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?