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Abstract
Introduction Pain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many EDs face challenges in pain management and present opportunities for improvement. This initiative aimed to expedite the administration of the first analgesic in patients with musculoskeletal pain in the ED.
Local problem Observations within our ED revealed that patients with musculoskeletal injuries triaged to yellow or green areas experienced prolonged waiting times, leading to delayed analgesic administration, thereby adversely affecting clinical care and patient satisfaction.
Specific aim The aim of our quality improvement (QI) project was to reduce the time to administration of first analgesia by 30% from baseline, in patients with musculoskeletal injuries presenting to our academic ED, in a period of 8 weeks after the baseline phase.
Methods A multidisciplinary QI team systematically applied Point-of-Care Quality Improvement and Plan-Do-Study-Act (PDSA) cycle methodologies. Process mapping and fishbone analyses identified the challenges in analgesia administration. Targeted interventions were iteratively refined through PDSA cycles.
Interventions Interventions such as pain score documentation at triage, fast-tracking of patients with moderate-to-severe pain, resident awareness sessions, a pain management protocol and prescription audits were executed during the PDSA cycles. Successful elements were reinforced and adjustments were made to address the identified challenges.
Results The median door-to-analgesia timing during the baseline phase was 55.5 min (IQR, 25.75–108 min). During the postintervention phase, the median was significantly reduced to 15 min (IQR, 5–37 min), exceeding the anticipated outcomes and indicating a substantial 73% reduction (p value <0.001) from baseline.
Conclusion Implementing simple change ideas resulted in a substantial improvement in door-to-analgesia timing within the ED. These findings significantly contribute to ongoing discussions on the optimisation of pain management in emergency care.
- Pain Management
- Emergency department
- Quality improvement
- Time-to-Treatment
Data availability statement
Data are available upon reasonable request. Data from this study are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Timely pain management in emergency departments is crucial for patient satisfaction, stress reduction, shorter hospital stays, cost-effectiveness and mitigating long-term consequences. Despite widespread recognition of its importance, challenges persist in achieving prompt analgesia.
WHAT THIS STUDY ADDS
Our study demonstrates the effectiveness of a multifaceted approach in improving the timeliness of initial analgesia for musculoskeletal pain patients. Through interventions such as pain score documentation, expedited processing for moderate-to-severe pain, resident training sessions, a comprehensive pain management protocol and prescription audits, we achieved a significant reduction in door-to-analgesia time, thus enhancing patient care.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study addresses a crucial gap by exploring resource-appropriate strategies to improve timely analgesia in emergency care in low-income and middle-income countries. It serves as a practical guide for enhancing emergency care practices, prompting further research in this area.
Introduction
Problem description
Pain is one of the most common presentations in the emergency department (ED). We observed that approximately half of the patients attending our ED suffered from pain, with musculoskeletal injuries accounting for 40% of these patients. The patients with musculoskeletal injuries being triaged to the yellow or green area had relatively longer waiting times, and often the time to administration of analgesia was delayed. This led to a decrease in patient satisfaction, heightened mental distress and prolonged duration of stay in the ED.1–3 The British Association of Accident and Emergency Medicine guidelines state that patients with moderate and severe pain should receive analgesia within 20 min of arrival to the ED.4 While studies conducted in various parts of the world have explored interventions to improve pain management in emergency healthcare, their applicability to low-income and middle-income countries like India is uncertain.
Available knowledge
Inadequate pain relief or oligoanalgesia is a frequent problem in ED due to factors like underestimation of pain severity, lack of pain score assessment at triage, insufficient physician training and inadequate patient reassessment for effective pain relief are some of the reasons.5–9 Prolonged uncontrolled pain increases sensitivity to painful stimuli. Inadequate or suboptimal analgesia in acute traumatic pain is a known risk factor for the development of chronic pain in the long term.9 10 Oligoanalgesia has psychological and physiological consequences for patients and the healthcare system.11 12 Hence, earlier effective pain management in the ED is of paramount importance in providing quality healthcare, achieving good patient satisfaction, reducing the time to return to regular activities, reducing hospital stay times, increasing earlier discharge rates from the ED and avoiding ED overcrowding.9 10 13 Studies have shown that pain assessment, pain score documentation and increased pain assessment frequency correlate with decreased time to analgesia.5 14 15
Rationale
Enhancing the timely delivery of analgesia in a high-volume academic ED within low-income and middle-income countries, such as India, is a critical concern as it holds the potential to significantly enhance the overall provision of quality healthcare. In contemporary emergency medicine practice, the time to administration of analgesia is a crucial quality indicator.5 16 Quality improvement (QI) initiatives in various countries have demonstrated positive outcomes in reducing analgesia administration times, but a literature gap exists in addressing this issue specifically in India.15 17 Hence, we embarked on this QI project, aiming to provide valuable insights that can inform and improve pain management practices in our setting.
