Introduction:

In 2007 a national clinical audit was undertaken across 36 Australian emergency departments which highlighted the need to improve current pain management practice against the NHMRC approved guidelines developed by the Australian and New Zealand College of Anaesthetists (ANZCA 2005). Three conditions were studied in the audit (migraine, abdominal pain and fractured neck of femur).

 The fractured neck of femur presentations showed the greatest deviation from recommended practice, with only 10% receiving a femoral nerve block.  Median time to analgesia was greater than 60 minutes, twice the recommended time of 30 minutes to analgesia based on patient preference (NICS 2005, Tanabe & Buschmann 1999).  Initial pain scores or assessment was documented in 57.9% of patients receiving analgesia with further reassessment in 67% of those patients who had initial pain scores documented.

 These audit findings confirmed the need for a national initiative aimed at improving pain management practices in Australian emergency departments.

 Aim:

A two-year project was developed to support up to 60 hospitals across Australia to measure the effectiveness of multiple targeted strategies to implement the NHMRC approved guidelines 'Acute Pain management: scientific evidence (2nd Edition)' which include specific recommendations for best practice pain management.

 Methods:

A stepped-wedge (multiple-baseline) design (Cook & Campbell 1979, Brown & Lilford 2006, Hawkins et al. 2007) was selected that supports sequential rollout of two waves with a 6 month interval between the commencement of each wave.  Fifty-two emergency departments were randomized to a wave and participated in the study over two years.  Data was collected using a web-based entry system for participants to enter retrospective data extracted from charts.

Results:

A total of 52 hospitals completed the two year project (July 2010) with early data analysis indicating improvements in all of the project indicators.  The stepped wedge design enabled the NHMRC to logistically manage a large number of sites (52) across Australia to collect sufficient data to be able to report both aggregate findings of clinical significance for the selected indicators and provide individual sites reports to demonstrate reliable trends in local performance. One quarter of the participants identified issues with data collection due to Department of Health changes to coding systems. 

Discussion:

A stepped wedge design was an effective design to use for this project as it allowed the project coordinators to reach a larger group of participating sites. The intervention developed by NHMRC Effective Practice Program consisted of 4 workshops and ongoing support, the logistics of operationalising this intervention was well supported within this design.  The value of this approach also enabled each participant act as it's own control.

Conclusion:

A stepped wedge design is an effective approach when the logistics of managing a large project are challenging, ethically the intervention reflects best practice and when comparisons may be compromised due to system differences potentially impacting on the data integrity.

Acknowledgements:

We wish to acknowledge the contribution of the 52 emergency departments that participated in this study and the NHMRC-NICS Pain Management Initiative Advisory Committee.

References:

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence 2nd edition. ANZCA. Melbourne; 2005.

Brown C & Lilford R. The stepped wedge trial design: a systematic review. BMC Medical Research Methodology 2006, 6:54

Cook T, Campbell D: Quasi-experimentation: Design and analysis issues for field settings. Boston: Houghton Mifflin Company; 1979.

 Hawkins N, Sanson-Fisher R, Shakeshaft A, D'Este C, Green L. The multiple baseline design for evaluating population-based research. American Journal Preventative Medicine 2007, 33:162-168.

 National Institute of Clinical Studies. National Emergency Department Collaborative Report. NICS, Melbourne. 2004.

 Tanabe, P. & Buschmann, M. A prospective study of ED pain management practices and the patient's perspective. Journal of Emergency Nursing 1999: 25(3),171-7.