Journal of Orthopaedic Nursing (2004) 8, 91–95

Journal ofOrthopaedic Nursing

www.elsevierhealth.com/journals/joon

The impact of introducing patient controlledanalgesia for trauma patients admitted throughaccident and emergency

Julie Gregory, RGN, ONC, BA(HONS), MSc *, Susan Jackson, RGN, TNCC,ACLS, DN

Royal Bolton Hospital, Minerva Road, Farnworth, Bolton BL4 0JR, UK

Summary An audit found pain assessment in a District General Hospital was rarelydocumented and the prescribing of analgesia inconsistent. Trauma patients weresubsequently admitted to the hospital wards in pain and delay in the prescribing andadministration of analgesia resulted. Changes in practice were introduced throughmulti disciplinary working, teaching and raising awareness, facilitated by theClinical Nurse Specialist (CNS) for acute pain.A disposable PCA device, pre-filled in the aseptic unit in pharmacy was introduced

for suitable trauma patients. Its use was positively evaluated by patients andhospital staff. This paper describes the changes introduced and the improvementsdemonstrated for the patients transferred from A&E to the hospital trauma wards.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSPain management;Patient controlledanalgesia;

Accident & emergency;Orthopaedic trauma;Practice improvement;Education;Clinical nurse specialist

Editor’s commentPractice improvement is often founded on intuition and information from audit processes rather than well organised large scaleresearch trials. This is an example of just such an approach and while it may be criticised on its lack of rigour and ‘scientific’evidence it demonstrates clearly what a team of committed health care professionals can achieve in improving patientoutcomes. PD

Introduction

Pain is one of the major symptoms experienced bytrauma patients attending the Accident andEmergency (A&E) department. Early and effectiveanalgesia is required by trauma patients, prefera-bly at the scene of the accident (Park et al., 2000).It is generally agreed however, that their painmanagement is poor (McCourt, 2001), yet effective

* Corresponding author. Tel.: +1-204-390-763.E-mail address: Julie.Gregory@boltonh-tr.nwest.nhs.uk (J.

Gregory).

1361-3111/$ - see front matter �c 2004 Elsevier Ltd. All rights reserdoi:10.1016/j.joon.2004.04.002

pain relief in an emergency is a marker of goodquality care (Sen, 2002).

The report produced by the Clinical StandardsAdvisory Group (CSAG) in 2000 found pain control inA&E needed to be improved. The main recom-mendations of the report included; the formal as-sessment of pain in A&E, that acute painmanagement becomes a higher priority in A&E andthat the department should liaise with the AcutePain Service (APS). This paper describes a projectintroducing Patient Controlled Analgesia (PCA) toan A&E department, which has worked towardsachieving these recommendations.

ved.

92 J. Gregory, S. Jackson

Background

The pain management of trauma patients in theA&E department of a District General Hospital hadbeen a cause for concern for some time. Theproblems were highlighted when this area ofpractice was critically examined by a staff nurse inthe department who was a link nurse to the acutepain service and was undertaking a pain manage-ment course. She identified that trauma patientswith severe pain may receive a bolus dose of in-travenous morphine initially. They then attend X-ray, and wait for a bed to be available on thetrauma ward. Once admitted to the ward, patientsfrequently have to wait for analgesia to be pre-scribed and administered.

The trauma ward nurses also expressed concernthat patients admitted to the ward were experi-encing severe pain that they felt could be allevi-ated by improved pain management. The A&Emedical staff prescribe a ‘one off’ analgesic dosewhich may no longer be effective by the time thepatient is admitted to the ward. The responsibilityfor continued pain management lies with the or-thopaedic medical staff whom may not be imme-diately available to prescribe the requiredanalgesia.

Initial audit

Kitson (1994) states that audit can challenge atti-tudes and prejudices. The results of an audit canhighlight deficits in care.

It was decided to use audit to identify currentpractice against basic standards of pain manage-ment. The aim of the audit was to examine prac-tice in the clinical area against agreed standards.

The initial audit findings confirmed a poor stan-dard of pain management for the trauma patientswith very few, if any, formal pain scores docu-mented and inconsistent prescribing. Althoughsome patients had IV morphine administered, oth-ers had co-dydramol and one young man with afractured patella had paracetamol only. This wasan unsatisfactory situation for patients with inju-ries requiring an accurate pain assessment andappropriate analgesia.

Improving the patient experience

Changes in practice were obviously required toimprove the management of pain in A&E and the

quality of care provided. For change to be effectiveand sustained and to reduce the effects of resis-tance, all the practitioners involved needed to beincluded in the practice developments (Douglas,1996). The link nurse identified key staff members,including medical staff to ‘champion’ the changesfor improving pain assessment. A small group metat regular intervals to plan the stages involved andto communicate progress made.

