Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends

Abstract

Introduction: This article examines acute pain assessment and pharmacological management in the emergency department that occurred over a period of time after the release of the new pain assessment and management compliance standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for accredited health care organizations. Data were available from that collected for a large-scale study testing a Translating Research into Practice intervention to promote use of evidence-based practices for acute pain management in older adults.

Methods: Medical records were abstracted from hospitalized older adult patients with hip fractures admitted through the emergency department (N = 1454). Records were from 12 acute care hospitals of patients receiving care in the emergency departments from 3 different periods between 2000 and 2002. Major variables examined were (1) pain assessment practices and (2) pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults.

Results: Trends over time illustrate improvements in pain assessment practices, with almost all patients having some documentation related to pain (99% in 2002), although only 54.4% had pain assessed with a numeric rating scale, 4.2% with a non-numeric rating scale (such as verbal descriptor or faces scale), and 7.4% with nonverbal pain behaviors. Thus, 34% of patients had no objective assessment of pain documented. The mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 periods. By the end of the study's final data collection point in 2002, only 60% of patients had any analgesic ordered, with more than half of this group (59%) having an opioid ordered. Of those administered an analgesic, more than 90% received an opioid. Practice improvements were noted over time in a decline in intramuscular opioid administration and overall meperidine administration and an increase in morphine as the opioid of choice in this setting.

Discussion: Pain assessment and management practices in the emergency departments showed improvements over time following the release of JCAHO standards for pain management. However, the care documented does not consistently represent best practices for all patients.