Implementation of a pain protocol in general

Clinical Bottomline

EM Online's definition of a pain protocol in general is that it was not explicitly mentioned in the study that analgesics were administered by nursing staff autonomously (nurse-initiated) or by nursing staff after physicians' signing off (nurse-driven). It was simply the use of a pain protocol for certain patients groups in the Emergency Department.

This was evaluated in 9 studies. These studies had a level of evidence 2b (5 studies) and a level of evidence 4 (4 studies). 


In these studies several populations were evaluated:

- traumatic injuries (3 studies: 2300 patients)

- renal colic / kidney stone (2 studies: 1056 patients)

- pain of any cause / mixed study populations (4 studies: 1120 patients)

In all studies, opioids were utilized and IV lidocaine was used in 1 study in order to treat patients with renal colic pain.

Taken together, it can be concluded* that...

1. a pain protocol in general increases analgesic administration

Level of recommendation B

Administration of analgesics increased in all (4) studies and this increment varied between 14% to 65%. As most studies included several different analgesics in the protocol, 2 studies specifically reported increased use of opioids. This increased from 10% to 17% and the IV route was used more frequently as this increased from 2 to 18% and 9% to 37%, respectively. Finally, 1 study evaluated the effect of a multimodal pain protocol on decreased opioid administration and reported a decrease in opioid usage from 65% to 58% and an increase of non-opioids from 56% to 65%.

2. a pain protocol in general leads to clinically relevant pain reduction

Level of recommendation B 

In 3 studies, pain reduction was measured. The first study reported no differences in pain decrease. The second study found a clinically relevant pain reduction of 2.41 NRS points in case the protocol was used. In the third study, the decrease in NRS points (5.36) was statistically significantly more profound after implementation and was obviously clinically relevant.

3. a pain protocol in general decreases time to analgesia

Level of recommendation C 

Time to analgesia decreased in 3 studies as compared to non-protocolized pain management. This absolute decrease varied between 7 to 34 minutes. One study did not find a significant difference after implementation and 1 study reported a paradoxical increase in time to analgesia of 16 minutes. More specifically, there was a proportional decrease from 17% to 7% of patients meeting the goal of a protocolized 30-minutes analgesia policy.

4. a pain protocol in general results is safe to use

Level of recommendation C

Three studies reported the occurrence of adverse events. Two studies utilized IV opioids (next to standard non-opioid analgesics) and did not show differences in adverse events compared to non-protocolized pain management. The other study used IV lidocaine and rescue IV opioids and reported a 1.8% incidence of adverse events, mainly sedation. Although the authors stated that none were associated with use of IV lidocaine, the other adverse events were arrhythmias, syncope, cardiac arrest and paresthesia. 

5. a pain protocol in general increases patient satisfaction

Level of recommendation B

This endpoint was reported in 4 level 2b studies and all studies showed higher satisfaction rates compared to non-protocolized pain management. This was measured using different methods in all studies.


* Disclaimer:

Included studies were different in several items, such as timing and methods of measurement of several endpoints; study population; baseline situation and pain medication. Due to these large differences in study methodology, results cannot be pooled and the level of recommendation should be regarded as an estimation of the true effect. The levels of recommendation were derived according to the OCEBM levels of evidence.