Clinical Question: Does the use of an observational pain assessment tool reduce the time to analgesia for (non-verbal) older people with advanced dementia presenting to the ED with a suspected long bone fracture?
Authors: Fry et al.
Published: EMJ, January 2018
Population: Adults >65 with a clinically suspected long bone fracture, and cognitive impairment (defined as score <4 on Six-Item Screening (SIS)), with exclusions, in 8 EDs in Sydney Australia
Intervention: Pain Assessment in Advanced Dementia (PAINAD) is an observational pain assessment tool, which scores 0-2 across 5 domains, giving a total pain score /10
Comparator: “standard methods of pain assessments”, such as a verbal rating scale or visual analogue scale
Outcome: time from arrival in ED to first dose of analgesia
Summary: The authors note that the most common form of ED pain assessment is patient self-report; however, for patients who are unable to communicate pain intensity verbally, clinicians often rely on subjective assessment, which can be unreliable. Observational pain scoring is widely used in paediatric EM. PAINAD is designed to give a pain score /10 for people with advanced dementia; it is is quick and easy (MDCalc!) but has not been formally trialled in ED.
This is a multi-centre (single city) study, which aimed to investigate whether using an observational pain score would improve time to first (any) analgesia for elderly people with cognitive decline, compared to standard practice. It is cluster randomised by 8 different EDs in the Sydney region. All sites were asked to screen their potentially eligible patients (>65y, suspected long bone fracture) with the SIS scale to identify those with cognitive impairment. At the 4 intervention EDs, those identified to have cognitive impairment would also be pain scored using the observational PAINAD score. The analysis of a cluster randomised trial compares all the people in the intervention clusters to all the people in the control clusters, regardless of whether the intervention was actually applied to all people in the intervention cluster.
The main analysis conducted was intention-to-treat, which means that all the eligible patients in the intervention clusters were compared to all the eligible patients in the control clusters, regardless of whether the nurse or clinician had time to use the SIS score, and the PAINAD score. There were 602 eligible patients, and after adjusting for age, fracture type, arrival mode, and triage category, they were unable to demonstrate a difference in time to analgesia between the two groups (HR 0.97, 95% CI 0.80 – 1.17, p 0.74).
A second sensitivity analysis was conducted including only patients in the study who had a documented SIS score. There were a total of 271 patients with a SIS score <4 across all clusters. 87% of those in the intervention cluster had been PAINAD scored. The sensitivity analysis found that the intervention sites delivered analgesia median 13 mins earlier than control sites, but this was not statistically significant (90 vs 103 minutes, p 0.62).
Strengths, weaknesses, and clinical relevance
This is a recent paper, published online in the middle of last year. It seems to demonstrate a reliable and replicable way of trialling an intervention in a busy and complex environment such as the ED.
There are notable differences between the patients at the intervention clusters compared to the control clusters, and although these are acknowledged and attempts are made to adjust for them, the differences are not fully explained.
It is interesting that time to analgesia has been chosen as an outcome when testing a pain scoring system. As the discussion notes, that there was no difference between clusters suggests that time to analgesia is affected by so much more than just being aware of a patient’s pain score, and suggests other system changes are needed to reach national targets of time to analgesia.
I would like to know wether using an observational pain score provides more appropriate analgesia to patients with advanced dementia. This study looked only at time to first analgesia for suspected long bone fractures, but has not provided details on whether this is, for example, paracetamol or morphine.
Are there any other observational pain scores at use in UK EDs?
Would the >65 years PRUH ED population benefit from an observational pain score?
If so, how could this be implemented?