Specific aims
The aim of our QI project was to reduce the time to administration of first analgesia by 30% from baseline in patients with musculoskeletal injuries presenting in our academic ED, in a period of 8 weeks after the baseline phase.
Methods
Study setting
Our hospital is a tertiary care centre with an academic emergency medicine department. Our ED caters to approximately 250–300 patients per day. All healthcare professionals work in three shifts in our ED with approximately 12 emergency medicine residents (three post-MD, seven postgraduate trainees in emergency medicine and two postgraduate trainees from other departments), 10 nursing officers, 4 emergency medicine technicians and many orderlies in each shift. All patients reaching the ED are being triaged by a triage team comprising a doctor and an emergency medical technician and directed to the red, yellow or green areas based on their acuity. Emergency Severity Index (ESI) is used as the triage tool.18 Patients categorised as ESI levels 1 and 2 are directed to the red area, while those designated as ESI level 3 are directed to the yellow area. Patients categorised as ESI levels 4 and 5 are directed to the green area. Triage times are recorded in the online triage entry form. Resident doctors assess and treat patients, prescribing analgesics based on pain severity. Medications are prescribed to patients after obtaining informed verbal consent, unless explicitly refused. Treatment is documented in the predesigned structured locally developed case proforma, and prescription slips are given to nursing officers posted in the respective area, who confirm patient identifiers (name, age and hospital identification number) and administer the drug. Ours is a publically funded institute and hence medications are provided to patients at no cost. Prescription slips are retained for audits, and medication details are recorded in registers.
Study design
The inception of this QI project stemmed from observations made by the investigators, which included an emergency medicine consultant and senior residents. We observed that patients with musculoskeletal injuries when categorised as less urgent (yellow or green), waited longer for treatment and often did not receive pain relief promptly. This led to recognising a need for improvement in managing these patients within the emergency care setting. A multidisciplinary QI team was formed, including the study’s primary investigator and coinvestigators, emergency medicine consultants, residents and emergency nurses. The project was supervised by a faculty member in the emergency medicine department.
The study was conducted using the Point-of-Care Quality Improvement methodology developed by the WHO South East Asian Regional Office and the Plan-Do-Study-Act (PDSA) cycle methodology. In this study, we included patients who presented with musculoskeletal injuries to the emergency medicine department at our centre. We excluded patients with mild pain (pain score <4 according to the numeric rating scale (NRS)), decreased level of consciousness (Glasgow Coma Scale score <15), haemodynamic instability and children incapable of self-reporting pain. Systematic sampling was performed. The ED was run in three shifts. To ensure representative sampling, patients were selected during every fourth shift. For instance, if the initial sampling occurred during the first shift on day 1, subsequent sampling occurred during the second shift on day 2. This sequence was continued, with every fourth shift chosen for sampling. During each designated shift, every consecutive patient in need of analgesia was included in the sampling.
The QI team convened at the project’s outset to establish its direction and to ensure consistency in documentation procedures. To standardise documentation before data collection, it was necessary to record the pain score using an NRS at the triage and record the drug administration time in the nurse register at each location in the ED. Data were acquired from the online triage entry form, written prescription slips and nursing counter registers maintained at each location in the ED. The following data points were recorded.
Door time: the time the patient entered the triage area; obtained from the online triage entry form.
First analgesia administration time: the time the patient received the first analgesia in the ED; obtained from the nursing counter registers.
The study was conducted in three phases: baseline, intervention and postintervention phases. The QI team met at the end of the baseline phase to identify bottlenecks, as well as before and after each PDSA cycle, to formulate change ideas for implementation in the next cycle and to evaluate the outcomes of the previous cycle. Additionally, the team met at the end of the postintervention phase to assess the sustainability of the results.
At the end of each phase, the data collected were graphically represented through a run chart and subjected to an objective analysis for the identification of non-random patterns in the data using the three probability-based rules (shift, trend and runs). Quantitative data were presented as medians and IQRs, and statistical comparisons were performed using the Mann-Whitney U test. The analysis was performed using IBM SPSS Statistics V.19.0 software (IBM Corp. Released 2010, Armonk, NY). Reporting of this QI project adhered to SQUIRE V.2.0.
Patient and public involvement
Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Baseline phase
The baseline phase was conducted for a period of 4 weeks, from 14 March 2023 to 10 April 2023, when the details on the analgesic prescription and the time to administration of the first analgesia were collected prior to the interventions. The median door-to-first analgesia administration time was found to be 55.5 min (IQR, 25.75–108 min) during the baseline phase.
