Improving Pain Relief in Elder Patients — I-PREP

Utilizing the I-PREP intervention to improve both the process and outcomes of ED pain management for older adults.

Teresita M. Hogan, MD, FACEP

This article was reproduced with permission from the authors. Original article from

The Hospital

University of Chicago

The Need

We identified inadequate and variable approaches to managing pain among our older patients as a problem.

The Improvement

I-PREP is an intervention to improve the care of ED patient’s ≥ 65 years, experiencing moderate to severe pain. I-PREP uses a multimodal approach to address ED staff behaviors in key area of elder pain management. To our knowledge this is the most effective intervention to date substantially improving both the process and outcomes of ED pain management for older adults.

The improvement targets were identified through review of the literature, institutional metrics and in-depth staff interviews. Barriers and opportunities identified in the interview process are published in: Gorawara-Bhat, Hogan TM, Wong A, Dale W. Nurse-Older Patient Communication on Pain Management in the Emergency Department: A Qualitative Study. Patient Education and Counselling. Aug 31, 2016.

A national expert panel assisted in the development of educational materials and a quality improvement tool kit containing educational and quality improvement resources for implementation. An information technology team developed electronic medical record interfaces for meaningful use, with screens that appeared at the proper time in staff workflow.

I-PREP developed separate ED nursing, and physician staff education highlighting best practices for the ED evaluation and treatment of older adults with pain. This education was linked to quality improvement metrics, electronic medical records interventions, and feedback reporting. Multiple PDSA cycles advanced by regular staff communication and feedback were used to identify barriers in process and implementation, and refine interventions accordingly.

The final outcome was a decreased pain score on the numeric pain scale from 0-10. Patients pain scores on ED discharge decreased from 6.6 to 3.6. Process improvements showed significantly more patients received analgesics, medications were dispensed earlier, and more patients obtained pain reassessment.

Flow Diagram of the Process: ED Management of Pain in Older Adults

We reviewed Existing Literature, got Data from In-Depth Interviews, and Studied our local environment and then proceed to an Expert Panel Consensus Process. Then we developed the Took Kit:

  1. Optimal Practice Standards for ED Management of Elder Pain
  2. Education Program: Older Adult Pain Management
  3. Performance Improvement Measures/Tracking Tools
  4. Electronic Medical Records Interface Screens

INTERVENTION: Education of ED interdisciplinary team with monitoring of clinical practice and feedback mechanisms and application of EMR screens

PDSA Cycle Refinements

Overall Performance Improvement Process

Process and Outcome Measures

The Challenges and Drivers

QI Team Guidelines and Workflows

SMART Aims Statement

To achieve tolerable pain levels in ED patients over 65 years of age at or before the patient’s ED disposition by X date.

“Tolerable” is defined by a “No” response when patients are asked if they would like more pain medication. Literature suggested end point is a pain scale score that is ≤ 4/10. Remember always respect patient preference over numbers please!

II. Sustainability Measure

The final version of “elder pain management protocol” and guidelines will be added to the institution’s dashboard and become part of the Standard Operating Procedure.

III. Targets for Improvement

1. Time from –
a. Triage to pain score documentation
b. Pain score documentation to medication administration
c. Medication administration to reassessment documentation

2. Drug Choice – guided by World Health Organization Step Ladder which appears as EMR screen when physicians go to write order

3. Dosage Choice – Guided by older adult start low go slow chart which appears as EMR screen when physicians go to write order

4. Locations for improvement
a. Waiting room
b. Main ED

5. Change in patient pain score from initial score to discharge score

IV. Measures

1. Primary:
i. time to assessment
ii. time to analgesia
iii. time to reassessment
iv. patient rejection of more medication at reassessment and/or score ≤4

2. Secondary:
i. potential adverse drug-drug or drug-disease interactions
ii.prescribing bowel regimens with opioids.

3. Balance Measure: (to make sure other operations in the ED are not affected by the project): time to nebulizer treatment for asthmatics (for patients of all ages) + others as needed

V. Educational Components

1. Nursing
a. Standard Assessment Scripting appears as EMR screen when nurses document pain assessment-
overcome practice of small/medium/large or other descriptions
b. Patient Report as Pain Gold Standard overcome current norms and biases
c. Pain Assessment knowledge tools
d. Reassessment algorithm EMR clock on RN screens start when meds given and flash at
suggested reassessment time stopping when reassessment entered

2. Staff physician
a. Standard Assessment Scripting
b. Patient Report as Pain Gold Standard
c. How to take an Older Adult Pain History
d. You will be timed from time of pain documentation until pain order is written
e. EMR clock to appear counting minutes/hours until order is in
f. Proper drug selection – World Health Organization Step Ladder appears as EMR screen
just above order writing area. Make suggestions easy click box choice and other choices
“harder to select”
g. Proper dosing- Guided by older adult start low go slow chart which appears as EMR
screen just above order selections
h. Reassessment standards

VI. Project team membership (ED level)

1. PI
a. Manager level
b. LEAN or PI expert
c. RA
d. Local “Champions” (RN, attending, resident)

VII. Baseline metrics

(PI and RA via data pact project with hand confirmation)

VIII. Development of PDSA cycles – Project team

1. Interventions phase:
a. Decide on what change is to be made to existing staff operations
b. Educate to the changes above
c. Attitude knowledge and skills for content
d. Culture
e. Flow charts EMR screen to prompt compliance at right workflow time

2. Impact and implementation phase:
a. Measure and record the effect of the changes
b. Data – huddle – change
c. Repeat
d. What is the data point? Example: Reassessment – if No to reassessment and % of no e. If nurse
manager knows good if not look at ED level if not look at RN level
f. Core team can expand and contract as needed
g. EMR screen to prompt compliance at right workflow time and record times used team review for
suggested improvements change. Implement and recount.



  • During every time interval, the post-intervention patients had improved time to first pain medication and reassessment
  • Compared to our pre-intervention cohort, in the post-intervention patients we significantly achieved
    • Greater reductions in pain
    • Increased percentages of:
      • Patients who received pain medication
      • Patients reassessed after receiving pain meds

Additional Comments

  • This project was published in Journal of the American Geriatrics Society Journal of the American Geriatrics Society 2016; 64: 2566-2571.
Study Link

Contributing Faculty

Teresita Hogan


Dr. Teresita Hogan is a Professor of Medicine and Director of Geriatric Emergency Medicine at the University of Chicago Medicine. Her clinical research interest are Geriatric EM, Quality Improvement, Emergency Pain Management, Emergency Management of Falls in Older Adults, and Models of Care. Dr. Hogan is the ACEP representative to the AGS and serves on the executive committee Section for Enhancing Geriatric Understanding and Expertise among Surgical and Medical Specialists. She is an expert in graduate medical education and led the expert consensus process to establish The Geriatric Competencies for Emergency Medicine Residents.

She has also worked on identifying the number and characteristics of geriatric emergency departments across the United States and is a member of the GEDA Board of Governors.

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