Pain

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Introduction

Frailty and persistent pain are both common amongst OAs and together contribute to disability and emotional distress. The impact of pain on everyday life is potentially modifiable with appropriate pain management techniques, but current services do not always take account of the needs of frail OAs. The Pain in Older People with Frailty Study (POPPY) is a mixed-method study to develop the content and implementation strategies for services to optimise the support available for OAs living with frailty and pain. Initial objectives of the POPPY study included seeking views from healthcare professionals (HCPs) and commissioners on existing local services including their experiences of the barriers faced by OAs with frailty accessing these services, and views on how resources might be best deployed to support OAs with frailty. 

Methods

In-depth qualitative interviews were conducted with HCPs from across England, based in specialist, secondary care and community services. Interviewees included commissioners, GPs, physiotherapists, occupational therapists, psychologists, nurses, doctors, and health coaches. A thematic approach to data analysis was used.    

Results

Forty-two HCPs and 2 commissioners from 9 pain services and 2 generic community services were interviewed. HCPs recognised that OAs living with frailty and pain formed a distinct group, experiencing shared facilitators and barriers to engagement. Meeting the needs of this group was challenging for services. Most HCPs thought a dedicated pain service for frail OAs was impractical and disagreed with the concept of age-based pain services. HCPs thought the needs of frail OAs were most likely to be met by community-based services, staffed with appropriately skilled multi-disciplinary teams, interacting effectively with other specialist services, and delivering holistic individualised approaches.   

Conclusion

Pain services need to be responsive to the specific needs of OAs with frailty and recognise the importance of adapting content and delivery of interventions to reflect this.  

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Introduction

Identification of pain generally relies on patient self-reporting of symptoms. Patients with limited communication, advanced dementia or learning disabilities are unable to self-report pain. This results in pain being under-recognised and under-treated. Consequences of this are serious and include physical and psychological distress, longer length of stay and worse outcomes.1

Methods

Abbey Pain Score (APS) (Figure 1)was introduced on a single Healthcare of the Older Person ward.2,3 It was used as the primary means of assessing pain in non-verbal patients (NVP) in place of the usual verbal pain scale (scored 0-10). Ward-based teaching for all doctors, nurses and healthcare assistants was conducted before introduction of the APS. Data was collected for 20 consecutive NVP (Figure 2). Figure 1: Abbey Pain Score (Six items observed & Score) Vocalisation: 0-3 Facial expression: 0-3 Change in body language: 0-3 Behavioural change: 0-3 Physiological change: 0-3 Physical changes: 0-3 Scoring scale No Pain (0-2) Mild Pain (3-7) Moderate Pain (8-13) Severe (14+)

Results

At baseline we identified that pain as a symptom was missed in 54 % of NVP using the verbal pain score. With introduction of APS this dropped only slightly at 3 months but there was an increased uptake in scoring NVP on APS. With persistent engagement there was a significant decline in number of patients with un-managed pain needs. Figure 3: Abbey pain score (All patients with any pain) Baseline : Pre-intervention: 21 / 39 (54 %) Post-intervention (3 months): 10 / 20 (50 %) Post-intervention (12 months): 1 / 19 (5 %)

Conclusion

ABP is a effective means of addressing pain in NVP. It is simple to implement and can lead to significant improvements in patient care.

Introduction: Acute pain is a common presentation of elderly and tends to be under-recognised and under-treated. Consequently, delayed and inadequate treatment of acute pain is known to lengthen in-hospital stay whilst reducing quality of life. Using local hospital guidelines for acute pain management in adults as gold standard, anecdotally we felt patients were not received medication as per guidance. A quality improvement project was undertaken with an aim to increase the number of patients >65 years old that received appropriate analgesia within the first 24-48 hours of presenting to the front door with acute pain by 15% within 8 months.

Methods: The study cohort composed of randomly selected patients > 65 years of age presenting to the front door with acute pain in the form of soft tissue injury, suspected/confirmed fracture. Parameters for data collection included cognitive background, pain assessment done on admission, analgesia prescribed in the first 24-48 hours and whether prescribed appropriately as directed by hospital guidelines. During the project period, the first intervention was aimed at sensitising medical staff of timely initiation and appropriate analgesia in elderly with an info graphic poster put up in the acute assessment unit and highlighted during Acute Medicine safety brief. A second intervention was directed at nursing staff regarding pain assessment on admission using a poster and emphasizing its importance during nursing handover.

Results: The percentage of patients who had pain assessment done increased from 27.8% to 75.0% during the project period. Similarly, of those prescribed analgesia, the percentage of patients prescribed appropriately rose from 66.0% to 86.8%.

Conclusion: This project has positively impacted the number of patients who received appropriate analgesia. Accurate pain assessment helped to determine choice of analgesia. Limitations include using age cut-off for elderly instead of frailty reflecting a role and need for frailty-based guidance.