specialtyMonitoring by own specialty Assume medicolegal riskAssume medicolegal risk Accreditation based on individual Accreditation based on individual

specialty standardsspecialty standards

CAEP Asthma GuidelineCAEP Asthma Guideline

►Tremendous consensusTremendous consensus Canadian Respiratory SocietyCanadian Respiratory Society Canadian Pediatric SocietyCanadian Pediatric Society Canadian College of Family PractitionersCanadian College of Family Practitioners

►More widespread needs, continuity of More widespread needs, continuity of care, buy-in requiredcare, buy-in required You have to “make it so”You have to “make it so”

►You cannot make a doctor provide You cannot make a doctor provide pain relief.pain relief.

►You You cancan ensure that once pain ensure that once pain treatment is started that it achieves a treatment is started that it achieves a standardized endpoint.standardized endpoint. Nurse driven analgesic protocolsNurse driven analgesic protocols PCAPCA

Nurse-driven protocolsNurse-driven protocols

►Kelly 2000, long bone fracturesKelly 2000, long bone fractures 1993: 53% of patients IM narcotic 1993: 53% of patients IM narcotic

analgesia, 6% IVanalgesia, 6% IV 1997: 5% IM analgesia, 54% IV1997: 5% IM analgesia, 54% IV

►Kelly 2000, renal colicKelly 2000, renal colic 1993: 76% of patients IM, 3% IV1993: 76% of patients IM, 3% IV 1997: 3% IM analgesia, 95% IV1997: 3% IM analgesia, 95% IVPhysician allowed to say patient needed analgesia then

protocol initiated by nurses

Nurse-driven protocolsNurse-driven protocols

►Fry 2002Fry 2002 Autonomous nurse-initiated IV morphine Autonomous nurse-initiated IV morphine

for patients in acute pain waiting for for patients in acute pain waiting for medical assessmentmedical assessment

Time to analgesia: 18 minutesTime to analgesia: 18 minutes Time to MD assessment: 52 minutesTime to MD assessment: 52 minutes Only additional treatment required: OOnly additional treatment required: O22

Average pain decrease: 8.5 cm to 4.0 cm Average pain decrease: 8.5 cm to 4.0 cm within 60 minuteswithin 60 minutes

Recognizing presence of painRecognizing presence of pain

► Jones 1999Jones 1999 4 hour educational program for residents 4 hour educational program for residents

on evaluating and treating painon evaluating and treating pain 65% of patients studied before the EP had 65% of patients studied before the EP had

significant reduction in their pain scores significant reduction in their pain scores after 30 min in the EDafter 30 min in the ED

Afterwards, 92% had a significant reduction Afterwards, 92% had a significant reduction in their pain scores at 30 min. in their pain scores at 30 min.

Significant improvement was also seen in Significant improvement was also seen in the patients' global evaluation of treatmentthe patients' global evaluation of treatment

Recognizing presence of painRecognizing presence of pain

►Thomas 2004Thomas 2004 VAS 11 times over 2 hoursVAS 11 times over 2 hours Either tabulated in chart Either tabulated in chart oror plotted on plotted on

graph at head of bed graph at head of bed oror controls controls If graphed at head of bedIf graphed at head of bed

►Treating physicians more likely aware of initial Treating physicians more likely aware of initial and final VAS scoresand final VAS scores

►Provided earlier analgesia Provided earlier analgesia ►Patients and physicians perceived that VAS Patients and physicians perceived that VAS

was usefulwas useful

Recognizing presence of painRecognizing presence of pain

►Silka 2004Silka 2004 Documentation of pain scores in trauma Documentation of pain scores in trauma

patients resulted in greater numbers of patients resulted in greater numbers of patients receiving analgesiapatients receiving analgesia

►Only 73% documented – the more obvious Only 73% documented – the more obvious ones, or the ones more in pain?ones, or the ones more in pain?

►If you do not think about it, why would you If you do not think about it, why would you treat it.treat it.

►Need to make scoring mandatory and visibleNeed to make scoring mandatory and visible

Acceptance of presence of Acceptance of presence of painpain

►““The patient rated their pain a 10/10 The patient rated their pain a 10/10 but I do not believe them”but I do not believe them” Systemic miscalibrationSystemic miscalibration Transferring patient’s past experience and Transferring patient’s past experience and

filtering it through yoursfiltering it through yours Disbelief of patient Disbelief of patient

►Patient does not understand scalePatient does not understand scale►Patient manipulating to be seen more quicklyPatient manipulating to be seen more quickly

Acceptance of presence of Acceptance of presence of painpain

► Weinstein 2000 Weinstein 2000 Medical student beliefs on Medical student beliefs on pain managementpain management Unchanged from start to end of studiesUnchanged from start to end of studies The professionalization process may reinforce The professionalization process may reinforce

negative attitudes. negative attitudes. Psychologic characteristics, fears of patient Psychologic characteristics, fears of patient

addiction and drug regulatory agency sanctions addiction and drug regulatory agency sanctions were associated with reluctance to prescribe were associated with reluctance to prescribe opioids. opioids.

Higher scores on reliance on high technology, Higher scores on reliance on high technology, external locus of control, and intolerance of clinical external locus of control, and intolerance of clinical uncertainty were associated with higher levels of uncertainty were associated with higher levels of opiophobiaopiophobia

Painless ED?Painless ED?

► Any plan for improving pain Any plan for improving pain management in the ED must:management in the ED must:

Include ongoing educationInclude ongoing education► To overcome beliefs and barriersTo overcome beliefs and barriers► To increase medication knowledgeTo increase medication knowledge

Achieve buy-in from nurses and physicians Achieve buy-in from nurses and physicians Establish nurse-driven protocolsEstablish nurse-driven protocols Allow variability in medications and Allow variability in medications and

patient-chosen endpointspatient-chosen endpoints

Buy-in from other Buy-in from other departmentsdepartments

►Always start from “what’s best for the Always start from “what’s best for the patient” positionpatient” position

►Develop an evidence-based argumentDevelop an evidence-based argument Consequences of not treating painConsequences of not treating pain Patient comfortPatient comfort Patient satisfactionPatient satisfaction

►Demonstrate expertise and knowledgeDemonstrate expertise and knowledge►Use neutral parties to mediate turf Use neutral parties to mediate turf

wars: your evidence should always win!wars: your evidence should always win!

►Make use of nursing involvementMake use of nursing involvement When nurses are strong advocates, they When nurses are strong advocates, they

influence nurses across hospital more influence nurses across hospital more than doctors ever can!than doctors ever can!