Three years ago many best practices already were in place at LDS Hospital in Salt Lake City, Utah, USA. The hospital was providing bedside registration, advanced triage protocols, point of care testing and real time radiology. A robust and comprehensive continuous quality improvement program had been established and as a result, higher patient satisfaction scores, declining walkaway rates and shorter turnaround times had been realized.
About LDS Hospital
LDS Hospital, part of Intermountain Health Care (IHC), is a 547-bed tertiary care, trauma and referral center in Salt Lake City. It has 31 emergency department beds. Its 2002 statistics include serving 36,000 patients, an admission rate of 19 percent and a walkaway rate of under 1 percent. The hospital is affiliated with the University of Utah School of Medicine.
Despite all of this, the hospital staff recognized a problem in the rapid treatment of painful conditions in the emergency department (ED). Alerted by a number of complaints from patients, the staff in the emergency department began a pain management initiative in 2002 to remedy the problem.
Pain is one of the major symptoms that cause patients to seek emergency medical care. Not surprisingly, studies have shown a correlation between pain relief and patient satisfaction. Numerous studies also have indicated that perceived waiting time is the most important variable contributing to patient satisfaction. Thus, while the complexities of pain management in the ED are only beginning to be unraveled, it is clear that timely alleviation of adverse symptoms deters patients from leaving before they have been seen by a doctor. This, along with the knowledge that feedback to caregivers through quality improvement data affects the behavior of healthcare providers, was utilized in tackling the defects in pain management in the LDS Hospital emergency department.
The Pain Reduction Project
With the goals of increasing the rate of administering pain treatment and reducing the time to administration, a quality improvement initiative was begun. It involved a chart audit, the formation of a work team, a root cause analysis, developing a new process and a second audit. The work team used the DMADV (Define, Measure, Analyze, Devise, Verify) roadmap to resolve the ED pain issue.
Using the DMADV Roadmap
- Define – The problem was increasing patient dissatisfaction regarding pain management.
- Measure – A screening tool was devised to audit medical charts to determine how often and how quickly patients’ pain concerns were addressed.
- Analyze – A work team was formed to address the problem. The team noted that many processes had to occur in the ED before a patient could receive pain treatment. Though necessary, these processes had no intrinsic value to the patient.
- Devise – Physicians and nurses were given feedback regarding an initial pain management audit, and an educational initiative regarding pain management techniques was begun. Ways to decrease the time to pain control were sought. A cultural change occurred within the department and an attitude of intolerance for untreated pain was fostered.
- Verify – A repeat audit of pain management in the ED revealed tangible improvements. Time to pain management went from 67 minutes to 46 minutes and untreated pain dropped from 39 to 11 percent. Further, the overall patient satisfaction scores improved.
A version of the visual analog scale (VAS) is used routinely in the department to assess the patient’s perception of pain and is included in the nurses’ computerized charting. Moderate to severe pain was defined as VAS 4 or higher. A search was done of patients using the VAS criteria and 100 charts were randomly audited using a chart screening tool. Time to pain management was defined as the interval between triage (when the patient was recognized as an ED encounter) and the administration of a pain medication or other intervention as documented in the nursing record. The rate of pain treatment was defined as the number of patients who received a pain intervention divided by the number of patient encounters audited.
The chief complaint, the pain scale number and the type of treatment given were all recorded, as well as the documentation of pain relief. Other data recorded included patient demographics such as age and gender. Comfort measures – defined as ice packs, warm blankets, splints or pillows/positioning of patient – were noted in the audits as well.
Physicians were made aware of the first audit findings and in monthly staff meetings began working on the development of chief complaint-based patient care protocols for painful conditions. The work on these protocols kept the focus of the department on pain management issues for an extended period of time.
Nurses were in-serviced with an educational module on pain management in the ED. Quality goals were set to improve the rate of administering pain medication and the timeliness of administering the medication. The work team also developed other advanced triage protocols (Table 1) which allowed staff to begin pain management through adjunctive treatments like splints, ice, warm blankets, local anesthetics and non-narcotic medications.
|Table 1: Process Redesign Using Advanced Triage Protocols
|4. M.D. Sees and
|Table 2: Results of Two Pain Management Audits
|Data Recorded (100 Patients)
|Top Pain Complaints
|Gender of Patients
|Time to Medication
|< 15 Mins.
|< 30 Mins. (cum.)
|< 1 Hour (cum.)
|< 2 Hours (cum.)
|> 2 Hours
Six months after the training module was complete and as the pain management initiative continued, a second chart audit was performed. One hundred charts were again randomly audited using the screening tool and the same criteria for moderate to severe pain. In addition, patient satisfaction surveys performed independently during the study period were incorporated into the study analysis.
Comparing Before and After Audits
The results of the two retrospective pain audits (Table 2) showed that the two groups of patients audited were closely matched in terms of age and gender. In both groups, the top two chief complaints of patients with moderate to severe pain were injuries and abdominal pain. Back pain, headache and flank pain also were fairly frequent. The average time to pain medication prior to the intervention was 67 minutes, while the average time to pain medication after the intervention was 46 minutes. Thirty-nine percent of the patients received no pain medicine in the first audit, while only 11 percent received no pain medication in the second audit.
Patient Satisfaction Scores Climb
In addition, the results of patient satisfaction surveys performed after the pain management education initiative and the implementation of the patient care protocols were analyzed in conjunction with the pain audit data. Between January and October of 2002, scores rose from 3.93 to 4.37 (see the figure below). Further, the number of patients who reported their pain control as “excellent” rose from 29.8 to 39.1 percent.
Conclusion: Project Achieves All Its Objectives
The initiative to improve the treatment of pain in the emergency department at LDS Hospital was successful. The goals of increasing the rate of administration of pain therapies and decreasing the time to pain management were met. And, this in turn had a positive effect on patient satisfaction.