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Older People with Musculoskeletal Conditions in Emergency Departments

Northern Sydney Local Health District
Project Added:
29 October 2014
Last updated:
30 October 2014

Assessment of cognitively impaired older persons with musculoskeletal conditions in Emergency Departments (EDs).

Summary

To conduct a comparative study assessing pain scores and analgesic administration in cognitively impaired and cognitively intact older people diagnosed with a long bone fracture. To conduct a cluster randomised controlled trial of the Pain Assessment in Advanced Dementia (PAINAD) screening tool for cognitively impaired older people presenting with suspected long bone fracture; To determine if the PAINAD screening tool assists emergency nurses’ pain assessment and facilitates timely analgesic responses. 

Aim

To determine the prevalence of older people presenting to EDs with painful musculoskeletal conditions or injuries and determine how emergency nurses currently assess, monitor and manage cognitively impaired and or older people with painful conditions or injuries. 

Research findings will assist to generate new knowledge and develop evidence based methods to evaluate pain in the older patient with cognitive impairment. The findings will provide evidence for clinical practices that will:

  1. enable appropriate and timely analgesia to this vulnerable patient group
  2. reduce untoward events associated with increased pain
  3. minimise decline in functional ability, including cognition, unless actively supported.

Project status 

Implementation: The study is in progress. Education sessions for all sites continue with regular updates of study progress.

The following phases have been implemented:

  • prevalence of older persons presenting to EDs – review of 168,000 patients
  • 16 Focus groups (n=80) have been conducted to determine how emergency nurses currently assess, monitor and manage cognitively impaired and or cognitively intact older persons with painful conditions or injuries
  • a randomised medical record audit (n=260) has been conducted to compare the assessment and analgesic management of cognitively impaired and cognitively intact older people diagnosed with a long bone fracture
  • the  cluster randomised controlled trial is recruiting older people presenting with suspected long bone fracture. 

Key dates

Project started: 1 January 2013

June-December 2014 - Continue administration and monitoring of PAINAD RCT (study 4).

June-December 2014 - Data entry for RCT to begin (study 4). 

January-February 2015 - Conduct focus groups on completion of the RCT.

Background

International research has identified that between 50% - 80% of patients presenting to EDs present with pain (Holdcroft & Power 2003; Tcherny-Lessenot et al. 2003). A national Australian audit identified that only 43% of patients in severe pain received an opioid analgesic (Fry, Bennetts & Huckson 2011). 

Within Australasia, emergency nurses routinely assess a patient’s pain using either a visual or verbal analogue scales (0-10 pain scale score) (Holdgate et al. 2003).  However, these scales do not meet the needs of the older person with cognitive impairment.  Given the lack of an appropriate screening tool, pain assessment and timely analgesic intervention is made more difficult for older person with cognitive impairment.  Therefore this program of study was implemented to make a difference in the care and outcomes for older people with cognitive impairment and experiencing pain.

Partnerships

  • University of Technology Sydney
  • South East Local Health District
  • Northern Sydney Local Health District
  • Consumer Advocate Group Northern Sydney Local Health District
  • Emergency Care Institute (ECI) at the ACI
  • The following Emergency Departments:
    • Manly Hospital
    • Mona Vale Hospital
    • Prince of Wales Hospital
    • St George Hospital.

Outcomes and evaluation

  1. Greater emergency clinician awareness for the care of cognitively impaired person presenting in pain
  2. Greater understanding of Dementia specific tools
  3. Focus groups will be conducted to measure the impact of the study
  4. Comparison will be made to determine whether assessment and analgesic interventions improve with the PAINAD assessment tool compared to standard care.  

Lessons learnt

Recruitment of RCT has been slow.

References

Arendts, G. & Fry, M. 2006, 'Factors associated with delay to opiate analgesia in emergency departments', The Journal of Pain, vol. 7, no. 9, pp. 682-3.

Australian Institute of Health and Welfare 2009, Australian Hospital Statistics 2007–08. Health Services Series no. 33. Cat. no. HSE 71, AIHW, Canberra. Australian Institute of Health and Welfare 2010, Australian Hospital Statistics 2009-2010, AIHW, Canberra.

Australian Institute of Health and Welfare 2012, 'Health Priority Areas'. Retrived August 16th 2012, from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr12-mb-mb082.htm

Contact

Professor Margaret Fry
Director of Research and Practice Development
Northern Sydney Local Health District
Phone: 02 9926 4693
Email: margaret.fry@health.nsw.gov.au 

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