Triage Pain Protocols

[jeremyRN]

I work in a large, busy, urban ER where patient's often experience extensive waits before physician evaluation. We are currently working on establishing a protocol that would allow us to administer pain medication in triage before the patient sees the physician. Depending on the patient's stated pain level and symptoms, it would allow us to administer NSAIDs as well as Percocet and Morphine IM.

Does your ER have a triage protocol or standing order for pain management? If so what are the parameters? Has this been successful, or have there been any adverse events related to this practice at your facility? Are the nurses obligated to medicate all patients with pain, or do they retain some discretion on when to enact the protocol?

Some of the concerns that our committee has had regarding this practice have been, safety - what if the patient has and adverse reaction, gets dizzy, falls etc.... What if the patient feels better then leaves the triage area after they are medicated, only to find out they have an appy or an ectopic? Will drug seeking be a problem?

Looking forward to any thoughts and discussion related to this topic.

[classicdame, MSN, EdD]

seems to me the MD or NP would need to do a focal assessment first. HOWEVER, my daughter recently broke her shoulder falling off a horse. The ER would not give her any pain med till MD had xrays and labs back. The xray was excruciating. I thought this was uncalled for and poor practice. She fainted from the pain. Even toradol would have helped. So I hope you get this resolved in your facility.

[Anne36, LPN]

Let me chime in my recent experience in ER. A few months ago I had a very bad ear

infection and was in so much pain I couldnt sleep or wait until Mon to see my Dr. After

I saw 2 Doctors and told them how bad my pain was and they told me I had a blister

on my ear drum and my ear was so bad they told me it was about to burst and dont

be surprised if you see blood! They told me I had to see a specialist as soon as

possible and then sent me on my merrry way with over the counter motrin I could

have gotten at home!!! Im still very angry.

[MCRNENC(C)]

no pain meds in our er until the patient is seen by the doc. and from the amount of people who come in with their coffee in hand and make-up on just so and dressed as if they were going to a party and not an er - and then tell the triage nurse their pain is 10/10 - i'm glad.

[bill4745, RN]

We are limited to motrin and tylenol. If we gave out percocet before people were seen by a dcotor, we would be overrun with drug-seekers.

[MCRNENC(C)]

we do give out motrin/tylenol for fever. we aren't that mean. lol!

[Flo., BSN, RN]

There really should be a protocol in place. I went to the ER s/p an abd sx. I had extreme vomiting. I could not even keep my own saliva down. The pain was unbelievable. The surgery was 2 days ago, I went in with my narcotic pill bottles and d/c instructions from that hospital. I had to wait about 3hrs to be seen in the worst pain in my life, holding a bottle of narcs that I couldn't take. I was begging the triage nurse to give me a shot of morphine and zofran. He was so unsympathetic and I remember his face to this day, 5 yrs later. Best part yet as soon as the MD sees me I get the morphine and zofran. Then I was transferred to a floor. Total time spent in the ER less than 20 mins. Yup I am still angry about it. No one should have to go through that.

[ThrowEdNurse, BSN, RN]

There really should be a protocol in place. I went to the ER s/p an abd sx. I had extreme vomiting. I could not even keep my own saliva down. The pain was unbelievable. The surgery was 2 days ago, I went in with my narcotic pill bottles and d/c instructions from that hospital. I had to wait about 3hrs to be seen in the worst pain in my life, holding a bottle of narcs that I couldn't take. I was begging the triage nurse to give me a shot of morphine and zofran. He was so unsympathetic and I remember his face to this day, 5 yrs later. Best part yet as soon as the MD sees me I get the morphine and zofran. Then I was transferred to a floor. Total time spent in the ER less than 20 mins. Yup I am still angry about it. No one should have to go through that.

So because the triage nurse was doing his job he was unsympathetic? The triage nurse always gets the blame. Do you have any idea how many people go through triage in 4 hours saying that they have unbearable pain? This is not to say that triage nurses don't feel sorry for the pts but there is literally nothing that you can do as a triage nurse but try to get the pts a room as fast as possible. Unfortunately, that's often not fast at all. On a side note, it is impossible to come across as sympathetic to every pt you see in pain in one shift in triage. Impossible. While pts continually pull you to the lobby to tell you about their pain that you are already aware of, they are stopping you from advocating to get them a bed, sometimes stopping you while you were actually on your way to clean the room for them yourself, and stopping you from triaging pts that have been waiting. The latter being unacceptable and unsafe. We know you are hurting, but our options are very limited. This doesn't make us uncaring. If we come across as unsympathetic, don't be surprised. But I also know my sympathy won't make you feel any less pain and it is pulling me away from my work. On a side note, you should be grateful to have only spent actually 20 min in the ER. That's no wait! How did they get your assessment, work up, and dispo plus getting you a bed so quickly done?

