English title dissertation Much to gain in pain. Early and initial pain management in trauma patients in prehospital and hospital based emergency care.
Name PhD (surname first) Berben, Sivera A. A.
Doctor is (has been) nurse
Date of promotion 31/10/2011
University Radboud Universiteit
Promotores Prof. dr. Theo van Achterberg, Prof. dr. Arie van Vugt
Linkedin-account linkedin.com
Researchgate-url researchgate.net
Abstract (English)

The overall aim of this thesis was to give insight in early and initial pain management for evaluable and adult trauma patients in emergency care. Furthermore, we aimed to gain knowledge that could contribute to the improvement of pain management by professionals for this patient group in emergency care. We started studying the prevalence of pain in trauma patients in prehospital Emergency Medical Services (EMS) and emergency departments (EDs) in the Netherlands. In addition, we analyzed (the effect of) current pain treatment on pain relief in trauma patients in prehospital EMS and the ED. We also examined the relation between Manchester Triage System (MTS) in the ED was and pain management in trauma patients, and studied barriers and facilitators in prehospital EMS and the ED. Finally, we reviewed evidence-based clinical guidelines on acute pain, and developed recommendations on early and initial pain management in trauma patients in (prehospital) emergency care.

Prevalence of pain and current pain management in Emergency Medical Services (EMS):
With a study on 1,407 patient files, we analyzed assessment and treatment of pain performed by paramedics and pain relief in trauma patients. The prevalence of pain in trauma patients in prehospital EMS was high, and a systematic pain assessment with a validated instrument was not common practice. The first step of the national Dutch EMS analgesia protocol was generally ignored by paramedics. Pain relief could not be evaluated in 90% of the patients with pain, for the other 10% pain treatment was clinically and significantly effective.

Prevalence of pain and current pain management in the emergency department (ED):
In this prospective study we interviewed 450 trauma patients on admission and discharge of the ED and studied their acute pain complaints. The prevalence of pain was high on admission, and most patients left the ED with moderate to severe pain still present. Medical and nursing staff in the ED gave little (non) pharmacological pain treatment. A third of the patients reported adequate pain relief, nearly half of the patients experienced no difference in pain, and a small group reported a more intense pain.

The relationship between implementation of systematic triage by the Manchester Triage System (MTS) and a (potential) relief of pain in trauma patients in the ED in the Netherlands:
The hypothesis was that implementation of MTS was a facilitator for pain management. With an uncontrolled before after design, we interviewed 1192 trauma patients on admission and at discharge from the ED, using a standardized pain measurement instrument (Numeric Rating Scale). The results showed that implementation of systematic triage by MTS had no significant effect on improvement of pain management and pain relief in trauma patients in EDs in the Netherlands.

Barriers and facilitators in the chain of emergency care (prehospital EMS and the ED):
We adopted a qualitative approach with the use of the Implementation Model of Change of Clinical Practice. Five focus group sessions and ten personal interviews were held with staff and managers in the chain of emergency care. Analysis showed that five concepts emerged as facilitators and barriers for the management of pain in the chain of emergency care. The concepts of knowledge, attitude and patient input were similar for the EMS and ED setting. Professional and organizational feedback occurred as new themes, and were specifically related to the different organizational structures of the prehospital EMS and the ED. We advised a comprehensive development of strategies focused on all five concepts, in order to improve clinical practice regarding pain management in the chain of emergency care.

Systematic review on pain guidelines:
This study showed six evidence-based guidelines on pain management, that could be (strongly) recommended based on a critical assessment with the Appraisal of Guidelines Research and Evaluation (AGEE) instrument. The number of recommendations in these guidelines varied as did the topics that were covered. Specific recommendations regarding (prehospital) emergency care were scarce, and there was no ‘single best’ amongst the six guidelines for the use in emergency care. We suggested that the six identified guidelines could provide “building blocks” for the development of a tailored guideline on pain management in trauma patients in (prehospital) emergency medicine.

Guideline:
The national guideline on pain management in trauma patients in the chain of care consists of five central topics and 81 recommendations. It covers recommendations on pain assessment, influencing factors on pain perception such as the use of alcohol and drugs, (non)pharmacological pain management, and the organization of pain management in the chain of emergency care. Furthermore, indicators and an implementation strategy was developed.

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