Small achievable steps were planned (Broome,1980); these included the introduction of an agreedpain scoring tool, increased use of IV morphine andthe introduction of PCA’s. The Clinical Nurse Spe-cialist (CNS) for Acute Pain was actively involved inthe meetings. One of the five elements of the CNSrole, as identified by Storr (1988), includes actingas a change agent. The CNS acted as a resource tofacilitate the change, educating, influencing anddeveloping staff in A&E (Footner, 1998). The CNSaimed not to be authoritarian but to share exper-tise by acting as a member of the team, recognisingother points of view and facilitating the develop-ment of knowledge within a nursing team (Ford andWalsh, 1994).

Pain assessment

The assessment of pain should be part of routinepractice, so that the treatment of pain is ap-proached in a logical, methodical and professionalmanner (Lovett, 1994). The lack of pain assessmentin the A&E department was resulting in inconsis-tent and poor analgesic prescribing. There was noconsistent recognised pain score tool in thedepartment.

A numerical pain rating scale of 0–10 was beingused by some nurses in A&E. The limitation of thisscale is the difficulty people have in imagining painas a number. Careful instruction is required makingthis a difficult tool to use when communication is aproblem and if the pain is severe (Baillie, 1993). Averbal numerical score, combining words andnumbers, was already used in the surgical areas ofthe hospital. This was quick and easy to use. Ac-cording to (Baillie, 1993) patients prefer this tonumerical rating only. They are easy to explain andcan be asked a simple question (Carr and Mann,2000). Laminated posters with the pain score wereplaced throughout the A&E department.

The Acute Pain Nurse (APN) was involved in aseries of teaching sessions for staff in the depart-ment, highlighting the importance of pain assess-ment and how to assess pain using the verbalnumerical rating scale.

The impact of introducing patient controlled analgesia for trauma patients 9393

Analgesia

Morphine is required for severe pain associatedwith trauma. Small boluses of IV morphine titratedto the required analgesic effect is ideal (Parket al., 2000). It was also felt that there was a needto maintain the analgesic effect by using a PatientControlled Analgesia (PCA) device, especially inpatients with long bone fractures of the humerusand femur, ankle fractures and dislocations. Acursory literature search failed to identify researchor other literature on the use of a PCA in A&Edepartments.

PCA is an established method of providingmorphine intravenously by the patient whenthey experience pain, giving the patient somedegree of control. Traditionally it has been usedfor post-operative pain relief. The analgesia isadministered quickly and avoids the delay asso-ciated with traditional administration. There islittle risk of overdose due to the lockout periodbetween the doses (Cowan, 1997). The patientneeds to be alert enough to press the button;they need to understand the instructions andthe concept. PCA’s are popular with nursingstaff once they are established. For trauma pa-tients, PCA offers the advantages of good paincontrol without excessive sedation (Park et al.,2000).

The Acute Pain Nurse (APN) taught on staff de-velopment days in the A&E department. Informa-tion about pharmacology, action and effects ofmorphine was provided. The principles and themonitoring and care of patients with PCA were in-troduced to all grades of staff.

Data collection

Data was collected about the trauma patients,the severity of pain experienced and potentiallyhow many devices may be required. The in-formation included; the age of patients, thefracture, the pain score and analgesia adminis-tered.

The data collection required a pain score to berecorded after the administration of IV morphine,following an X-ray and on admission to the ward.Initially just a few forms were completed; thenumber increased as the teaching sessions pro-gressed, raising awareness of the importance ofthese among the staff.

Over a three month period 46 patients wereadmitted to the trauma wards with completedforms:

• 91% (n ¼ 42) of the patients had a pain score re-corded.

• 67% (n ¼ 28) of these patients had a high painscore indicating severe pain.

• 89% (n ¼ 25) of these patients experienced painrelief following IV morphine.

Pain scores increased following X-ray for 23%(n ¼ 10) of patients and 19% (n ¼ 8) of patients hadan increased score when admitted to the traumaward. It was felt that the patients with increasedpain scores in X-ray and on arrival to the traumaward may have benefited from a PCA to maintaintheir pain relief.

The PCA device

Within the same hospital, electronic PCA deviceswere used extensively on the surgical wards forpatients in pain both prior to and following surgery.All the devices are stored in the recovery area oftheatre and available to all. The A&E nurses werenot familiar with theses devices; training sessionswould be required for the staff to set up the ma-chines. Other problems identified in using thesedevices included the delay incurred by staff leavingthe busy department to collect the machines fromtheatre and there were only a limited number ofdevices available for patients in the Hospital.

Disposable systems were chosen to trial becauseof these problems. Pharmacy advised the teamthat the device must be filled and primed in theiraseptic area, not in the A&E department. The de-vice was sent to A&E ready to be attached to thepatient’s venflon following an initial bolus dose ofIV morphine. Little further training of A&E staffwas therefore needed.