Understanding and analysing processes of care
A QI team meeting was conducted after the baseline phase, process mapping was performed and the process of patient flow was drawn for patients presenting with pain due to musculoskeletal injuries to the ED (figure 1A). Fishbone analysis was performed to identify the causes of delay in the administration of the first analgesic (figure 1B). The major bottlenecks identified were communication delay between the triage team and resident doctor, communication gap between the resident doctor and nursing officer, and knowledge gap regarding pain management among the residents. The QI team formulated change ideas based on identified bottlenecks and tested them in four phases of 1 week each, that is, during the intervention phase.
(A) Process flow diagram, (B) fishbone analysis. *Not a walking patient referring to patients in wheelchair or trolley beds. MRD, Medical Records Department.
Interventions
Strategy
The intervention phase was conducted from 11 April 2023 to 8 May 2023. The change ideas were tested using PDSA cycles, and successful ideas were implemented.
Intervention phase 1 (11 April–17 April 2023)
Bridging the communication delay between the triage officer and the resident doctor
Pain management initiation hinges on effective pain assessment, but overcrowding in the yellow or green areas led to delays in patient assessment by resident doctors. Communication delay between triage team and resident doctors regarding pain severity was identified as a bottleneck. Despite patient details being entered in the online triage system, there was a real-time delay in notifying resident doctors about their assigned patients through the web-based system. Patients were being given a slip at the triage in which the patient’s name, age, sex and vital signs were written along with specific assignment details. Despite the pain score being entered into the online triage entry form, it was not routinely mentioned in the triage slip. We formulated a printed ‘ED Triage Slip’ and pain score was included as one of the vital signs in it. Pain scores were made compulsory on the triage slip, with scores of 4 or more highlighted. To expedite care for patients with moderate-to-severe pain, a ‘runner’ from triage was assigned to notify resident doctors. Additionally, colour-tags (yellow) were implemented at triage for easy identification of patients requiring pain management.
Intervention phase 2 (18 April–24 April 2023)
Emphasising pain assessment and early analgesic administration
QI is an iterative process. We identified a significant bottleneck attributed to resident doctors not giving sufficient attention to pain assessment and early pain management. To address this issue, we strategically placed a picture-based NRS at resident doctors’ desks, and conducted didactic sessions emphasising the need for proactive pain management before transporting patients to the radiology room for investigation. Posters reinforcing these principles were prominently displayed throughout the ED.
Intervention phase 3 (25 April–1 May 2023)
Formulating departmental pain management protocol for musculoskeletal injuries
Despite prior efforts to prioritise pain management, a knowledge gap persisted among resident doctors, particularly first-year emergency medicine postgraduate trainees and those from other departments on peripheral posting in the ED. Identified as a bottleneck was the absence of a departmental pain management protocol. To address this, the investigators developed a protocol tailored to managing musculoskeletal pain in the ED. Training sessions were then conducted for resident doctors by the investigators, initially covering all three shifts to include all residents, followed by biweekly sessions to train rotating postgraduate trainees from other departments.
Intervention phase 4 (2 May–8 May 2023)
Bridging the communication gap between the resident doctor and nursing officer
The communication gap between resident doctors and nursing officers regarding analgesic prescriptions posed a challenge. To address this, didactic sessions were held to instruct resident doctors on structured prescription writing. Structured prescription writing involved using a standardised format for documenting prescription orders. It included patient’s details (name, age, gender, hospital ID), medication details (medication name, form, dosage, route of administration, frequency of administration, special instructions if any), clinical indication and prescribing doctors’ name and signature. Prescription audits were conducted to monitor adherence, with corrective feedback provided as needed.
Results
The results of the QI project are presented in table 1 and the run chart is depicted in figure 2.
Run chart. ED, emergency department.
Results of various phases of study
During the first PDSA cycle, the reduction in median door-to-analgesia time (45 min (IQR, 30–71 min)) was not statistically significant (p=0.349) and no shift or trend in the data points was observed in the run chart. Despite this, we opted to persist with the intervention in the subsequent phase, considering that the effects of the change might require additional time to manifest. Furthermore, this intervention had a positive impact on communication and patient care. Therefore, we chose to retain it to prevent potential negative effects on workflow and patient outcomes if withdrawn. During the second PDSA cycle, we observed a significant improvement in median door-to-first analgesia administration time (decreased to 40 min (IQR, 17–58 min), p=0.041) and a positive pattern was evident in the ‘shift’ observed in the run chart. During the third PDSA cycle, though there was a substantial improvement in the median door-to-analgesia time (reduction to 26 min (IQR, 15–51 min), p=0.017) and a noticeable shift was observed, no specific trend was identified in the run chart. During the fourth PDSA cycle, the median door-to-analgesia time significantly decreased to 20 min (IQR, 6–40 min) (p<0.001) and a distinct shift was observed in the run chart compared with the baseline median.
