Approaches To Pain Management
Approaches To Pain Management
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
An Essential Guide for Clinical Leaders, Second Edition
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition, offers practical advice on how to
meet The Joint Commission’s and Joint Commission International’s standards on assessing and treating pain. It features
clinical leaders recounting how they developed and implemented their pain management activities and successfully
addressed these standards.
This updated edition is a comprehensive and practical resource for health care organizations wishing to develop, evaluate, or
improve the way they assess and treat pain. In addition, the book includes the pain standards for international organizations
and introduces two international best-practice organizations describing their experiences in maintaining successful pain
management programs.
Approaches to
Clinical leaders will benefit from the following:
• Guidance on addressing challenging issues in pain management and committing an organization to improving its pain
Pain
Management
program
• Summaries of every Joint Commission and Joint Commission International pain assessment and management
requirement across most health care settings
• Examples of policies, care plans, protocols, treatment guidelines, and education materials for patients, staff, and family
• Plus, valuable “Online Extras” with additional information and case studies available only via the Web
Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of Joint Commission
International. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special
consideration or treatment in, or confidential information about, the accreditation process.
The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such
organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval.
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Table of Contents
Foreword ........................................................................................................................v
Daniel B. Carr, M.D., D.A.B.P.M.
Introduction..................................................................................................................vii
Judith A. Paice, Ph.D., R.N., F.A.A.N.
Acknowledgments ........................................................................................................ix
Index ..........................................................................................................................155
iii
Foreword
v
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Yet unlike exercises in science or mathematics, the problems successfully attained shared goals by applying distinct
faced by clinicians treating pain involve people who suffer strategies tailored to local circumstances, The Joint
and toward whom we feel compassion. The aggregate of Commission has continued to foster a shared sense of
wisdom shared by the clinicians whose efforts are presented community among pain clinicians worldwide. In so doing, it
herein constitutes a powerful collective narrative.4 Humans’ deserves the gratitude not only of patients and their families
sense of empathy reflects the function of a system of mirror but also of we who care for them.
neurons, premotor neurons that discharge when an animal
acts and when the animal observes the same action Daniel B. Carr, M.D., D.A.B.P.M.
performed by another animal.5 The mirror neuron system Saltonstall Professor of Pain Research
allows us to refine our actions by letting us visualize and Department of Anesthesia
internalize the success or failure of the actions of others. By Tufts University Medical Center
providing examples of how clinicians from around the world Boston
References
1. Brennan F., Carr D.B., Cousins M.: Pain management: A fundamental human right. Anesth Analg 105:205–221, Jul. 2007.
2. McNutt R.A., Livingston E.H.: Evidence-based medicine requires appropriate clinical context. JAMA 303:454–455, Feb. 2010.
3. Howard ME, Paret P (eds and translators). Carl von Clausewitz On War. [originally published in 1832 as Von Kriege]. Princeton, New Jersey:
Princeton University Press, 1984: 158.
4. Gundel H., Tolle T.R.: How physical pain may interact with psychological pain: Evidence for a mutual neurobiological basis of emotions and
pain. In Carr D.B., Loeser J.D., Morris D.B. (eds.): Narrative, Pain, and Suffering: Progress in Pain Research and Management, vol. 34. Seattle:
IASP Press, 2005, pp. 87–112.
5. Rizzolatti G., Sinigaglia C.: Mirrors in the Brain—How Our Minds Share Actions and Emotions. New York City: Oxford University Press, 2006.
vi
Introduction
vii
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
The exemplars in these chapters propose universal themes, Northwestern Memorial Hospital, we have created a “pain
and it is crucial that anyone working to improve pain icon” on our intranet that allows professionals to access
management in his or her institution carefully consider the pain-related materials in one easy location.
following subjects: • Evaluation of outcomes must be ongoing and in real time
• Any efforts to address pain must be interdisciplinary. Any as much as possible; otherwise, leaders cannot measure
professional who interacts with patients must be engaged, changes in time to foster improvements or address declines.