The PCA device had to be tested independentlyfor stability and sterility; this resulted in over sixmonths delay. Once filled and primed the devicemust be stored in a fridge. A lockable fridge wasobtained and positioned near the controlled drugscupboard. The A&E staff and the APN producedguidelines for PCA use in A&E, including identifyingsuitable patients, information for patients whichdiscussed the care and monitoring required. Aspecific chart including the prescription of theinitial IV bolus of morphine and PCA was produced.This chart included an area to record the obser-vations taken: the pain scores, sedation, respira-tory rate, BP and Pulse. The chart has beencompleted consistently and accurately by A&E staffsince the introduction of the PCA device (Fig. 1 theA&E PCA chart).

Figure 1 Patient controlled analgesia.

94 J. Gregory, S. Jackson

The device was introduced as a trial in June 2001for trauma patients admitted to the hospital.

Evaluation

The impact of the device was measured by inter-viewing patients and by a postal questionnairesurvey of the staff involved.

Twenty-five patients (n ¼ 25) were interviewedby the APN on the trauma wards following ad-mission from A&E with a PCA. The patients wereaged from 18 to 91 years with a variety of frac-tures including: fractures of the femur, humerusand ankle and one lady with a pathological frac-ture secondary to breast cancer. The majority ofthe patients had a severe pain score initially; thiswas subsequently lower on admission to thewards. All the patients felt the device was effec-tive.

Macintyre and Ready (2001) suggest that patientsatisfaction with a PCA is high generally due to thedegree of control they have. The patients inter-viewed rated the device as excellent (36% n ¼ 9)very good (44% nþ 11) and good (20% n ¼ 5). Theircomments included “worthwhile”, “sorry to see it

go” and “saved having to ask the nurses”. Somepatients also stated a preference for the disposabledevice to the heavier and larger electronic deviceused post operatively.

A questionnaire was devised and distributed tothe medical and nursing staff in the A&E depart-ment. Of the five doctors who responded (3 Con-sultants and 2 Specialist Registrars), 3 hadprescribed the PCA device.

Eleven (17%) out of 65 of the nursing staff re-sponded (D to G grades), of these 82% (n ¼ 9) hadattached the device to patients in A&E. Commentsmade by A&E staff included “very effective, anal-gesia without bolus” and “enhanced patient care ifwait is long”. One nurse pointed out the need forpatients to be able to understand the device andhow to use it.

A similar questionnaire was answered by 13(42%) out of 31 of the nurses on the two traumawards, representing A to G grade nurses. All of therespondents had nursed patients with the dispos-able device from A&E. The ward nurses commentsincluded, “pain score¼ 0 when admitted”,“patients in control” and “clients happy to usethem and stay pain free”. It was observed by somestaff that nausea was a problem and the patientsneeded to be “of sound mind”.

The impact of introducing patient controlled analgesia for trauma patients 9595

Since the introduction of PCA to the A&E de-partment, retrospective audits of A&E documen-tation were conducted. Patients from a wide agerange with a variety of fractures have been pre-scribed PCA. An initial pain score was recorded inup to 70% of patients. Severe pain was recorded for75–80% of the patients on admission to A&E. Morepatients had an initial IV bolus of morphine ad-ministered. The number of PCA’s attached varied,one weekend 7 were used.

Conclusion

The use of PCA’s has been safely introduced andfound to be of benefit to trauma patients admittedthrough A&E. It has involved a multidisciplinaryapproach including medical, nursing, and pharmacyand pain team staff.

The initial idea for the changes came from astaff nurse within the department and with thesupport of the APS, medical, nursing staff and thenurse manager, the project has been successful.The staff responding to the survey felt the deviceimproved patient care and the problems identifiedsuch as determining patient suitability should im-prove with experience. The problem of nausea isbeing controlled by the appropriate prescribing anduse of anti-emetic therapy. The preparation of thedevice in pharmacy ensures it is easy and quick toattach to the patients. However, the pharmacydepartment has limited staff and time to fill thedevice and are cautious about any expansion of itsuse.

As a result of this project, the number of painscores being documented has improved. Intrave-nous morphine is being used more consistently forall trauma patients. The use of the PCA’s hasbenefited trauma patients and improved the con-tinuity of pain relief from A&E to the wards. Thepatients interviewed are satisfied with the painrelief obtained from the PCA device as it allows adegree of control at a very stressful time. Painmanagement has improved prior to and following

surgery. It has been noticed that the trauma pa-tients are being given a PCA more often post sur-gery since the introduction of the device throughthe A&E department. The staff caring for the pa-tients on the wards feel that the use of PCA is ef-fective and improves the quality of patients care.

As a result of this positive experience, theteam are now reviewing practice in other areasand looking to expand the use of PCA’s within A&Efor patients with other acute pain problems, forexample pancreatitis, abdominal pain, fracturedribs and its use in paediatric care is beinginvestigated.

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