Editor,—I read with interest the paper by Kelly¹ on a “process approach” to pain management that outlined some change strategies for a pain protocol implementation. It was unfortunate that the journal did not include a copy of the tritrated IV narcotic policy for readers to assess separately. Novel approaches to improving pain management are always welcome and the author clearly illustrates the failure in emergency departments 10 years ago to provide adequate analgesia. It is interesting to note that despite the stated successful implementation of the policy, 10% (5 of 50 who received narcotic analgesia in 1997) of patients still had at least one dose of analgesia intramuscularly.

Many of the processes described in this paper are based on subjective assessment rather than any more robust analyses. The rationale for using a nursing led process seems to have been justified because “it was felt” that they would provide more formal review and assessment, rather than any evidence that the emergency department doctors were unable to do so. In addition the conclusions that practice has changed permanently seems to be attributed to the “example of senior staff” and that the …