[Medic2RN, BSN, RN, EMT-P]

As the triage nurse, I would be very concerned about administering a narcotic to a patient and sending him back out into the waiting area to wait to be seen. What would be your liability in that situation? Would the person receiving the pain medication be placed in a special area where they could be monitored more closely?

There have been many patients who decide not to wait longer than they deem to be reasonable and leave without being seen. They have a right to exercise that freedom. If they had received narcotics, are you not responsible if they drive after leaving?

I know we want to do what is best for our patients and alleviate their pain/ relieve their suffering, but I don't know about this protocol being delivered in triage. I'm sure your legal department would have to study these issues before implementing them.

As far as the drug seekers, if I was addicted to drugs and discovered that your hospital had a policy regarding dispensing narcotics...I would visit your ED often.

These are just a few quick thoughts on your situation.

[Flo., BSN, RN]

So because the triage nurse was doing his job he was unsympathetic? The triage nurse always gets the blame. Do you have any idea how many people go through triage in 4 hours saying that they have unbearable pain? This is not to say that triage nurses don't feel sorry for the pts but there is literally nothing that you can do as a triage nurse but try to get the pts a room as fast as possible. Unfortunately, that's often not fast at all. On a side note, it is impossible to come across as sympathetic to every pt you see in pain in one shift in triage. Impossible. While pts continually pull you to the lobby to tell you about their pain that you are already aware of, they are stopping you from advocating to get them a bed, sometimes stopping you while you were actually on your way to clean the room for them yourself, and stopping you from triaging pts that have been waiting. The latter being unacceptable and unsafe. We know you are hurting, but our options are very limited. This doesn't make us uncaring. If we come across as unsympathetic, don't be surprised. But I also know my sympathy won't make you feel any less pain and it is pulling me away from my work. On a side note, you should be grateful to have only spent actually 20 min in the ER. That's no wait! How did they get your assessment, work up, and dispo plus getting you a bed so quickly done?

No he was unsympathetic because he did not show any signs of caring. I might of well have been dealing with a machine for all the human emotion that he showed. I was in tears and he did not even offer me a tissue. Even with a box right beside him. My mom had to dig through her purse to get one. If you do not have an ounce of compassion left you are offically burned out and should leave nursing for a while.

Even though you can not give narcotics there are other pain options that may help. Heat/ ice bags, positioning,

lighting etc Even just expressing to people I know you are in pain and I believe you helps. I honestly felt like this man thought I was a drug seeker.

Oh and on a side note, I am very grateful to have spent about 20 mins in the ER. It was amazing to see how fast they worked. I was very impressed. I am not angry with that, just the triage system that involves no pain meds.

[Fribblet]

On a side note, you should be grateful to have only spent actually 20 min in the ER. That's no wait! How did they get your assessment, work up, and dispo plus getting you a bed so quickly done?

They didn't. If she did only spend 20 minutes in the back, then it would appear that this terrible, uncaring, unsympathetic triage nurse set about getting things in motion so that her stay could be shortened. Such as, calling the surgeon and informing him of her presence so that she could be admitted quicker.

If the triage nurse did not alert anyone to her presence, then the poster is full of it. No patient gets to the floor in 20 minutes unless labs, radiological studies, informing physicians are done while the patient is waiting in the waiting room.

[ThrowEdNurse, BSN, RN]

I know I am burned out but really, quit for a while? In this economy? That's unrealistic. I can still save lives and do my job burned out. I may not be happy at the end of every shift but my job is always done properly. I could never seriously offer someone heat or ice or repositioning if they were in excruciating pain. It would sound sarcastic. Plus, I don't think heat or ice or repositioning are going to help an abd pain in the lobby. And why didn't you just tell the receptionist (note not the nurse) that you would like tissue? Faster for everyone! Plus I find that not all men consider these kind of things like offering tissues, etc. My husband is trained to offer me tissue if I am crying but it has taken years!