"Barriers to Adequate Trauma Pain Management at The Emergency Departments of Public Tertiary Referral Hospitals in Rwanda".

Abstract

Background: Pain control after trauma is an important and basic aspect of emergency management. Most patients at the Emergency Department (ED) commonly complain of pain, but many barriers prevent adequate assessment and treatment. Examples include level of staff education, availability of analgesics and lack of appropriate assessment tools. The use of guidelines and protocols to improve patient satisfaction is key to address trauma pain at the ED. In this study the impact of provider training in basic pain management on pain of trauma patients in the ED in two tertiary hospitals, was assessed. Methods: A pre and post intervention study was adopted: in the ED of the two main public referral hospitals in the country, the pre along with the post-intervention pain management data using a questionnaire were collected. The use of pain management protocols or guidelines, and perceptions of patients, physicians and nurses about barriers were also assessed.

The pre and post intervention study was used over a period of 6 months starting from September 2019 to April 2020 and consisted of 3 phases. Phase I: Pre-intervention: an observation of routine practice on pain assessment and management over a period of 2 months; Phase II: Intervention: Training and mentorship on the practicability of the WHO Pain Assessment and Management Ladder-based protocol and the ACS guideline for trauma pain management during 1 week; Phase III: Post intervention: Observation while using the guideline and protocol on pain assessment and management. We collected pre-intervention and post-intervention pain management data using a questionnaire. It assessed pain management practices and perceptions of patients, physicians and nurses about barriers.

Results: Over 6 months 309 participants were enrolled in the study. Of those participants,149 observed throughout the pre intervention phase and 160 participants during the post intervention one. In the pre intervention phase 94% of patients observed were males while in post intervention phase males represented 73%. The median age was 35 years (IQR [25-48]) years in both phases. The most used practiced in approach to pain control was cold packs 6

(5%)[p< 0.001] in phase one, increasing up to 24(18%) [p<0.001] in phase three. The majority of patients received morphine: 51 (41%) [p<0.001] and 74 (54%) [p<0.001] in phase one and phase three respectively. Paracetamol was administered to 85 patients (69%) [p<0.001] in phase I and 115 (84%) [p<0.001] in phase III. Low VAS (mild-moderate) pain scores were present in 2(16%) [p<0.001] pre- intervention vs 28(20%) [p<0.001] in post intervention.

Staff listed multiple barriers to adequate pain assessment and treatment: inexperience,9(36%) [p<0.010] vs 15(64.7) [p<0.010] time constraints 8(32%) [p<0.010] vs 11(47.4%)[p<0.010], poor communication 19(76%) [p<0.010] in pre-intervention vs 16 (69.4%) [p<0.010] in post intervention. Documentation was occasionally: 17(68%) [p<0.001] in pre vs 12(52%) [p<0.001] in post-intervention. Patient satisfaction was improved by the intervention: from 43(24%) [p<0.001] in pre-intervention vs 81(60%) [p<0.001] in post intervention.

Conclusion: In CHUK and CHUB ED the adherence of patients and staff to pain management guidelines and protocol improved after education. This intervention improved the assessment of pain using the VAS Scale and the use of multiple types of treatments in combination, with different targets to pain management. Despite perceived barriers due to lack of experience and poor communication for ED staff, the overall satisfaction of patients was improved.