including nurses, physicians, pharmacists, physical/ • All these interventions require institutional commitment.
occupational therapists, chaplains, social workers, and
others. Consideration of the patient and family should be Pain management has advanced astonishingly in the past few
at the core of all these efforts. decades. Evidence for this progress includes the reduced use
• Assessment must be ongoing and incorporate the whole of inappropriate drugs, such as meperidine, propoxyphene, or
patient, including physical, emotional, cultural, and placebos. Additional support for this evolution includes the
spiritual domains. development of tools to assess pain in special populations,
• Therapy should be evidence-based and multimodal, such as neonates and infants; children; cognitively impaired,
employing pharmacologic and nonpharmacologic ventilated patients; and those with dementia. And largely due
techniques to meet the patient’s individual needs. to efforts of The Joint Commission, more regular assessment
• Pain strategies should address the entire continuum of care, and documentation of pain occur.
from the physician’s office to inpatient departments,
outpatient centers, home care programs, skilled nursing Now we must more effectively act on this information. This
facilities, and rehabilitation facilities. Electronic medical book is an outstanding reference for all medical, nursing,
records, if facile and accessible, allow this provision of pharmacy, quality improvement, and other leaders working
continuity of care. to relieve pain within their settings of care. For those
• Although education alone is insufficient to promote passionate in their quests to relieve pain, this book provides
enhanced pain care, it is one pillar of any pain an essential guide or road map, making a complex
management program. Mentoring programs that phenomenon much easier to address.
incorporate role models and coaches are crucial to molding
excellent practices. Other creative educational solutions Judith A. Paice, Ph.D., R.N., F.A.A.N.
include written pocket cards, posters, toolkits, in-services, Director, Cancer Pain Program
more extensive courses, online educational programs, and Division of Hematology-Oncology
television programs directed to patients and their family Feinberg School of Medicine, Northwestern University
members. All materials should be easy to locate. At
viii
Acknowledgments
Joint Commission Resources (JCR) is grateful to the We also thank the clinical leaders who contributed their best
contributors who either shared their work in pain practices to this book’s first edition in 2003, including Judy
management for this revised edition or cooperated in Bartel, M.S.N.; JoAnn Beasley, R.N.; Patricia H. Berry,
updating their stories from the last edition. Their enthusiasm Ph.D., A.P.R.N., B.C., C.H.P.N.; M. Soledad Cepeda, M.D.;
about and concern for the well-being of those they serve were Eneida Cruz, R.N., M.A.; Donna Dombrosky, R.N., M.P.H.;
readily evident. These individuals include the following: Mary Beth Guilbert, R.N., M.A.; Lewis L. Hsu, M.D.,
Ph.D.; Vivian Carri Leahy, Ed.D., R.N., C.S.; Keith Myers,
Katie Cahill, R.N., The Stone Center of New Jersey, L.L.C., L.N.H.A., B.S., M.H.S.A.; Allan F. Platt, Jr., P.A.-C.,
Newark M.M.S.c.; Jan Scholke, R.N., B.S.N.; Pamela Tropiano,
Diane Korman, R.N., M.S.N., C.H.P.N., Montefiore R.N., B.S.N., M.P.A., C.R.N.H.; Phil Wiffen,
Residential and Community Services for Seniors, M.R.Pharm.S.; and Harriet Wittink, P.T., Ph.D.
Beachwood, Ohio
Kay Fei Chan, R.N., M.N., M.B.A., Tan Tock Seng We are particularly grateful to Dan Carr for his guidance and
Hospital, Singapore invaluable assistance regarding the use of evidence-based
Amany Ezzat, M.D., F.I.P.P., Dar Al-Fouad Hospital, Cairo practice in pain management, as well as for contributing this
Debra B. Gordon, R.N., M.S., F.A.A.N., University of edition’s Foreword. We likewise thank Judy Paice for her
Wisconsin Hospital and Clinics, Madison contribution of the preceding Introduction.
