Improving pain management for trauma patients at two Rwandan emergency departments.

Background: Little is known regarding the effectiveness of pain protocols and guideline use in Emergency Departments (ED) in Sub-Saharan Africa. Therefore, to shed light on this research gap, this study had the following objectives: 1) to evaluate if the implementation of the Essential Pain Management (EPM) course combined with mentorship to use the World Health Organization (WHO) pain ladder-based protocol improves the quality of pain management among trauma patients at the ED of two teaching hospitals in Rwanda; and 2) to determine barriers to implementing the WHO pain ladder-based protocol among trauma patients in the same settings. Methods: This was a pre- and post-intervention study. The intervention was 1-day essential pain management training for ED clinical staff followed by 1 week mentorship on the use of the WHO pain ladder-based protocol. Results: We enrolled 261 patients (47.5% pre versus 52.5% post intervention), most of them were aged between 21 and 40 (60% pre versus 33% post intervention), and male (76% pre versus 73% post intervention). The quality of pain management at the ED improved as shown by the decrease of the number of patients with undocumented pain scores from 58% to 24% after the intervention (p-value > 0.001) and the increase of the number of patients with mild pain from 37% to 62% (p-value > 0.001). In addition, patients who were satisfied with the quality of pain management increased significantly from 42% before the intervention to 80% (p-value > 0.001). Barriers to the implementation of the WHO pain ladder-based protocol were identified related to staff (i.e. inadequate experience), to the hospital (i.e. poor documentation), and to patients (i.e. reluctance to report pain). Conclusion: The implementation of the EPM course along with mentorship to use the WHO pain ladder-based protocol significantly improved the quality of pain management for trauma patients in EDs of both referral hospitals. Despite this, some barriers remain unfixed such as inadequate staff experience, poor documentation, and patient's reluctance to report pain. Appropriate interventions should be implemented to address the identified barriers and ensure adequate pain management for patients admitted at EDs in public hospitals in Rwanda.