Literature on pain protocols
1999

Coman M, Kelly AM

Safety of a nurse-managed, titrated analgesia protocol for the management of severe pain in the emergency department

Emergency 1999; 11: 128-132

Our Observations

In this retrospective case-series, the authors evaluated the safety profile of a previously implemented pain protocol in which nursing staff could administer and subsequently titrate IV pethidine or IV morphine to adult patients after signing off by the treating physician. This means this was a nurse-driven pain protocol (not nurse-initiated). The exact protocol was not reported in the publication.

​Although the authors stated that the use of titrated IV pethidine and IV morphine was safe to use in a nursing-managed pain protocol, there was an incidence of 4.7% of adverse events. Although no respiratory depression was noted, there were 17 patients with hypotension; 1 patient with an allergic reaction and 1 patient with a vasovagal reaction. Of the patients who developed hypotension, 6 patients had sepsis, cardiogenic shock, bradycardia or they used vasodilatory drugs and subsequently developed hypotension. 

Overall, pethidine was used most often (74%) followed by morphine (25%) and both were used in 1% of patients.

 

Pros

This was the first study to evaluate the safety of an Emergency Department based nurse-driven pain protocol. 

The authors included all consecutive patients in order to minimize selection bias or differential loss to follow-up.

​Limitations

This study had a retrospective design, with high risk of confounding.

The primary outcome was the occurrence of adverse events and these might not have been documented in all patients properly (information bias). The study population consisted of one patient group without a comparison group. Lastly, it is not exactly clear how long after implementation of the pain protocol this study was performed. No formal sample size calculation was performed.

 

​Clinical applicability

The use of a nurse-driven pain protocol in adult patients with various traumatic and non-traumatic causes of pain in the Emergency Department is safe in general, however when using IV pethidine and IV morphine, patient selection should be careful in order to prevent adverse events, such as hypotension.

Level of evidence 4

 
 
2000

Kelly AM

Nurse-managed analgesia for renal colic pain in the emergency department

Aust Health Rev 2000; 23(2): 185-192

Our Observations

The same Australian research group that performed the safety profile study of a nurse-driven IV narcotic pain protocol published this comparative, retrospective observational study in which they evaluated the effect of the implementation of the nurse-driven pain protocol. In this protocol nurses were able to titrate opioids after initial signing off by the treating physician.

In the current study the main focus was on the route of analgesic administration (IM versus IV) in Emergency Department patients presenting with renal colic. Patients treated according to the protocol were compared with patients 1 years before implementation.

Pros

The authors emphasized the importance of IV analgesic administration, as titration is possible and this has faster onset. In order to prevent the ‘honeymoon’ period, data of the second patient group were selected at 2 years after implementation.

Limitations

Because of the retrospective design, confounders may have influenced study results. As the second study period was 2 years after implementation, other factors might have influenced study results.

Selection bias cannot be excluded to have played a role, as well as information bias as data were collected by chart reviews of a single reviewer who was trained, however it was not described what level of training this was.​

The pain protocol that was implemented included incorporation of pain measurement as routine observations, but these results were not presented.

Clinical applicability

The implementation of a nurse-driven, titrated IV narcotic pain protocol increases the proportion of IV administration at the expense of IM administration in adult patients presenting to the emergency department with renal colic. 

Level of evidence 4

 
2000

Kelly AM

A process approach to improving pain management in the emergency department: development and evaluation

J Accid Emerg Med 2000; 17: 185-187

Our Observations

The same Australian research group that published the 2 previous studies described above, performed the current study in which a nurse-driven IV titrated narcotic pain protocol was evaluated. In the current study they evaluated the effect in patients with pain due to long bone fractures and the authors found that (as well as in renal colic patients in the former study) IV administration of narcotics improved significantly and the IM route of administration decreased significantly after implementation of the protocol as compared to the baseline situation. 

 

Pros

The authors also described the results of a reviewing process that preceded to the development of the nursing protocol, in order to identify major deficiencies in pain management. These results were:

- Pain was poorly recognized and documented

- Inadequate dosages of pain medication were administered

- Routes of administration of analgesics were inappropriate

- There were delays in analgesic administrations

- Pain management was not regarded high priority

The proposed strategies that eventually led to the development of the nurse-driven pain protocol were: routine patient reporting of pain; trying to change the Emergency Department culture surrounding pain and pain management and propagating the use of IV opioids as the preferred method of administration of narcotic analgesia. 

​Limitations

This was a retrospective study and confounding probably influenced results and as the second study period was 2 years after implementation, other factors might have influenced study results as well.

A single reviewer (with unknown level of training and experience) collected data utilizing chart review and selection bias and information bias could have influenced results.

The pain protocol that was implemented included incorporation of pain measurement as routine observations, but these results were not presented.

The authors stated that analgesic timelines were not evaluated and that it was questionable whether these study results could be extrapolated to other conditions (questionable external validity).

​Clinical applicability

The use of a nurse-driven IV titrated narcotic pain protocol increases the use of IV narcotic analgesic administration compared to IM administration and therefore improves pain management in patients with acute long bone fractures. 

Level of evidence 4

 
2007

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: 819-826

Our Observations

The authors of this comparative, before and after implementation study in the USA evaluated the effect of implementing a pain management protocol in patients who had established trauma activation criteria.