During the postintervention phase, which extended from 9 May 2023 to 5 June 2023, sustainability of results was evaluated. On analysing the run chart plotted for the postintervention phase, shifts in the data were identified, yet no distinct trend emerged. Notably, there were numerous runs and the data points did not consistently cluster on one side of the median. This observation implies a degree of randomness or variability in the process. However, the median time from door to analgesia administration decreased to 15 min (IQR 5–37 min), significantly lower than the median time in the combined baseline and intervention phases, that is, 45 min (p<0.001). These findings suggest that the positive changes implemented during the intervention phase were effective and sustained, contributing to continued process improvement.
Discussion
This QI project aimed to reduce the time to analgesia administration in patients presenting to the ED with musculoskeletal injuries. Our focus was on generating change ideas that are suitable for implementation in high-volume EDs with resource constraints. These change ideas were tested through PDSA cycles and subsequent implementation. We adopted simple measures, such as documenting pain scores at triage, organising didactic sessions on proactive pain management for resident doctors, formulating a departmental pain management protocol and conducting prescription audits.
Our first intervention aimed to address the communication delay between triage officers and resident doctors. By introducing an ‘ED Triage Slip’ that included the pain score as a vital sign, and implementing colour-coded tags for patients with a pain score of 4 or more, the project aimed to streamline communication and expedite the assessment of patients with moderate-to-severe pain. The inclusion of a designated ‘runner’ further aimed to facilitate prompt communication, although the availability of the runner was not guaranteed during busy periods. Although the reduction in median time to first analgesic administration was not statistically significant, the positive impact on communication between triage officers and resident doctors encouraged the continuation of this intervention into the subsequent phases. Pain score assessment at triage has been shown to decrease the time to prescription of the first analgesic in previous studies.14 15 Additionally, nurse-initiated analgesia at triage has been associated with reduced analgesia administration time.17 19 20 However, this optimal change idea was not feasible in our context due to the absence of triage nurses capable of administering analgesia.
Recognising the importance of pain assessment and early analgesic administration, the second phase strategically positioned a picture-based NRS on the desks of resident doctors. The NRS is a validated pain scale for measuring acute pain in the ED settings.21 While NRS can be verbally administered, our deliberate approach aimed to enhance adherence through visual cues. In addition, instructional sessions emphasised proactive pain management, prioritising pain assessment before other diagnostic investigations, particularly in non-life-threatening or limb-threatening cases. This phase yielded a statistically significant reduction in the median door-to-first analgesic administration time (40 min), demonstrating the effectiveness of reinforcing pain assessment practices.
Despite progress, a knowledge gap regarding pain management persisted among resident doctors. To address this gap, a comprehensive departmental pain management protocol has been developed. A multifaceted approach was adopted to ensure effective implementation. Didactic sessions were meticulously organised to educate resident doctors, seamlessly integrated into their shifts to ensure comprehensive coverage. Residents from other departments, rotating through the ED, and newly joining residents were promptly trained on their first day, emphasising the importance of standardised pain management practices from the outset. To reinforce adherence to the developed protocol, visual aids in the form of posters were strategically placed in all areas of the ED. This ensured constant reinforcement of the protocol and served as a visual reminder to residents. The impact of this intervention was notable, with a significant reduction in the median time to administration of the first analgesia (26 min). This outcome highlights the critical need to standardise pain management protocols across departments, aligning with findings from prior research.10 13
In the fourth phase, instructional sessions on prescription writing were conducted to bridge the communication gap between resident doctors and nursing officers. Prescription audits and corrective feedback were used to reinforce structured prescription writing, resulting in a significant reduction in the median time for first analgesic administration (20 min).
The interventions led to sustained improvement in the door-to-analgesia administration process during the postintervention phase. Despite stochastic variation, the median time decreased to 15 min, reflecting the continued positive impact of the changes. The introduction of systematic protocols, continuous training sessions and feedback mechanisms contributed to sustained improvement in the process.
