Relief of chest pain in the Emergency Department (RELIEF)

Recommended guidelines are based of current, evidenced-based guidelines. The documentation of pain scores should be documented as part of patient assessment, and ongoing observations. The Australian (NHMRC) guidelines recommend time to analgesic of <30 minutes after presentation. Further, the 2014 best practice guidelines from the UK College of Emergency medicine call for an analgesic medication to be administered within 20 minutes of ED arrival. For those with severe pain, the effectiveness of analgesics should be re-assessed within 30 minutes of receiving the first dose (The College of Emergency Medicine Best practice guideline, Management of pain in Adults, 2014). The type of analgesics included in the educational campaign are recommended in the Australian (NHMRC) guidelines, and include: •GTN • Simple analgesics – paracetamol and non-steroidal anti-inflammatory medications. Note that aspirin will not be considered to be a simple analgesic as this is used for antiplatelet effect and not as an analgesic in chest pain management) • Narcotic analgesics – Morphine, Fentanyl • Other agents – Antacid, Liquid xylocaine In the pre-intervention stage, observational data on time to first analgesic, time to analgesia, and study outcomes will be collected. Our previous work has demonstrated that recruiting 100 patients will take approximately 8 weeks. The post-intervention stage will be conducted one month after completion of the RELIEF campaign. Data collection will be identical to the pre-intervention phase. This data will be used to identify the efficacy of the intervention; whether the time to first analgesic and time to analgesia has been reduced after a period of intense educational and training support and visual pain sign is implemented at the site. The CI will be responsible for ensuring that patients enrolled in the study meet inclusion criteria. The CI and AIs will also ensure that educational resources are available and that in-service teaching sessions occur. • The education campaign: This campaign will incorporate information on the ‘why’; that is, it will provision education around the importance of early analgesic use for patients and in the process of assessment for chest pain specifically. Information will be provided about the importance of documenting pain scores in the patient notes, as this has been shown to improve the provision of timely analgesics. • Clinical champions on the floor. The campaign will target both nursing and medical staff. Clinical champions (study AIs) will be recruited to disseminate the message during clinical shifts and during educational in-services. These clinicians will be experienced and well-known staff members who can motivate their colleagues to change practices around the provision of analgesics. • Recommended guidelines for the provision of analgesics will be developed and provided to all clinical staff as educational material (e.g., posters). These guidelines will include information on the ‘how’: agents that may be given by nursing staff without medical prescription, and information about the agent’s mechanism of action in chest pain. • Patient controlled sticker system. Pain has long been considered the ‘fifth’ vital sign (American Pain Society, Principles of analgesic use in the treatment of acute pain and cancer pain, 1999) . However, unlike other vital signs such as blood pressure and heart rate, pain does not have a simple, ongoing visual representation of monitoring display that is directly visible to clinicians. The RELIEF intervention proposes a novel approach to patient reported pain via a visual, deliberate representation of pain that is directly visible to clinicians. Patients will be provided with a red sticker (15 cm diameter) to place on their chest. They will be instructed to remove this sticker if they have no pain but are encouraged to place it on whenever they experience pain. This will be a visual prompt for clinical staff to complete a pain assessment, provide appropriate pain relief, and document the patient’s pain score. In the pre-intervention phase, observational data will be collected. This will include time to first analgesic, time to analgesia and other study outcomes to determine a baseline for standard care for patients presenting to the ED with chest pain. We anticipate that our pre-intervention data collection, our intervention period and post-intervention data collection periods will take 2 months each to complete.