Bone Fracture, Elderly, Emergency Department, Older Adults, Pain, Acute
Conditions
Keywords
Bone Fracture, 75 years old, Elderly, Older adults, Pain scale, Pain documentation, Analgesics, Acetaminophen, Opioid, Nonsteroidal anti-inflammatory drugs, Emergency Department
Brief summary
The PAINFREE (Improving PAIN control following FRactures; towards an Elder-friendly Emergency department) Initiative is a patient-centered multifaceted intervention which aims to improve pain management in patients 75 years and older presenting with a fracture at 7 Emergency Department of participating Montreal hospitals: 1. Montreal General Hospital 2. Royal Victoria Hospital 3. Ste Mary's Hospital 4. Hôpital de Verdun 5. Hôpital du Sacré-Coeur de Montréal 6. Jewish General Hospital 7. Lakeshore General Hospital
Detailed description
Using a stepped-wedge cluster randomized trial design, we will implement PAINFREE sequentially in 7 Emergency Departments (EDs) in the greater Montreal area where as each ED site acts as its own control and provides data in both pre- and post-implementation periods. Mixed methods analysis will be used to link quantitative (pain management indicators pre- and post-implementation) to qualitative (feasibility, fidelity and acceptability of implementation) data sets to facilitate data triangulation to evaluate the effects of PAINFREE in real world settings. PAINFREE Initiative at each site includes 3 phases: pre-implementation, implementation, and post-implementation. The approach is patient-centered and is composed of three complementary components: a patient component, a physician component, and a nursing component. Each program phases include the following steps: 1. Pre-implementation (2 months): 1. In all study sites, distribution and analysis of a web-based survey for nurses to document factors that can impact PAINFREE implementation in their environment 2. Review of medical records of the target population for extraction of selected variables 2. PAINFREE implementation (6 months): 1. Awareness campaigns will be organized throughout the institution of each study site (posters, brochures, billboards, lanyards) 2. Profession-specific educational presentations (1 hour) for physicians and nurses, accredited as part of continued professional development programs 3. Distribution of standardized point-of-care tools to improve pain assessment and documentation (pocket cards, use of validated pain scales), treatment (standardized prescription) and re-assessment 4. Distribution of educational material and tools targeting pain care literacy (pain scale interpretation, pamphlet) for patients and their families 3. Post-implementation (4 months): 1. Review of medical records of target population for extraction of selected variables 2. Distribution of report cards comparing each ED's post- and pre-intervention performance on pain management indicators and comparing their performance to that of other sites 3. Phone call interviews with patients 4. Focus group interviews (physicians and nurses)
Interventions
OTHERImplementation
The PAINFREE Initiative is a Multifaceted intervention: 1. Educating and providing point-of-care tools to nurses working at Emergency Department to improve pain management in older adults with fractures 2. Educating and providing point of care tools to Emergency Departments physicians working at Emergency Department to improve pain management in older adults with fractures 3. Inform the patients and their family about how to better manage the pain after a fracture
Sponsors
Research Institute of the McGill University Health Center
Canadian Institutes of Health Research (CIHR)
McGill University Health Centre/Research Institute of the McGill University Health Centre
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
Pragmatic Stepped Wedge Cluster Randomized Trial
Eligibility
Sex/Gender
ALL
Age
75 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age 75 years old or older * Visiting Emergency Departments for a fracture
Exclusion criteria
* Having a skull fracture * Having only fingers or toes fractures
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Time to achieve pain score documentation, and/or administration of an analgesic, within 2 hours of triage, in at least 80% of patients. | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Evidence of worsening of Patients mental status while in Emergency Department | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | — |
| Mean length of stay in Emergency Department | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | — |
| Return to the Emergency Department within 7 days after the first Visit with an uncontrolled pain due to the fracture | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | — |
| Documentation of pain score | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | — |
| Time to first pain score documentation | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | — |
| Effectiveness of analgesia | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | Patients with pain score ≥7 who have pain score reduced by ≥ 3 points within 1 hour |
| Type of analgesia used | Pre-implementation (baseline) and at 6 to 8 months (post-implementation) | — |
Other
| Measure | Time frame | Description |
|---|---|---|
| Change from immediate post-implementation time to analgesia administration at 2 months (end of post-implementation period) | 2 months (end of post-implementation period) | — |
| Predictors of successful implementation | at 6 to 8 months after the implementation (post-implementation) | Qualitative Analysis: Nurses and physicians perceptions and behaviors toward pain management in older adults with fracture at Emergency Department |
Countries
Canada
Outcome results
None listed