Pain management in emergency departments has improved but can still be better

Research Activities, March 2010, No. 355

Emergency departments (EDs) are doing a better job of helping older adults manage their pain, but room for improvement exists, according to findings from the University of Iowa. Marita Titler, Ph.D., R.N., F.A.A.N., now with the University of Michigan School of Nursing, and Keela Herr, Ph.D, R.N., A.G.S.F., F.A.A.N., reviewed medical records of 1,454 older patients who ended up in EDs with broken hips in the 33 months after the Joint Commission issued new pain assessment and management standards in 2000. Over the study period, an average of 96 percent of patients with broken hips had pain documented in their medical records. Use of a standard numeric rating scale (NRS) that lets patients report pain on a scale of 0 to 10 rose from 16.5 to 54.4 percent. This signaled an improvement in ED pain assessment practices, but also indicated that more could be done.

At the end of the study, almost a quarter of older patients with hip fractures still received no pain medicine in the ED. The authors suggest this may be particularly harmful because undertreating pain can affect outcomes. Further, while physician orders for morphine rose over the 18 months, the amount of the drug actually administered to patients did not match the orders. This indicates that either the patient refused to receive the drug or the nursing staff did not deliver it.

On a positive note, intramuscular injections to deliver pain medicines declined from 38 to 24 percent. These injections are not recommended for older adults because older adults may have wasting muscles or lack fatty tissue, potentially slowing drug absorption. Additionally, researchers noted decreased use of meperidine, a drug that can cause neurologic toxicity in seniors. The authors recommend several strategies for improving adoption of evidence-based pain management strategies. These include improving communication between doctors and nurses, appointing an ED nurse as a pain management champion, and using patient education materials that address pain assessment and treatment. This study was funded in part by the Agency for Healthcare Research and Quality (HS10482).

See "Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: Review of ED trends," by Drs. Herr and Titler in the July 2009 Journal of Emergency Nursing 35(4), pp. 312-320.

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