QUALITY GUARANTEE STUDY: EFFECT OF A CORRECTIVE MEASURE ON THE TREATMENT OF THE PAIN OF SERIOUS TRAUMATIC PATIENTS. Jiménez Moral, G.

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1 QUALITY GUARANTEE STUDY: EFFECT OF A CORRECTIVE MEASURE ON THE TREATMENT OF THE PAIN OF SERIOUS TRAUMATIC PATIENTS Ayuso Baptista, F.; F Jiménez Moral, G.; Chacón n Manzano, Mª M C.; Martín n Castro, C.; Sánchez Molina, F. and Ledesma Mesa, M.

2 INTRODUCTION: Acute pain in a serious traumatic patient is one of the main factors that contribute to strengthen the patients cardiorespiratory instability, generating a feeling of anguish, both in the patients and their relatives.

the patients cardiorespiratory instability, generating a

3 The presence of pain entails both anxiety and vegetative responses, provoking: 1. Increased sympathetic activity. Increase of SAP and DAP with increase of cardiac output, which conditions an increase in oxygen consumption. Increase of intestinal motility and gastric secretion, which increases the possibility of vomiting with probable aspiration. Urinary retention. Bronchoconstriction. 2.-Hormonal changes. It increases resistance to insulin with decrease of blood sugar. Increase of platelet aggregation. Ketosis. Retention of water and sodium. Increase of ADH and catechisations. 3.-Changes in the psychic sphere. Anxiety. Psychosis. Insomnia.

Increase of intestinal motility and gastric secretion, which increases the possibility of vomiting with probable aspiration. Urinary retention.

4 In the case of unconscious patients we can only detect indirect signs of pain : lacrimation,tachycardia, tachypnea, mydriasis, arterial hypertension as a consequence of the sympathetic hyperactivity produced. The presence of these signs will tell us if a critical patient is sufficiently under the effect of an analgesic. Prior to increasing the doses of analgesics in a patient presenting some of these signs, it will be necessary to discard other causes that may lead to a similar clinical picture.

The presence of these signs will tell us if a critical patient is sufficiently under the effect of an analgesic.

5 OBJETIVES: Analysis of traumatic patients under the effects of an analgesic before and after the implantation of a corrective measure in the 061 provincial service of Cordoba.

6 MATERIAL AND METHODS: Retrospective transversal observational study In two phases. Population: patients with a trauma ICD-9 attended by emergency teams for an 8-month period (n=416). The data were obtained from the clinical histories and from the SICOM integrated communication system.

Population: patients with a trauma ICD-9 attended by emergency teams

7 MATERIAL AND METHODS: 1st phase: Analysis of percentage of traumatic patients transported in a Mobile ICU and who receive analgesia. 2nd phase: Presentation of the results to all the service professionals with an improvement plan including a sedoanalgesia training programme. 3rd phase: Application of improvement plan. 4th phase: Analysis of the results following the starting of the plan. Variables: age, sex, analgesia, medicine used, pain scale.

2nd phase: Presentation of the results to all the service professionals with an improvement plan including a

8 MATERIAL AND METHODS: Variables: age sex analgesia medicine used pain scale

9 In order to measure the pain the patient was asked to value the painful feeling from 0 to 10, 0 corresponding to a total absence of pain and 10 to the greatest pain he or she had ever experienced.

10 RESULTS: Prior to the improvement plan the percentage of analgesiated traumatic patients was of 31%, 44.4% corresponding to non-analgesiated patients without an exclusion motive. 2 months after the corrective measure the percentage of analgesiated reached 91.7%.

4% corresponding to non-analgesiated patients without an

11 RESULTS: The medicines initially used were opiate+nsaid 15%; ketorolac 14%, morphine 7%, metamizole 4%, meperidine 3% and fentanest 1%. Following the intervention, the opiate+nsaid association was of 26%, ketorolac 15%; fentanyl 10%, morphine 5%, meperidine and metamizole 2%.

12 Nsaid + Opiates Metamizole Fentanest Morphine Meperidine Befor e 15% 4% 1% 7% 3% After 26% 2% 10% 5% 2%

13 CONCLUSIONS: The care quality regarding the trauma under our service has spectacularly improved upon detecting a deficit, communicating this to the professionals and raising the adequate corrective measures. This quality control procedure could be exportable to other services as well as to other processes.

professionals and raising the adequate corrective measures.

14 All of the provincial services favoured this good practice and adopted the following as a specific objective The patients transported by ET due to a traumatic pathology (ICD-9 from 800 to 959.9, inclusive, the following codes are excluded ICD_9 905 to 909.9, 931 to 936, 938, to and to and 958.5), must have their Medical Record include that they have been given pharmacological analgesia, Sp long as this is not contraindicated (Allergy, severe hypotension...).

9, inclusive, the following codes are excluded ICD_9 905 to 909.9, 931 to 936, 938, 952.0 to 952.9 and 958.0 to 958.

15 The punctuations on the pain scale before and after ET care must be entered in the Infirmary Record or otherwise in the medical record. It is also necessary to enter the use of adequate immobilisation means on these patients in the medical record.

16 Apart from this objective there was an incorporation in the Charter of Rights and Obligations of the Citizen of the analgesic treatment and the pain relief as one of its key points.

17 A specific objective has been incorporated to the annual objectives plan of the year 2003 for the nursing category: Carry out in at least 90% of the visits to patients with acute coronary syndrome traumas an adequate evaluation of the pain and a nursing care plan in keeping with the evaluation.

the visits to patients with acute coronary syndrome traumas an adequate

18 % of analgesia per services 100% 96% 100% 97% 98% 98% 100% 95% 87,8% 90% 90% 85% 80% 75% Almería Cádiz Córdoba Granada Huelva Jaén Málaga Sevilla 70% 65% 60% Datos obtenidos de la Empresa Pública de Emergencias Sanitarias

19 Evolucion of % of use of opiates 100% 90% 80% 70% Trauma Thoracic Pain Global 60% 50% 40% February March April May June July August September October

20 It is necessary within the pre-hospital area to make effective use of analgesia, this being regarded as a quality norm in the care process

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