In the past two decades, a number of reports have identified inadequate treatment of pain among emergency department patients. No study has evaluated the frequency or effectiveness of early analgesia in the trauma patient. The objective of this study was to determine the effect of a protocol-driven pain management scheme on time to initiation of analgesia among trauma patients.
A fentanyl-based protocol was developed with patients being assigned to one of three treatment arms based on hemodynamics and Glasgow Coma Scale (GCS) score. Using an institutional review board-approved before and after study design, patients over the age of 14 and meeting trauma system activation criteria at the Dartmouth-Hitchcock Medical Center were eligible. Results were compared with a retrospective chart review of eligible patients treated during a matched preprotocol time period in 2002. The primary outcome measure was time to initiation of analgesia. Secondary outcome measures included (1) the proportion of patients receiving their first analgesia dose within 30 minutes, (2) the number of patients receiving multiple doses of analgesia in the trauma bay, and (3) adverse events. Pain level was assessed using either a Numeric Pain Scale (for patients with a GCS score of 15) or a Behavioral Pain Assessment Scale (GCS score <15).
Implementation of the protocol resulted in a decrease in the mean time to initiation of analgesia from 53.61 minutes ± 6.88 minutes to 27.94 minutes ± 3.34 minutes (p = 0.001). The protocol also increased the percentage of patients receiving analgesia within the first 30 minutes of arrival from 44.4% to 74.6% (p < 0.001). There were no differences between the two groups in terms of baseline characteristics or adverse events.
The implementation of a fentanyl-based pain management protocol resulted in a marked reduction in time to initial analgesia among trauma patients. There was no evidence of an increase in adverse events. This tool has the potential to be easily extrapolated and applied to other trauma systems.