Table 1

Processes and structures relating to pain management

Case 1Case 2Case 3
EDTrauma unit, colocated primary care serving urban population of 200 000Trauma unit, colocated primary care serving urban population of 330 000Trauma centre with primary care collaborative on same site, but not colocated. Serving urban population of 550 000
PopulationMixed adult and paediatric population (60 000–65 000 attendances p.a.). 93% white British, 20% patients>70Mixed adult and paediatric population (80 000–85 000 attendances p.a.). 97% white British, 24% patients>70Adult only ED (140 000–140 000 attendances p.a.). 91% white British, 22% patients>70.
Significant organisational changes during course of fieldworkThe ED moved location during the fieldwork into a new purpose-built emergency care centre with colocated emergency admissions unit.Changes made to improve flow, including introduction of ambulatory pathways and introduction of medics from Medical Assessment Unit assessing patients within the ED.The Trust became ‘paper-free’ and the electronic patient record was introduced throughout the organisation during the fieldwork.
Changes made to improve pain management prior to fieldworkIntroduction of PGDs for analgesia at triage in 2004, in response to nurse-led review of pain management.
Changes to documentation to make pain assessment central for both initial assessment and reassessment. Time of prescription and time of administration added to notes as mandatory fields.
Introduction of management plans for patients who attended regularly for analgesia
During the previous year, staff had been asked to complete the pain score on the observation chart. Analgesia had been placed in a small cupboard in triage.
Other changes had been introduced but not followed through, including the introduction of pain scoring within the triage assessment which was removed as it was felt not to add any value.
Some work had been undertaken to develop management plans for patients who regularly attended for analgesia, but not completed as was time-consuming.
Introduction of PGDs for paracetamol, co-codamol and ibuprofen. More senior nursing staff encouraged to undertake nurse prescribing courses.
Analgesia cupboards had been introduced in the corridor by triage/ambulance coordinator station alongside a water fountain so that patients could take analgesia at ambulance triage.
LayoutPhysically small layout, with majors and minors centred around a central staff base which enabled communication between staff, and enabled requests for analgesia. After the move, the layout was in a grid system with separate areas linked by wide corridors. The physical space made communication more difficult but staff contacted each other using personal wifi-enabled communication devices.Cramped and unwieldy layout, which made movement of patients round the department difficult, and made it difficult to locate staff. Staff relied on face-to-face communication, except for when communicating with staff in the observation unit, who were contactable via the telephone.Physically large space with long corridors and large distances between different areas of the department.
In particular, the distance between the triage areas and majors areas made it difficult to hand over different components of pain management. Staff used a tannoy system to contact staff within other areas of the department.
Triage proceduresWalk-in patients triaged by triage nurses who all had PGDs for paracetamol, ibuprofen and codeine (8 mg, 30 mg).
Patients brought in by ambulance triaged by senior nurse coordinator.
Walk-in patients always asked about pain (whether or not they were presenting with a painful condition) and offered analgesia. Ambulance patients not always asked unless prompted by paramedic.
Both walk-in and ambulance patients assessed by triage nurses, some of whom had PGDs or paracetamol and/or ibuprofen. Patients often not asked about pain and rarely given analgesia at triage.
New system of senior doctor triage was introduced during fieldwork, to support triage nurses 9–5 during weekdays, but was intermittently in operation during fieldwork.
Walk-in patients triaged by triage nurses who all had PGDs for paracetamol, ibuprofen and co-codamol (although not codeine separately).
Walk-in patients were routinely asked about pain and offered analgesia.
Patients brought in by ambulance were triaged by senior doctors from 08:00 to 20:00 (triage nurses outside these hours). Patients were routinely asked about pain and may have been prescribed analgesia, but rarely had it administered at ambulance triage.
Documentation of pain0–10 pain score mandated within computer triage and on triage documentation. ED notes contain space for pain score and time of assessment and details of prescribing. Also introduced space for reassessment pain score and time during the course of fieldwork.Optional scoring of mild/moderate/severe pain within computer triage. No mention of pain score in computerised ED notes. Analgesia prescribing documented on separate notes from main ED notes.Optional scoring of mild/moderate/severe pain within computer triage at initial visits, then 0–10 pain score mandated within computer triage during course of fieldwork. Analgesia prescribing documented within ED notes.
Pain management roles outside triageAll nurses trained to cannulate.
Nurses with PGDs able to prescribe repeat analgesia within the ED.
All consultants and registrars (plus some junior doctors) trained to undertake nerve blocks for fracture neck of femur.
Some nurses trained to cannulate.
Nurses were unable to prescribe repeat analgesia within the ED.
Most consultants trained to undertake nerve blocks for fracture neck of femur. No registrars or junior doctors trained.
Observation unit often staffed by nurses who were unable to prescribe and relied on calling doctors through to the unit.
Cannulation undertaken by phlebotomist. Some nurses trained to cannulate.
Nurses were unable to prescribe repeat analgesia within the ED.
Unable to give details of numbers of consultants and registrars trained to undertake nerve blocks for fracture neck of femur, but described as ‘patchy’.
Clinical decisions unit staffed by nurses who were unable to prescribe analgesia and relied on doctors responding to tannoy announcements.
Access to analgesia in triageParacetamol, ibuprofen and codeine available from lockable cupboard in every triage room. Keys held by nurse in triage.
Prior to move, all analgesia, including controlled drugs held within a central cupboard between majors and minors, and another cupboard within the resus room. After the move, analgesia was available via biometric controlled cupboards (Omnicell) in resus and minors rooms.
Cupboard in triage room reported to hold paracetamol and ibuprofen, but key was lost for 6-month duration of fieldwork. Some triage nurses with PGDs carried paracetamol in their pockets. Otherwise, triage nurses could get paracetamol or ibuprofen from analgesia cupboard in minors department. This was not always well stocked and did not contain co-codamol or codeine due to concerns about theft. Other analgesia was available further away from the swipecard entry cupboard in majors.During early fieldwork, a lockable cupboard containing paracetamol, ibuprofen and co-codamol (but not codeine separately) was accessed from the corridor by triage rooms. Keys were kept variably by triage nurse or nurse in charge.
During fieldwork, cupboards were placed in each of the triage rooms, with the keys held by the triage nurse and a single key to fit all analgesia cupboards.
Access to controlled drugsPrior to the move, analgesia was kept in a locked cupboard in resus room. Keys held by nurses in charge of resus.
After the move, controlled drugs held in biometric operated cupboard (Omnicell) in resus, and Omincell in minors.
Controlled drugs held in Onmicell in resus and in a locked cupboard in swipecard entry room in majors (keys held by nurse in charge).Controlled drugs held in locked cupboard in resus room. Keys held by nurse in charge of resus (different key from other analgesia cupboards).
StaffingHigh turnover of staff led to push for nurses to undergo triage training. A third of the consultant posts were vacant, and a third of middle grade posts were filled by regular locums. Agency and locum staff have no access to OmnicellHigh turnover of nursing staff. 1/5 of consultant posts were vacant. Relied heavily on locum and agency staff for middle grade posts. Agency and locum staff have no access to main swipecard entry drugs cupboard or Omnicell. Agency nursing staff could not access computerised notes. Teaching sessions introduced towards end of fieldwork as sickness had led to PGDs and training not being up to date.No permanent consultant vacancies. Used agency staff but less reliant on locums than other sites. Agency staff could use the computerised notes using a ghost log-in.
  • PGD, patient group directive .