The protocol was nurse-driven (physician order was necessary initially, but further assessment and administration of analgesics was on discretion of nursing staff) and consisted of the administration of IV fentanyl 25-50ug and titrated each 5 minutes (stable patients) or each 15 minutes (potentially unstable patients). For this purpose, patients evaluated at the trauma bay were classified as unstable; stable but with abnormal vital signs and stable vital signs. Before implementation, the protocol was officially presented to staff.

 

The authors found that time to analgesia significantly decreased and that there were no adverse events due to IV fentanyl administration.

 

Pros

A sample size calculation was performed in order to detect a 50% reduction in time to analgesia (assuming a before-implementation mean time to pain meds of 72 minutes)

 

Limitations

It was not clear whether the after-implementation group was recruited prospectively and by whom. The before-implementation group consisted of a historical control group.

After implementation 104 patients were recruited and 74 were deemed appropriate to receive protocolized fentanyl, of whom 67 actually did. The difference of 30 patients (104 to 74) were patients in the unstable vital signs group who actually received IV fentanyl. However, these patients were not included in the analyses and it is not clear why they weren't. Moreover, 18 additional patients from the same group who got analgesics were included in the study.

The amount of 25-50ug IV fentanyl might be too low for some patients, as dosages were not calculated by body weight.

Prehospitally administered analgesia was not accounted for.

 

Clinical applicability

The use of a nurse-driven pain protocol in trauma patients evaluated in the trauma bay utilizing IV fentanyl in incremental dosages reduces time to analgesia and seems safe to use.

Level of evidence 4

 
2015

Tanabe P, Martinovich Z, Buckley B, Schmelzer A, Paice JA

Safety of an ED high-dose opioid protocol for sickle cell disease pain

J Emerg Nurs 2015; 41(3): 227-235

Our Observations

The authors of this retrospective case-series reported the effect of a high-dose opioid pain treatment protocol in adult patients presenting with vaso-occlusive crisis of sickle cell disease in an Emergency Department in the United States.

The protocol was partly nurse-initiated (first dose autonomously administered and 2nd and 3rd dose after consulting physician):

- in case patient already took opioids last 24 hours: IV/SC hydromorphone 2mg OR morphine sulfate 10mg IV/SC and titrated after 20 minutes with 4 and 20mg, respectively. The initial dose was combined with ibuprofen 600mg PO + diphenhydramine 25mg PO (in case of itching).

- in case patient did not take opioids last 24 hours: opioid dosages less than described above.

All physicians and nurses were educated in using the protocol, including education regarding a sedation scale that was used in reassessments.

 

They found that although high doses were administered (mean morphine equivalent was 63 during Emergency Department stay, adverse events occurred in 63/603 patient visits. These were respiratory events, not requiring interventions.

 

Pros

The inter-rater reliability of IV morphine sulfate equivalents that were calculated in this study was tested with a blinded second research assistant (Pearson r 0.84)

Multiple logistic regression was used in order to identify factors that might predict abnormal vital signs.

 

Limitations

This was a case-series without a control group.

Regarding retrospective analysis of adverse events, it must be noted that patients with vaso-occlusive crises in sickle cell disease usually receive additional oxygen (by nasal canula). It was not possible to make a distinction between standardized oxygen administration or as a response to hypoxemia/hypoventilation. This might have confounded the rate of adverse events.

 

Clinical applicability

Nurse-managed opioid pain treatment utilizing high IV dosages in patients with vaso-occlusive crises in sickle cell disease is safe.

Level of evidence 4

 
2016

Barksdale AN, Hackman JL, Williams K, Gratton MC

ED triage pain protocol reduces time to receiving analgesics in patients with painful conditions

Am J Emerg Med 2016; 34(12): 2362-2366

Our Observations

The authors of this retrospective before- and after implementation study from the USA evaluated the introduction of a triage pain protocol that was built in the electronic medical record system.

The protocol was meant for adult patients between 18 and 65 years of age presenting to the Emergency Department with 1 of 6 selected conditions / complaints: back pain; dental pain; extremity trauma; sore throat; ear pain; pain due to an abscess.

The triage nurse was allowed to administer acetaminophen, ibuprofen or oxycodone autonomously and was able to give additional medication one hour later in case NRS pain scores remained >5.

Pros

A large group of patients was screened for eligibility in this study.

Although a respectively small number of patients received analgesics according to protocol, it seems positive that a total of 489 patients received protocolized pain medication of conditions not described in the protocol. This means nursing staff probably feels comfortable utilizing this pain protocol.

Limitations

The study was retrospective and therefore potential (unknown) confounding factors might have played a role. It was not clearly described who collected the data and what experience of training this / these person(s) had.

A total of 1002 patients received pain medication according to the protocol, this seems a small number compared to the total study population. Reasons for lack of adherence with the protocol were not described in the study. The authors mention as limitation that study results might have been influenced by variation in Emergency Department patient volumes and crowding. 

Pain scores were not recorded and might have influenced study results. 

Clinical applicability

Implementation of a nurse-initiated triage pain protocol in patients' electronic medical records resulted in significant shorter times to orally administered analgesia in patients with several painful minor conditions. 

Level of evidence 4

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