Protocol addresses pain of adult trauma patients
Patients, nurses, and doctors benefit
Do your trauma patients suffer longer than they need to because of delays in pain management?
"There is no doubt that this is an issue for everybody," says Jean Proehl, RN, MN, CEN, CCRN, FAEN, emergency clinical nurse specialist at Dartmouth-Hitchcock Medical Center in Lebanon, NH.
Since a fentanyl-based pain management protocol was implemented for adult trauma patients at Dartmouth-Hitchcock, analgesics are given in 28 minutes on average, compared with 54 minutes before the protocol. The percentage of patients receiving analgesics within the first 30 minutes of arrival increased from 44% to 75%.1
Kevin M. Curtis, MD, the study's lead author and assistant professor of medicine in Dartmouth-Hitchcock's Section of Emergency Medicine, says, "The ED nurse has the primary role in the fentanyl protocol."
Based on an assessment of the patient's pain, hemodynamic stability, and Glasgow Coma Scale score, the ED nurse initiates the protocol, he says. If approved by the trauma physician, the nurse then performs frequent reassessments and gives additional doses of analgesics as appropriate, says Curtis. "The protocol has become such an integral component of our adult trauma management that any member of the team knows that it can be initiated by a simple verbal request to 'initiate the fentanyl protocol,'" he says.
Previously, it took about an hour for most trauma patients to receive analgesics, and this time frame has been cut in half in most cases, says Proehl. "When you think about a seriously injured trauma patient who has just arrived, 30 minutes is pretty good, because there are a lot of things that have to be done initially," she says. "Sometimes pain management isn't the first priority when you are trying to get the patient stable."
Before the protocol was implemented, all ED nurses were inserviced on medication dosages, with parameters available at the patient's bedside and in trauma rooms. "We had used fentanyl a fair amount before this, but now we were totally switching to fentanyl from morphine for trauma patients," says Proehl.
The ED already used the Faces, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scale for pre-verbal children, but staff needed a scale for adults unable to communicate verbally, so the Behavioral Pain Assessment Scale is used.
Obtaining a physician's written order for pain medication in the middle of caring for a trauma patient is not very realistic, says Proehl. "They are supposed to include a fair amount of detail in written orders — dosing, time intervals — and that is never going to happen in the heat of battle," she says. "And it may not even happen afterward because they may not have time."
Now, all the ED physician has to say is "fentanyl protocol," and nurses can assess the patient and give medications as needed. "The best thing for us is we can manage the patient's pain and don't have to track down a doctor down to write orders repeatedly," says Proehl. "We've got our time intervals and physiologic parameters. We are in charge, and it makes it much easier. The docs love it too, because we're not bothering them. And the patient is comfortable."
Reference
- Curtis KM, Henriques HF, Fanciullo G, et al. A fentanyl-based pain management protocol provides early analgesia for adult trauma patients. J Trauma 2007; 63:819-826.
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