2.2 Acute Pain Management

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Description of Indicator

Relationship to Quality  Medical care should be timely, effective and patient-centered
Type of Indicator Prehospital and Hospital process, Hospital level
Proposed Data Source EMS Records, ED Records
Definition Documented pain assessment and a reassessment within 30 minutes of first medical contact with injured patient
Numerator All injured patients age 18 years and older with documented pain assessment AND reassessment within 30 minutes of first medical contact
Denominator All injured patients with first medical contact (EMS and/or ED)
Benchmark Not applicable
Risk Adjustment Not applicable

 

Summary
This indicator is intended to monitor the assessment and reassessment of acute pain for injured patients following first medical contact. The indicator originally included initiation of pain management, but given that there are many ways to manage pain (e.g. pharmacological, immobilization, changing physical position etc.) it was revised to include a reassessment of acute pain.


Panel Review
Panelists emphasized the importance of this key patient-centered indicator. From a patient perspective effective acute pain management was described as imperative. Panelists reported evidence that acute pain may be associated with long-term pain, and that if inadequately treated acute pain has measurable physiological and psychological sequelae.
Looking at implementation of this indicator, panelists agreed that evaluation needs to include both prehospital and ED care. Panelists reported that both assessment and management of acute pain needs to be measured and may be most practically performed using medical record documentation.


Trauma Center Review
The trauma centers highlighted that multiple pain assessment tools are employed in practice and questioned whether indicator performance would be impacted by the tool used. Reassessment of pain was noted to be difficult to determine as EMS providers may not quantify pain during reassessment. In addition, a question was raised about how the indicator would perform for patients transferred to ED care within 30 minutes of the initial pain assessment. Documentation of pain assessment was reported to be inconsistent and potentially challenging to obtain from prehospital records. It was suggested that a change in the culture of some EMS organizations may be necessary to develop comprehensive pain assessment and reassessment practices and consistent documentation of these procedures.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study showed that the implementation of a fentanyl-based pain management protocol resulted in a marked reduction in time to initial analgesia21.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: No data identified.
Different tools have been tested for measuring acute pain in the prehospital setting. Maio et al.22 recommended the use of 2 verbal pain-rating scales for out-of-hospital evaluation of adults, adolescents, and older children: (1) the Adjective Response Scale, which includes the responses “none,” “slight,” “moderate,” “severe,” and “agonizing,” and (2) the Numeric Response Scale, which includes responses from 0 (no pain) to 100 (worst pain imaginable)22. Several studies have shown that providing injured patients with analgesia within the first 30 minutes of contact with EMS personnel is feasible21,23,24.

 

Source
This quality indicator was proposed by the Quality Indicators in Trauma Care Consensus Panel.

 

References
21. Curtis KM, Henriques HF, Fanciullo G, Reynolds CM, Suber F. A fentanyl-based pain management protocol provides early analgesia for adult trauma patients. J Trauma. 2007;63(4):819-826.
22. Maio RF, Garrison HG, Spaite DW, et al. Emergency Medical Services Outcomes Project (EMSOP) IV: pain measurement in out-of-hospital outcomes research. Ann Emerg Med. 2002;40(2):172-179.
23. Chao A, Huang CH, Pryor JP, Reilly PM, Schwab CW. Analgesic use in intubated patients during acute resuscitation. J Trauma. 2006;60(3):579-582.
24. Abbuhl FB, Reed DB. Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehosp Emerg Care. 2003;7(4):445-447.