Challenges faced
Despite continuous training on pain assessment using the NRS, the triage team faced challenges in interpreting patient responses. While the NRS is intended to be a subjective and patient-reported pain scale, its application proved challenging in patients already experiencing distress. Staffing shortages in our bustling ED posed significant challenges, with nursing officers managing multiple patients simultaneously, administering various medications in addition to analgesia, leading to occasional delays in analgesia administration. Due to staffing constraints, implementing a ‘runner’ from triage to expedite pain management for patients was not always feasible. Additionally, burnout among ED residents occasionally hindered project execution, impacting their performance and engagement in improvement efforts.
Strengths
One notable strength of this study is its prospective design, which allows for the collection of real-time data, enhancing the reliability of the findings and provides a robust foundation for analysing the impact of interventions. Moreover, in this study, focusing on the time to analgesia ‘administration’ rather than ‘prescription’ provided a more clinically relevant outcome measure, as it reflects the actual time it takes for patients to receive pain medication.15 The incorporation of educational training programmes and creation of posters served as effective strategies in this study. These initiatives enhanced the knowledge and skills of the healthcare staff and also provided visual reminders, reinforcing adherence to standardised pain management practices. The strategic implementation of educational training for residents during their shifts ensured comprehensive coverage, allowing us to reach all residents on the first day of each intervention phase. Integrating training into their shifts addressed attendance challenges associated with traditional classroom sessions in the dynamic ED setting. This innovative approach facilitated greater accessibility and engagement among residents, enhancing the effectiveness of our intervention.
Lessons learnt and limitations
Although the project demonstrated significant improvements, certain limitations should be acknowledged. The observed randomness in the postintervention phase suggests challenges in maintaining consistent improvement, highlighting the need for continuous monitoring. Future initiatives could explore strategies to minimise variation and enhance consistency. In this study, we focused solely on the time to the first analgesic administration, excluding factors like pain reassessment and overall pain relief. Therefore, our assessment may not fully capture the comprehensive impact of our interventions on pain management outcomes. We excluded patients in the red zone to maintain consistency and prioritise patient care, but this may limit the generalisability of our findings. Given the prevalent societal issues surrounding opioid abuse and addiction, it is imperative to approach pain management with careful consideration and attentiveness. However, our study lacked specific measures to identify drug-seeking behaviour or substance abuse disorders before providing pain relief. To mitigate this issue, we suggest implementing screening protocols and using validated assessment tools to identify individuals at risk and evaluate their susceptibility to drug-seeking behaviour. Though educational elements were incorporated into the third and fourth PDSA cycles, we had a lack of documented evaluation regarding their effectiveness in enhancing the learners’ knowledge base. We lacked a structured feedback mechanism from staff and residents, limiting our understanding of their experiences and challenges in executing changes. The hospital administration was not involved in this project, and was conducted solely at the ED level. Their input could have provided valuable insights into broader organisational strategies, allocation of resources and policy changes necessary to support the project’s implementation and sustainability.
Our sustainability plans encompass integrating pain management training sessions not only into the induction programme for new residents joining the department but also into the training curriculum for all relevant ED staff. We aim to engage hospital administration and foster collaboration with other departments and hospital policies to amplify the project’s overall impact. Through consistent implementation of these strategies over an extended period, we anticipate their integration into the department’s ethos, ensuring enduring sustainability. Additionally, we plan to institute regular reviews and audits to meticulously monitor adherence to established protocols. This commitment to ongoing evaluation will enable us to continuously refine and enhance our practices.
Conclusion
This QI project successfully addressed communication gaps, enhanced pain assessment practices, and streamlined processes, resulting in a substantial and sustained reduction in the median time to the first analgesic administration. The multi-phased approach, emphasising education, protocol development and effective communication, proved to be instrumental in achieving the project’s objectives. It is evident that even simple change ideas can significantly impact outcomes. Continuous monitoring, targeted interventions and a comprehensive approach are pivotal in sustaining and optimising the achieved improvements.
Data availability statement
Data are available upon reasonable request. Data from this study are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study was approved by the Institute Ethics Committee for Observational Studies (Project Identification Number JIP/IEC-OS/2022/325) in line with the Declaration of Helsinki.
Acknowledgments
All the QI team members (Dr Balamurugan N, Dr Anandhi D, Dr Ezhilkugan G, Nursing team- Sr Nithyavani, Sr Shanthi G) and emergency department staff for their involvement and contributions to this project.
References
Footnotes
X @Drmanuayyan
Contributors ASS was responsible for the conduction of the improvement process, data collection and contributed to the drafting of the manuscript; AK was responsible for the conduction of the quality improvement process, data collection and contributed to the drafting of the manuscript; SSN was responsible for data collection and compilation, SMA participated in the project concept and design as well as the manuscript writing, data analysis and revisions and is the guarantor of the overall content of this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.