An audit of the pain pathway from admission to discharge ... · PDF fileAn audit of the pain...

Are you in any pain? An audit of the pain pathway from admission to discharge in fractured Neck of Femur Patients Presented by Dr Andrew Kermode

KSS ASHN #NOF Collaborative Meeting 24th June 2015

Contents • Aim

• Patient Journey

• Current NICE Guidelines

• Developing an Audit Proforma

• Methods

• Results

• Discussion

• Action Plan

• Available proforma

Aim • Our aim was assess the patients pain pathway from first contact

with healthcare workers to the post-operative period. • Subsequently, any possible areas for improvements to aid pain

management

• Identify what analgesia a patient was receiving, who was giving it, and how long it took them to receive it, including any adjuvant analgesia.

• Create a universal Audit Proforma that can facilitate the audit process, and be made available to other trusts.

Current Patient Journey • Patient picked up by ambulance

• Analgesia given en-route

• Arrival at ED • Crew registers patient arrival with Reception • Verbal handover to Nursing staff

• Triage by nurse

• X-ray to rule out #NOF

• Seen by ED Doctor

• #NOF call via 2222

• Clerked by Orthogeriatrics/Ortho in ED/Ward in #NOF MDT Booklet • Transferred directly to Orthogeriatric/Ortho ward

• Operation within 24hrs of admission

• Rehab

Current NICE Guidelines (CG124) • Assess the patients pain

• Immediately

• 30minutes following initial analgesia

• Hourly until settled

• As part of routine observations

• Ensure analgesia is sufficient enough to allow movements necessary for investigations and for nursing care and rehabilitation

• Offer paracetamol every 6 hours pre-operatively and post-operatively

• Offer additional opiates only if paracetamol alone is ineffective

• Nerve block if paracetamol/opiates ineffective or to limit opiate use

• Avoid the use of NSAIDs

Developing an Audit Proforma We assessed divided sections based on NICE Guidelines and

criteria we wished to include:

1. Patient Demographics • Hospital Number/A&E Cas Card Number

• Sex

• Age

• Weight

2. Pain assessment at presentation • Pain on arrival – at rest and on movement

• Pain 30 minutes after analgesia given

• Pain assessed hourly until settled

• Pain scores as part of routine observations

• Pre-operative pain scores

Developing an Audit Proforma 3. Analgesia in the Pre-hospital Environment and in the

Emergency Department (ED) • What analgesia was given by the ambulance crew? • Length of time to analgesia offered in A&E? • Was paracetamol given/offered in A&E? • Were opiods required? If so, what dose & route? • Was an NSAID given? • Was the A&E page of our MDT booklet filled out?

4. Fascia Iliaca Compartment Blocks (FICB)

• Was it offered? • Was it given? • Where was it performed? • Who provided the FICB? • Length of time to FICB being given? • Did the patient have subsequent 3 observations 15minutes apart? • What was the response to the nerve block?

Developing an Audit Proforma 5. Post-operative pain assessment • Pain score on arousal post-operatively?

• Assessed as part of the ward round?

• Part of routine observations?

• Documented on Day 1 post-operatively at rest and on movement

Methods • Assessed every patient admitted to the hospital with a #NOF for

5-6 weeks

• Collate information from:

1. Paramedic documentation

2. A&E clerking & triage

3. Documentation in the Orthogeriatric #NOF MDT Booklet • A&E first page

• Clerking

• Pre-operative assessment

• Anaesthetic notes

• Post-operative notes

• Ward round

4. Vital PAC (electronic observations)

5. Drug chart

Results • 31 patients assessed – 23 females (74%), with average age of 85

• 2 incomplete data sets – pre-op transfer/missing A&E notes

• Poor at recording pain scores: • 62.1% of static pain scores recorded, average of 4.5/10

• 6.5% of dynamic pain scores recorded (2/31)

• 10% of pain scores recorded after analgesia.

