title: Emergency Department Pain Management in Adult Patients With Traumatic Injuries Before and After Implementation of a Nurse-Initiated Pain Treatment Protocol Utilizing Fentanyl for Severe Pain.
abstract: BACKGROUND
  Pain management in the emergency department (ED) remains suboptimal. Nursing staff protocols could improve this, but studies show divergent results.
  
  
  OBJECTIVE
  Our aim was to evaluate a nurse-initiated pain-management protocol in adult patients with traumatic injuries in the short and in the long term, utilizing fentanyl for severe pain.
  
  
  METHODS
  In this pre-post implementation study, ED patients were included during three periods. The protocol allowed nurses to administer acetaminophen, non-steroidal anti-inflammatory drugs, or fentanyl autonomously, based on Numeric Rating Scale pain scores. Primary outcome was frequency of analgesic administration at 6 and 18 months after implementation. Secondary outcomes were pain awareness, occurrence of adverse events, and pain treatment after discharge.
  
  
  RESULTS
  Five hundred and twelve patients before implementation were compared with 507 and 468 patients at 6 and 18 months after implementation, respectively. Analgesic administration increased significantly at 18 months (from 29% to 36%; p = 0.016), not at 6 months (33%; p = 0.19) after implementation. Pain awareness increased from 30% to 51% (p = 0.00) at 6 months and to 56% (p = 0.00) at 18 months, due to a significant increase in pain assessment: 3% to 30% (p = 0.00) and 32% (p = 0.00), respectively. Post-discharge pain treatment increased significantly at 18 months compared to baseline (from 25% to 33%; p = 0.016) and to 6 months (from 24% to 33%; p = 0.004). No adverse events were recorded.
  
  
  CONCLUSIONS
  Implementation of a nurse-initiated pain-management protocol only increases analgesic administration in adult patients with traumatic injuries in the long term. Auditing might have promoted adherence. Pain awareness increases significantly in the short and the long term.
authors.affiliation: Department of Emergency Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Milan L
authors.initials: ML
authors.lastname: Ridderikhof
authors.affiliation: Department of Emergency Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Frederick J
authors.initials: FJ
authors.lastname: Schyns
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Niels W
authors.initials: NW
authors.lastname: Schep
authors.affiliation: Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Philipp
authors.initials: P
authors.lastname: Lirk
authors.affiliation: Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Markus W
authors.initials: MW
authors.lastname: Hollmann
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000700:Analgesics / Q000494:pharmacology / Q000627:therapeutic use; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data; D005260:Female; D005283:Fentanyl / Q000494:pharmacology* / Q000627:therapeutic use; D017408:Guidelines as Topic / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010146:Pain / Q000188:drug therapy; D059408:Pain Management / Q000379:methods* / Q000706:statistics & numerical data; D010147:Pain Measurement / Q000379:methods / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000150:complications*
chemical_list: D000700:Analgesics; D005283:Fentanyl
keywords: musculoskeletal disorders; orthopedics; pain; pain management; trauma