Rationale

Improve overall patient care; ensure safe administration of analgesics; prevent complications of unmanaged pain; and improve patient satisfaction.

Authorized Prescribers

  • ED Staff Physicians and their medical delegates
  • Trauma Team Leaders and their medical delegates
  • Nurse Practitioners (currently may use non-narcotic components of the order set)

Indications/Contraindications

Indications
ALL patients registered in the SMH ED are eligible for consideration of the ED-EPM Protocol.

Contraindications
  • Glasgow Coma Scale (GCS) < 14
  • Allergy to prescribed medications
  • Patient declines analgesia

Precautions
  • Elderly patients (age > 65 years) are more sensitive to sedation and respiratory depression
  • Traumatic injury
  • Potential drug interactions
  • Acute intoxication, psychosis or metabolic changes limiting the ability to assess patient condition and manage pain
  • Any comorbid factors that increased the patient's risk for adverse outcome if the protocol is implemented (see list below)
  • Sensitivity to NSAIDS
  • Systolic blood pressure (SBP) < 100 mmHg
  • Heart rate less than 60 bpm
  • Respiratory rate less than 10/min

Protocol Initiation

The ED-EPM is initiated by an ED RN and starts with a formal assessment of pain. The RN completes a standardized assessment including: VS, GCS, Patient Pain Score, Patient Pain Goal, medical history, current medications (including previous/last dose of analgesia prior to presentation to the ED, including doses given by pre-hospital care providers), drug allergies, prior opioid history.

Patient Pain Score: (NRS 1-10), the level of pain at rest and during activity.
Patient Pain Goal: (0-10) what the patient deems to be an acceptable/tolerable level.

MD Options

  1. Initiate the ED-EPM Pain Protocol by signing the PRN order set prior to seeing the patient; OR
  2. Initiate the ED-EPM Pain Protocol by signing the PRN order set after assessing the patient; OR
  3. Decline to use the PRN order set.

Appropriate analgesia orders are still the responsibility of the authorized prescriber in the event that the ED-EPM Pain Protocol is not implemented. If declined, the RN is to document the reason in the nursing documentation. For Options 1 and 2, the ED-EPM PRN Order Set is then used to prescribe analgesic.

Treatment Options

Non-Pharmacological
Consider use of local heat, local cold, splinting, positioning.

Pharmacological
Non-opioids such as acetaminophen, NSAIDS (ibuprofen, naproxen, keterolac).
Opioids such as hydromorphone, morphine, fentanyl.

Monitoring Requirements

IV - Intermittent (mini-bag or bolus)

Pre- and 30 minutes after 1st dose:
  • Pain score
  • Pain goal
  • Respiratory rate
  • Sedation score
  • Blood pressure
  • Heart rate
  • Nausea/vomiting
  • Pruritus

Reassessment 30 minutes after EACH DOSE:
  • Pain score
  • Pain goal
  • Respiratory rate
  • Sedation score
  • Nausea/vomiting
  • Pruritus

"Routine" assessment (Q8H or at dose interval):
  • Pain score
  • Pain goal
  • Respiratory rate
  • Sedation score
  • Nausea/vomiting
  • Pruritus

PO/PR (immediate release)

Pre- and 30 minutes after 1st dose:
  • Pain score
  • Pain goal
  • Respiratory rate
  • Sedation score
  • Blood pressure
  • Heart rate
  • Nausea/vomiting
  • Pruritus

Reassessment 60 minutes after EACH DOSE:
  • Pain score
  • Pain goal
  • Respiratory rate
  • Sedation score
  • Nausea/vomiting
  • Pruritus

"Routine" assessment (Q8H or at dose interval):
  • Pain score
  • Pain goal
  • Respiratory rate
  • Sedation score
  • Nausea/vomiting
  • Pruritus

Discontinuing the Order Set

The MD must write a discontinuation order in the chart. Examples of when to discontinue:
  • The patient no longer requires pain medication
  • The patient is discharged home
  • The patient is referred to a consulting service at which time the consulting service writes the admission orders
  • The patient condition changes at which time the ED-EPM Pain Protocol is no longer appropriate

Important Reminders

  • The ED-EPM Pain Protocol is restricted to the ED
  • The order set must be signed (no verbal order)
  • Consultants from outside the department may NOT sign the ED-EPM Pain Protocol order set (Trauma Team excluded)