• No patient had hourly pain scores until they moved onto the ward

• Pre-hospital Analgesia (n=) • 69.2% of crews gave analgesia (18)

• 36.7% gave Paracetamol AND/OR Morphine (11)

• IV was the preferred route for Paracetamol (8)

• IV was the preferred route for Morphine (10)

• Ibuprofen 400mg PO was given on two occasions

• Co-codamol 30/500s were given on two occasions

Results • In Accident & Emergency (n=)

• 46.7% of patients were given Paracetamol (14)

• Average time of 105 minutes till given/offered

• 26.7% received an opiate in the ED (8)

• No further patients received an NSAID

• 80.8% received paracetamol in the pre-hospital or A&E environment (21)

• MDT #NOF Booklet Compliance • 16.7% of ED booklets were completed (5)

• 40% were Incomplete (12)

• 43% had no documentation at all (13)

Results • Fascia Iliaca Compartment Blocks (n=)

• 80% of patients were offered (24), 76.7% were given (23)

• No documentation of contraindication was noted or Inappropriate reason

• 69.6% received a FICB in A&E (16)

• 30.4% received a FICB in theatre (7)

• Average time to FICB was 189 minutes – 3hr 9mins (for those done in the ED)

• Who performed the FICB? • A&E staff performed 60.9% (14)

• A&E Registrar performed 47.8% (11)

• Anaesthetists performed 30.4% (7), all in theatre

• Orthopaedic Team performed 8.7% (2)

• Only 60.9% of required observations recorded (14)

• 78.3% had a good apparent response to FICB (18)

Results • Anaesthetic (n=)

• 44.8% had a GA (13)

• 62.1% had a spinal (18)

• Post-operative pain scores (n=) [avg] • 100% of patients had a pain score on arousal (30) [0.4]

• 100% had pain scores recorded routinely through VitalPACS

• 76.7% of patients had a pain score recorded on Day 1 WR (23) [0]

• 56.7% had a static pain score recorded on Day1 Post-op (17) [0]

• 20% had a dynamic pain score recorded on Day1 Post-op (6) [0]

Discussion • Difficulty obtaining information • Multidisciplinary working & collaboration

• A&E/Anaesthetics/Orthogeriatrics/Ortho/Paramedics

• Time consuming • Roughly 20mins a patient = 10 hours 20 mins data collection time

• Pain scores poorly recorded • Static pain scores more likely to be recorded • Pain scores which are 0 more likely to be recorded • Discrepancy between post-operative and pre-operative pain score regular

assessment • VitalPACs on the wards, not present in A&E

• Inconsistent Analgesia in Pre-hospital environment • Morphine just as likely to be given as Paracetamol • 3 patients received 7.5-10mg of IV Morphine • NSAIDs given in ambulance despite not being recommended by NICE • 4 ambulance charts missing – what was given?

Discussion • A&E • 105 minutes to receive paracetamol in A&E – Could be better?

• 80.8% of patients offered analgesia in pre-hospital or ED environment – Shouldn’t we be aiming for 100%?

• FICB • Majority given in A&E setting, by the A&E registrar

• Poor documentation of observations done – 60.9% had 3xObs recorded

• Poor uptake of the #NOF Booklet, which includes contra-indications/observations

• 3hours 9mins - Good amount of time

• Difficult to interpret response - taken from notes describing patients apparent comfort levels.

Action plan • Improving awareness of pain scores

• Streamlining the Pain pathway

But that’s what the MDT Booklet is for? • Currently MDT booklet isn’t being used.

• Doesn’t include paramedic analgesia given

• Relies on ED staff to find and use it – no incentive

….so how?

• To be given out by receptionists and stuck into A&E notes along with demographic frontsheet

• Area for Paramedics to transcribe when key medications were last given

• Areas for dynamic pain scores

• Pre-prescribed medications, in line with guidance

• Contraindication for FICB included

• Observations, with inclusion of pain score, for duration of stay in A&E

• Styling in line with current A&E notes

• Suspected #NOF pathway currently under discussion, and hopefully will be implemented soon

• VitalPACs to be incorporated into A&E • Improving regular pain score recordings

• Re-audit once change implemented

Action plan

Available Proforma • Created for MDT assessment by myself, Dr Wilson

(Orthogeriatrics) & Dr Minardi (Emergency Medicine)

• Blank proforma available • Focussed on pain assessment

• Made generic for use at other hospitals

• Automatic results calculator

Any Questions?