Time to Analgesia Audit

This project audits whether patients presenting with acute pain receive timely, well-documented pain assessment and analgesia. It reviews arrival and triage times, initial pain assessment and pain scoring, whether analgesia was indicated and offered, the time to first analgesia against a locally agreed standard, the route given, documented contraindications, allergies, refusals or reasons for delay, non-pharmacological measures, reassessment and response, escalation where pain remained uncontrolled, special-population considerations and handover or discharge analgesia plans.

• Emergency department, urgent treatment centre, minor injuries and acute medicine teams
• Trauma and orthopaedic, orthogeriatric, frailty and surgical teams
• Nursing teams, pharmacists, acute pain services, ACPs and PAs
• QI leads, governance and patient safety teams, supervisors and educators

• Measure whether acute pain is assessed, scored and documented on presentation
• Assess time to first analgesia against a locally agreed, configurable standard
• Review reassessment, response to analgesia and escalation of uncontrolled pain
• Identify delays, variation across clinical areas and documentation gaps
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, assessment context)
• Clinical area / location and optional specialty / service
• Nineteen time-to-analgesia criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• Royal College of Emergency Medicine

  Management of pain in adults in the emergency department(opens the original source in a new tab)

  Suggested source requiring user review — confirm which RCEM pain standard and timeframe the project has locally adopted.

• NICE

  NG38: Fractures (non-complex) — assessment and management(opens the original source in a new tab)

  National guideline covering timely pain relief in non-complex fractures.

• NICE

  NG39: Major trauma — assessment and initial management(opens the original source in a new tab)

  National guideline covering pain assessment and analgesia in major trauma.

• NICE

  CG124: Hip fracture — management(opens the original source in a new tab)

  National guideline covering pain assessment and analgesia on the hip fracture pathway.

• NICE

  CG138: Patient experience in adult NHS services(opens the original source in a new tab)

  National guideline on responsiveness to pain, communication and involvement in decisions.

• Local policy

  Local acute pain, ED analgesia, PGD/nurse-led analgesia and opioid safety policies

  Local policy defines pain-score thresholds, time-to-analgesia standards, medicine choice, route and reassessment intervals. Confirm the local standard before setting targets.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports, but does not replace, clinical judgement. Follow local acute pain, analgesia, PGD, opioid safety and escalation policy, the local formulary and specialist advice.
• Time-to-analgesia thresholds, pain-score thresholds, medicine choices, doses and routes are locally configurable and are not presented here as national standards. This is not a prescribing protocol.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Quality ImprovementDocumenting PDSA Cycles for Effective Quality ImprovementThis guide provides practical advice on documenting Plan-Do-Study-Act (PDSA) cycles, a crucial component of effective quality improvement in the NHS, ensuring learning is captured and shared.
• Quality ImprovementHow Many PDSA Cycles Does a Quality Improvement Project Need?This guide explains the iterative nature of PDSA cycles and offers practical advice for determining the appropriate number of cycles needed for effective quality improvement in NHS settings.
• Quality ImprovementPlanning Effective PDSA Cycles for Quality ImprovementThis guide provides a practical, step-by-step approach to planning effective Plan-Do-Study-Act (PDSA) cycles for quality improvement initiatives within the NHS, focusing on robust design and learning. It covers essential considerations from defining your aim to anticipating challenges, helping teams systematically test changes.