OP-21: Time to Pain Management for Long Bone Fracture

Background

As many of you are aware, one of the current ED Core Measures is OP-21:

Median Time to Pain Management for Long Bone Fracture.

OP-21: Time to Pain Management for Long Bone Fractures

Background

We see median times of 55-65 minutes (or more) to treat these

painful fractures. These times are reported at various hospital

meetings, and on various reporting websites such as Hospital Compare.

???Question

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Why do we seem to be so slow with Pain Management

for Long Bone Fractures?

Hospital Example:By going to Hospital Compare, we find the following data for a given hospital:

Does it really take 54 minutes across the country for a patient to receive pain medication for a painful long bone fracture?

The wording above is quite interesting and leads us astray about what is really going on. So let’s take a 5 patient quiz and see how we do calculating how long a patient waits for pain medication

for a long bone fracture …

Patient # 1

40 year old patient from an MVC has an open fracture of the right femur. He is in severe pain and receives 100mcg fentanyl by EMS. He continues in pain on ED arrival and receives multiple doses of Dilaudid, with the first dose given 2 minutes after arrival. He is admitted for surgery.

What time is calculated “Time to Pain Management” for this patient?

Patient #1Answer

This patient doesn’t count!

He is excluded from calculation, having received medication prior to arrival.

Actually, any pain medication given prior to arrival, including oral medication would exclude the patient from the measure.

Patient # 2

80 year old patient falls and injures her right hip, no medications given by EMS (with the concern of altering the patient’s mental status). However, morphine is given in the ED 3 minutes after arrival. Patient is found to have a hip fracture and is admitted for surgery.

What time is calculated “Time to Pain Management” for this patient?

Patient # 2Answer

This patient also doesn’t count!

OP-21 is an “Outpatient Measure” (OP stands for “outpatient”) and only includes patients either discharged or transferred.

Patient # 3

12 year old patient with wrist pain after a fall 4 days earlier. Parents haven’t been giving pain medication at home as relatively painless, and are only in the ED because of wrist swelling and some trouble writing at school. Wrist x-ray comes back after 1.5 hours showing a buckle fracture. The wrist is splinted and the parents, now feeling guilty, ask for a dose of Tylenol prior to leaving. Tylenol is given 2 hours after arrival to the ED.

What time is calculated “Time to Pain Management” for this patient?

Patient # 3Answer

120 minutesThe patient has a long bone fracture, no pain medication at home, and first pain medication is given 120 minutes after

patient arrival to the ED.

Patient # 4

42 year old patient with ankle pain after twisting his ankle playing basketball. The patient is found to have a small avulsion fracture of the distal fibula on x-ray. The patient receives a shot of Toradol 1.5 hours after arrival.

What time is calculated “Time to Pain Management” for this patient?

Patient # 4Answer

90 minutesThe patient has a long bone fracture, no pain medication at home, and first pain

medication is given 90 minutes after patient arrival to the ED.

Patient # 5

75 year old patient falls injuring his wrist which has an obvious deformity. He doesn’t want pain medication as he says it doesn’t hurt if not moved.The physician writes in the record that the patient “is not in pain” and doesn’t give pain medication. The nurse writes in the medical record “pain is 0/10”. The x-ray shows a Colles’ fracture that will require reduction. Reduction is set up, including finger traps, splint, etc, and a hematoma block is given 2 hours 10 minutes after arrival.

What time is calculated “Time to Pain Management” for this patient?

Patient # 5Answer

130 MinutesOK, intentionally a little tricky here. The hematoma block is considered pain medication, and is the first given after the patient arrived. However, if the nurse or physician documented the initial refusal of pain medication, the patient would be excluded. But as

there was no specific statement (only the documentation of no pain), the patient is included.

These examples show the challenges with this measure. Given the patients above, most might think that the hospital did an appropriate job of pain control, yet Hospital

Compare would list 120 minutes for this hospital as “Time to Pain Management”. The median (not the mean) for these 5 patients (excluded, excluded, 90,120,130) is 120

minutes. The wording from Hospital Compare (below) doesn’t appear correct as those patients we think about requiring immediate pain medication (the first 2 patients) are

excluded:

“Average (median) time patients who came to the emergency department with broken bones had to wait before getting pain medication.”

Rules to follow…

Inclusion

• Patients >2 years old with a long bone fracture (any fracture of the humerus, radius, ulnar, femur, tibia, fibula)

• 2-17.9 years old: Given oral, intranasal, IM or IV medications, conscious sedation, or any nerve block/hematoma block in the ED

• 18+ years old: Same list but if first does is oral, patient is excluded. Otherwise, same as above.

Exclusion

• < 2 years old

• No pain medication in ED given

• Patient is admitted

• Pain medication (including oral Tylenol/Motrin) given prior to arrival OR taken on regular basis in patient of any age

• For patients >=18 years old, first dose of pain medication is oral medication

OP-21 Children Ages 2-18th Birthday

So inclusion is no pain med PTA, pain med in ED (any route), and not admitted.

Pre-Hospital ED Disposition

Exclusion1. Regular pain

medication2. Acute pain medication

1. No pain medicine given (any route).

2. Specific statement of pain medication refusal.

Admission

InclusionNo pre-hospital pain medicine (PO, IV, IM, IN) given (chronic or acute) including Motrin/Tylenol.

Time of first pain medicine is the measure (PO, IM, IV, IN).

Home or Transfer

OP-21 |patients >18 years old

So inclusion only if no pain med PTA, first dose IM, IV, IN (not oral) and patient discharged or transferred.

Pre-Hospital ED Disposition

ExclusionAny pain medicine given (PO, IV, IM, IN) either chronic or for acute episode

1. No pain medicine given.2. First dose pain

medicine oral route.3. Specific statement of

pain medication refusal.

Admitted

InclusionNo pre-hospital pain medicine (PO, IV, IM, IN). No chronic pain medicine (including Motrin/Tylenol).

Time to first pain med as long as IM/IV/IN. (First dose oral excludes patient.)

Home or Transfer

Summary1. Most important is to take great care of patients in pain by continuing to give

timely pain medications to appropriate patients (although the obvious patients will likely be excluded from this measure).

2. A triage protocol that insures everyone receives an oral dose of medication for a potential long bone fracture may greatly improve Pain Management times.

3. Patients with any (documented) pain medication prior to ED are excluded, even if oral medication.

4. If patient refuses pain medication initially, document that statement. 5. Patients who are admitted are excluded.

I hope this clears up OP-21!