Improving Pain Relief in Elder Patients — I-PREP

This article was reproduced with permission from the authors. Original article from geriatric-ed.com.

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.