Flow Hacks 9 – OUCH! Timely analgesia administration for patients with MSK injuries in the ED.

In Education & Quality Improvement, FLOW Hacks by Laila NasserLeave a Comment

To continue our FLOW Hacks series, Victoria Woolner (NP, MN, MSc QIPS) writes about another initiative her team has taken on, this time tackling timely analgesia administration for patients with MSK injuries in the ED.  This innovation was also the winner of the Top QIPS Abstract Award at the Canadian Association of Emergency Physician’s Conference in 2019. 


This intervention was carried out at Toronto General Hospital (University Health Network), an academic site with 53,000 annual patient visits. 

Description of the innovation

Of the 42,000 patients per year coming to Toronto General Hospital for pain-related concerns, 3,300 (8.6%) are for musculoskeletal pain (i.e. back or extremity pain). These patients are typically triaged as low-acuity presentations, resulting in longer waits for clinician assessment. Delay to providing adequate analgesia results in unnecessary suffering, poor patient care and satisfaction and thus increased patient complaints. 

The performance of a root cause analysis resulted in a plan for improvement, with four ensuing Plan-Do-Study-Act (PDSA) cycles:

  1. Nurse initiated analgesia at triage.
  2. A new sticker to be placed on paper charts at triage as a documentation aid for medication administration. 
  3. A quick reference medical directive badge tag (Figure 1) for nurses (including the new algorithm for pain management on the back in addition to pre-existing directives on the front). The ease of use was tested and iterative versions were created resulting in the final version below. 
  4. A weekly targeted feedback session on progress at clinical team huddle.
Figure 1. Back of new badge tag

Was a quality improvement methodology used?

The model for improvement in the project was iterative PDSA cycles. 

What data was used?

Outcome measures: 

  1. Time-to-analgesia (time from triage to first dose of analgesia documented)
  2. Length of Stay

Process measures:

  1. Percent of patients receiving analgesia
  2. Percent of patients receiving analgesia via medical directives

Balancing measures:

  1. Adverse events captured via incident reporting
  2. Time spent triaging by the nurse

Who was on the team?

Nurses, physicians, nurse practitioners, physician assistants, registration clerks, department leadership, a nurse manager and nurse educator were involved in this project.

What performance measures were used?

Length of stay (LOS) and time-to-analgesia. 

How was it implemented?

Nurse champions completed an initial trial. Education sessions were conducted during huddles bi-weekly for 2 weeks. Once solidified, the process was disseminated to the entire department for trial. Weekly feedback was then discussed on progress, successes and barriers, allowing for further iterations and improvements to be made. 

How did you get buy in from physicians, nurses, administrators and other allied professionals?

From project initiation, it was ensured that nursing staff would be the process owners, and would be heavily involved in the development of the intervention. This was in addition to gathering wide stakeholder feedback throughout the project, which was maintained by effective communication about the project’s evolution during the process. 

What was the impact on your department?

An increase in use of pre-existing medical directives has resulted in continued improvement to timely analgesia administration. 

Time-to-analgesia decreased from 129 minutes (n=153) to 100 minutes (22.5%; n=87, p<0.05). ED Length-of-stay decreased from 580 minutes (n=361) to 519 minutes (10.5%; n=187; p=0.77).

From a balancing perspective, the total number of patients receiving any analgesia increased from 42% (n=361) to 47% (n=187, p=0.13), and the number of patients receiving medication via directive increased from 22% (n=150) to 44% (n=87, p<0.001). 

What were some of the barriers to success?

Change management with a large group of providers was challenging. Despite education, explanation and evidence of success, adherence was difficult when the department was busy. 

If you could do it all over again, what changes would you make?

From a data perspective, the team would exclude admitted patients from their study, or implement a “stop the clock” on length of stay at time of referral. This change would be implemented because the team is based in the ED, and it is difficult to incorporate and document care changes when consulting services are involved.

See their website here for more information. 

This article was copy-edited by Jung-In Choi.

Laila Nasser

Dr. Laila Nasser is a resident physician in emergency medicine at McMaster University. She has strong interests in quality improvement and resident wellness.

David Savage

David Savage is a resident in the FM/EM program at NOSM, Thunder Bay. His interests include EM policy and the application of analytics techniques to physician scheduling, patient forecasting, and capacity planning.