The effect of a triage pain management protocol for minor musculoskeletal injury patients in a Hong Kong emergency department

Summary 

Background

Pain management in an emergency department traditionally relies on a doctor's prescription, which is affected by long waiting times, and consequently results in decreased patient satisfaction. Triage nurse-initiated pain relief has been evident as an effective measure for pain management in many countries [Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emerg Med 2002;14(3):249–54; Fry M, Ryan J, Alexander N. A prospective study of nurse-initiated panadeine forte: expanding pain management in the ED. Accident Emerg Nurs 2004;12(3):136–40]. This paper aims to: (1) evaluate the effect of a new triage pain protocol on pain assessment for patients with minor musculoskeletal injury in a Hong Kong emergency department; (2) to determine the analgesic efficacy, safety, and time to initial administration of oral Paracetamol at triage; (3) to evaluate barriers to implementation of this protocol.

Method

A mixed-method research design using a pre-test–post-test control group was used while a qualitative research design was used for process evaluation. Two hundred and ninety-five patients aged ≥18 years, with minor musculoskeletal injury of an isolated single limb, participated in this study. Interventions included a triage pain protocol with pain assessment and use of Paracetamol at triage. A convenience sample of 20 patients and five triage nurses were recruited for the process evaluation stage.

Results

There was an increase in the rate of nursing assessment of pain between the pre-test and post-test period (19% versus 81%; p<0.0001). During the post-test period, the time to initial analgesic was shorter (9min versus 93min, p<0.005) and pain reduction score at one hour was greater in the nurse-initiated Paracetamol group compared with patients who waited for a doctor to prescribe analgesic (Z=−4.25, p=0.001). Patient belief and staff work-related stress were identified as the main barriers for triage pain management.

Conclusion

The triage pain protocol is effective for pain management in terms of increasing rate of pain assessment and achieving greater pain reduction at one hour post arrival. However, the consideration of patients’ pain beliefs, pain outcomes, and practitioner compliance is essential for the ongoing success of a triage pain protocol.

Keywords: Triage analgesia, Pain protocol, Musculoskeletal injury, Accident and emergency department, Emergency department