Pain

Introduction

Frailty and persistent pain are both common amongst OAs and together contribute to disability and emotional distress. The impact of pain on everyday life is potentially modifiable with appropriate pain management techniques, but current services do not always take account of the needs of frail OAs. The Pain in Older People with Frailty Study (POPPY) is a mixed-method study to develop the content and implementation strategies for services to optimise the support available for OAs living with frailty and pain. Initial objectives of the POPPY study included seeking views from healthcare professionals (HCPs) and commissioners on existing local services including their experiences of the barriers faced by OAs with frailty accessing these services, and views on how resources might be best deployed to support OAs with frailty. 

Methods

In-depth qualitative interviews were conducted with HCPs from across England, based in specialist, secondary care and community services. Interviewees included commissioners, GPs, physiotherapists, occupational therapists, psychologists, nurses, doctors, and health coaches. A thematic approach to data analysis was used.    

Results

Forty-two HCPs and 2 commissioners from 9 pain services and 2 generic community services were interviewed. HCPs recognised that OAs living with frailty and pain formed a distinct group, experiencing shared facilitators and barriers to engagement. Meeting the needs of this group was challenging for services. Most HCPs thought a dedicated pain service for frail OAs was impractical and disagreed with the concept of age-based pain services. HCPs thought the needs of frail OAs were most likely to be met by community-based services, staffed with appropriately skilled multi-disciplinary teams, interacting effectively with other specialist services, and delivering holistic individualised approaches.   

Conclusion

Pain services need to be responsive to the specific needs of OAs with frailty and recognise the importance of adapting content and delivery of interventions to reflect this.  

Introduction:

Opiates are suitable analgesics in acute pain. However, there is no evidence to support their use in chronic pain and NICE discourages its prescription. Opiates are commonly prescribed amongst the elderly, and long-term use is associated with immunosuppression, hyperalgesia, fractures, falls and dependence. Once opiates are prescribed for acute-on-chronic pain, we should discourage long-term use by ensuring they are reviewed and weaned in the community and that patients are counselled on their risks. We aimed to promote effective opiate weaning practices upon patient discharge.

Methods:

Over 7 months, we reviewed discharge summaries and clinical notes across 3 geriatric wards, looking for patient education and advice given to GPs to review and wean opiates. Along with departmental teaching, we designed two text templates that could be automatically added to discharge summaries by doctors and pharmacists. One text educated patients and the other advised GPs to review opiates.

Results:

Post intervention data for 2 months showed improvements in both outcomes. The monthly percentage of discharge summaries including advice to GPs and patient counselling/education rose from a baseline median of 33% to 83% and 0% to 83% respectively.

Conclusion:

This quality improvement project demonstrates how introducing a text template to discharge summaries improves opiate stewardship and hence patient safety across geriatric wards. Next steps include introducing a patient information leaflet and further work with pharmacy to ensure our intervention’s ongoing use. With the assistance of local GPs we also aim to expand our project to wean opiates that patients were on pre-admission.

Pain management is essential for quality care in all inpatient settings, where pain may stem from trauma, acute medical conditions, or surgery. Patients with cancer or chronic pain often experience acute exacerbations or may develop acute pain related problems.

This audit aimed to assess adherence to best practices in pain management for hospitalized patients and compare current pain management services in UK.

We conducted an 8-week audit at Derriford Hospital, Plymouth, using patient records from seeEHR. We assessed the effectiveness, safety, and immediacy of pain relief actions and whether patients with complex pain were referred to the Integrated Pain Service (IPS). We also examined if discharge summaries detailed the analgesia provided. Additionally, we surveyed medical staff (doctors and nurses) on their pain management knowledge.

The audit included 50 patients: 32 (64%) from geriatric wards, 10 (20%) from oncology, and 8 (16%) from haematology wards. Patients on at least step 2 of the pain ladder were included. Results showed that analgesia was 74% effective and 26% ineffective. Analgesia was 100% safe, with no antidote used. Immediate action was taken in 96% of cases and a delayed action in  4% cases.

However, none of the discharge summaries (0/50) mentioned pain relief provided, and no patients (0/50) were referred to IPS. The medical staff survey revealed that 50% were unsure when to refer to pain teams. All doctors knew the pain ladder.

The audit indicates timely, effective, and safe pain relief but highlights the need for improved referral practices to IPS for complex pain and detailed analgesia records in discharge summaries. Educating staff on hospital pain management protocols is crucial.

This project is significant for all healthcare professionals and enhances patient care quality. Recommendations were made after the first cycle, and data collection for the second cycle is ongoing.

Introduction

Rib fractures are very common worldwide, particularly in the elderly due to the increased risk of fragility fractures. They are associated with significant morbidity and mortality, largely due to respiratory complications secondary to pain. For each additional fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27% . It is therefore crucial that recognition and effective analgesia is done promptly. This quality improvement project aimed to assess demographics and management of patients presenting to the Emergency Department (ED) at Weston General Hospital (WGH) with rib fractures.

Methods

Data was collected over a one-year period from 1/09/2021. A total of 199 patients were diagnosed with rib fractures and a random selection of 57 patients' data was analysed using basic statistics.

Results

The average age was 68. 93% had unilateral fractures and 59% had either one or two rib fractures. However, only 9% had severity scores recorded. Despite 29% having a pain score of 8 or more, there was no recorded analgesic prescription for 22% of patients. Of those that did receive analgesia, 33% received strong opioids.

Conclusion

Our data showed that there is scope for improvements in calculation of severity scores and analgesia, and therefore hopefully a reduction in complications. Following this data collection, new guidelines on rib fracture initial management have been produced and implemented at WGH. Going forward, we hope the new guidelines will provide a clear pathway for appropriate assessment and management for different severities of rib fractures, thus improving patient care.