Susan Leininger Hogan, R.N., M.S.N., Allegheny General
Hospital, Pittsburgh Thanks also go to the Joint Commission, Joint Commission
Nagwa El Hosseiny, M.D., Dar Al-Fouad Hospital, Cairo International, and JCR staff members who reviewed the
Meg O'Toole Oser, R.N., M.A., The Stone Center of New manuscript of this revised edition and advised on development.
Jersey, L.L.C., Newark Special thanks goes to several on staff who played a critical role
Virginia Maripolsky, Bangkok Hospital, Bangkok, Thailand in identifying the contributors and organizations for the
Regina Prosser, R.N.-B.C., M.S.N., C.D.O.N./L.T.C., chapters by clinical leaders, including Roberta Fruth, Jeannell
Montefiore Residential and Community Services for Mansur, and Paul Reis.
Seniors, Beachwood, Ohio
Natalie Toomey, R.N., M.S.N., South Beach Psychiatric Finally, we reserve our greatest debt of gratitude for Julie
Center, Staten Island, New York Chyna, Ruth Carol, and Kathleen Vega, for their excellent
job in writing this publication. Their effort, patience, and
skill are very much appreciated.
ix
Chapter 1
Overview of
Pain Management
1
Chapter 1
3
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
people report having experienced pain in the past month, In addition to the previously mentioned illnesses and
and 4.2 million report having chronic pain.7 conditions, pain can result from many other health-related
problems, such as arthritis, headaches, gastrointestinal
Unlike chronic pain, acute pain is described as pain that diseases, and so on.11
comes on quickly, is severe, and lasts a relatively short
amount of time. Treatment for such pain may be intense and Surgical pain is also prevalent across patient populations. In
of short duration, resulting in relatively quick resolution of some cases, surgery is performed to address pain, and in
symptoms. Acute pain is typically associated with tissue other cases it can cause pain. It is estimated that 40 million
injury and inflammation. It generally goes away as the Americans undergo surgery and suffer from inadequate
healing process moves forward. postoperative pain control.12
Many different illnesses and injuries can cause pain. For Unfortunately, the presence of comorbidities can render
example, among those patients receiving treatment for cancer, evaluation of pain and its response to treatment—as well as
30%–50% experience pain, with 70%–90% of patients with the provision of such treatment—challenging. Subjects with
advanced cancer suffering from disease-associated pain.8 complex diseases, such as cancer or AIDS, often have other
medical conditions, such as renal dysfunction, depression,
Musculoskeletal injuries can also cause pain. These types of anxiety, and cognitive impairment. In addition, these patients
injuries typically occur because of repetitive strain, overuse, may simultaneously experience acute and chronic pain,
and work-related musculoskeletal disorders. They can affect nociceptive and neuropathic pain related to their primary
bones, joints, muscles, or surrounding structures. These diagnoses or their treatments, or pain from unrelated,
injuries are associated with acute and chronic pain, which possibly preexisting medical conditions.
