Key messages from studies grouped by rationale for intervention
| Method | n Studies | Key messages |
|---|---|---|
| 1. Interventions aiming to encourage objective measurement of pain by using pain scoring tools | Six studies reported on the use of a pain-scoring tool alone, either as an addition to the existing triage tools or as a mandated part of the triage process. A further 12 used pain scoring within a multifaceted intervention.One RCT reported 3 different methods of displaying pain scores. | Studies concluded that improving the use and availability of pain-scoring tools increased the documentation of pain, but that this did not translate into an increase in the proportion of patients receiving analgesia (with the exception of one study43). Little discussion as to why the use of a pain score had not translated into improved analgesia. The use of pain-scoring tools was common in multifaceted interventions and appeared to be an inexpensive, simple and acceptable method of improving pain management. The single RCT identified within this review compared different ways of presenting the VAS and reported higher physician awareness of pain scores where VAS was measured every 12 min and reported on a graph at the end of the bed, compared with two measurements of VAS at presentation and 2 h. This was associated with expedited analgesia (p,0.00001) but there was no significant difference in the % given analgesia (p=0.69)53 |
| 2. Interventions aiming to remove structural barriers that lead to delays in the provision of analgesia | Seven studies reported interventions that included introduction of nurse-initiated analgesia as a method of reducing delays to analgesia but these were all part of multifaceted interventions. No interventions aimed to remove structural barriers alone. | Organisational changes reported as part of a multifaceted intervention included nurse-initiated analgesia as an alternative to clinician-administered analgesia (n=7), changes to physical access to opioids (n=1) and changes to the process of physician prescribing to decrease the length of time required to obtain analgesia (n=1). Changes to the role of nursing staff were felt to have a positive impact upon the pain management process. Interventions aimed at involving nurses more in the assessment and treatment of pain suggested that nurses can make autonomous decisions regarding the prescription of analgesia and the use of nurse-initiated analgesia was safe and well accepted by nurses.42 There was some evidence that interventions aimed at nurses had improved uptake than those aimed at doctors.43 46 The high turnover of medical staff has been identified as a barrier to the uptake of interventions45 and, therefore, the lower turnover of nursing staff should enable effectiveness of interventions to be sustained. |
| 3. Interventions aiming to remove attitudinal and knowledge barriers to pain management | In total, 33 studies reported on interventions incorporating pain protocols or education to improve knowledge around pain management. Eighteen studies reported on the use of an educational intervention either alone (n=3) or within a multifaceted intervention (n=15) and 28 studies reported on interventions including protocols or guidelines, either alone (n=6) or as part of multifaceted interventions (n=22). | Studies of educational interventions reported varying levels of success in improving pain documentation and administration of analgesia. Interventions differed in content, format, length and coverage. Success was attributed to the active nature of an educational intervention,40 simplicity51 and ability to fit round work schedules.40 Ongoing education and reminders are needed due to rapid turnaround of medical staff. Protocols ranged from simple guidelines offering specific treatment and dosing guidance for a well-defined group of patients,50 to more complex protocols providing specific information as to how pain should be managed within the departments, and may include reinforcement of existing procedures or a change in pain management procedure, or reinforcement of existing procedures.21 Some included department-specific information as to how the patient should be assessed, by whom, and specific recommendations for reassessment of pain. Considerable variation in the level of detail of the contents of protocols reported within studies, making comparison of their content difficult. Authors offered little insight into the feasibility or acceptability of protocols, despite largely concluding that the introduction of a protocol led to improved outcomes in their populations. Two studies reported variable or poor compliance with the protocol but did not discuss potential reasons.31 28 The use of pain-scoring tools within protocols was felt to help appropriate pain management, as recommended analgesia route and dosage was often related to pain severity |
| 4. Multifaceted interventions aiming to combine different methods of improving behaviour change to address different aspects of poor pain management | The majority (n=26) of studies reported on multifaceted interventions that included more than one of the individual ‘types’ of interventions | Interventions most commonly combined a protocol with use of pain-scoring tool (n=10) or protocol and educational intervention (n=13). Interventions were also considered multifaceted if they made use of additional tools to improve implementation that have been shown to work in other settings (eg, audit, feedback, reminders). Only a subset of these interventions referred to themselves as ‘multifaceted interventions’. Interventions reported on a range of outcomes and authors concluded that it was difficult to differentiate which parts of the multifaceted intervention had contributed to any success. There was little discussion of the benefits of multifaceted interventions, although one study undertaking preintervention audit concluded that a range of drivers were essential, as optimising one driver at a time did not achieve the magnitude of effect required.32 |
| 5. Interventions based upon diagnostic analysis of department specific problems in order to understand how pain can be managed better within that department. | Seven studies reported multifaceted interventions with an explicit theoretical framework that had been developed following research or audit into the barriers existing within their department | Studies provided little detail on how the research or audit that identified the barriers around which interventions were developed. Studies did not comment on how the targeting of interventions to department-specific problems may have impacted upon the uptake or success of the intervention. Doherty et al25 developed a national project to compare pain management based upon findings of an extensive barrier analysis59 and reported results of a large study with step-wedged design. Local protocols were developed at each site, addressing 4 main clinical indicators aimed at monitoring key components of analgesic practice. There was no significant decrease in pain levels, although an increase in documentation of pain scores and reduction in time to analgesia was observed. As there was no single protocol, it was not possible to attribute any improvements in outcome to any specific part of the intervention. |