could be focal or diffuse. Lower back pain is the most
common example of chronic musculoskeletal pain. Other Patient Populations at Greater Risk for Pain
examples include tendonitis, neuropathies, myalgia, and stress Although pain can affect anyone, certain populations are at
fractures.9 Musculoskeletal pain from overuse affects 33% of greater risk for experiencing pain. In general, women report
adults and accounts for 29% of lost workdays due to illness. experiencing more recurrent pain, more severe pain, and
In Western society, lower back pain is the most prevalent and longer-lasting pain than men do. Not only do women have
common work-related injury as well as the most costly work- lower pain thresholds and tolerance to a range of pain stimuli
related musculoskeletal disorder. The economic burden of when compared with men, they also can experience more
musculoskeletal pain is second only to that of cardiovascular painful conditions than men. For example, women are more
disease.9 likely to have fibromyalgia, irritable bowel syndrome,
temporomandibular disorder, rheumatoid arthritis and
Patients with human immunodeficiency virus (HIV) can also osteoarthritis, and migraine headaches. In addition,
experience high levels of pain. This pain can be varied, menstrual cycles, pregnancy, and other female-only
diverse, and associated with significant psychological and conditions can be quite painful.13
functional effects. Unfortunately, this pain is also
undertreated across the world.10 Age can also impact the presence and reporting of pain. For
example, elderly patients are more likely to experience pain
Nerve damage can also cause severe pain. Pain due to nervous and be sensitive to it, specifically chronic pain.14 Pain in
system injury is called neuropathic pain, whereas pain arising elderly patients is not a new phenomenon. For 20 years,
from injury to previously intact tissue is termed nociceptive studies have shown pain as a common symptom in nursing
pain. Neuropathic pain results from a disturbance of function home residents, and it continues to be underrecognized and
or a pathologic change within a nerve or nerve pathway. In undertreated.15 Age-associated factors within the elderly
contrast to nociceptive pain, neuropathic pain may persist in population, such as multiple comorbidities, cognitive
the absence of ongoing noxious stimuli or new tissue impairment, depression, loss of family and friends, loss of
damage. independence, and the use of multiple medications, may
4
Chapter 1: Overview of Pain Management
contribute to pain and suffering in this population. Such certain populations are more at risk than others. For example,
symptoms as depression and anxiety, sleep disturbances, women, minority groups, elderly persons (particularly
weight loss, and cognitive impairment may be related to pain nursing home residents), children, and individuals with
and even be manifestations of pain in older people.14 certain diseases, such as cancer and AIDS, are at appreciable
risk for suboptimal assessment and treatment of pain. There
Children are another vulnerable population. Cancer is the are many reasons for this, including societal norms about
second-leading cause of death in children, after accidents. pain, economic factors, lack of education about pain
Many children dying of cancer suffer greatly in the last management, lack of ability to communicate pain
month of life. In fact, pain in children with cancer is now management needs, and so forth.
recognized as a significant symptom of cancer that requires
comprehensive assessment and management.16 Although undertreating pain can be detrimental to patient
outcomes and quality of life, treating and continuously
The Importance of Treating Pain managing patient pain can have several positive effects,
Pain is a common experience among health care patients including keeping the patient more comfortable, improving
across the world. As seen in the previous section, myriad clinical outcomes, reducing readmissions, and decreasing
statistics show that pain is a very real problem for individuals. length of stay. In the acute care setting, proper pain
Despite its prevalence, pain is often undertreated. According management often allows patients to recover from injury or
to one statistic, treatment for pain fails to achieve adequate illness faster, thus leading to better outcomes and improved
results in 40% of patients reporting pain, despite the functioning.21 Those individuals with chronic pain can realize
availability of effective treatment modalities.17 Although increased mobility, strength, and stamina with effective pain
experts agree that overall pain is generally well addressed in management.
the acute care setting for those with new pain that results
from an intervention, such as surgery or labor and delivery, Not only is the appropriate and effective management of
the health care system is still woefully inadequate in patient pain helpful in improving outcomes and reducing
managing pain once individuals leave the acute setting and costs, it is also the right thing to do. The fundamental goals
return home or to another level of care. In addition, effective of the health care profession are to improve patient health,
management of chronic pain for inpatients and outpatients is address symptoms, and encourage recovery where possible.
lacking.18,19,20 Pain management plays a critical role in all these goals and
thus should be considered a priority for all who work directly
Undertreated pain yields several negative consequences. For with patients.
example, it can result in unnecessary patient suffering,
reduced functioning, exhaustion, depression, loss of hope, Pain management has been characterized as a moral
and diminished quality of life. Pain is one of the key factors obligation or duty,22 and undertreating pain and poor pain
that degrade health-related quality of life. For patients who management are thought to violate patient rights. The Joint
are dying, undertreated pain can decrease the will to live. Commission and Joint Commission International (JCI)
Pain can also exacerbate some conditions, such as cognitive include pain management as part of their standards
impairment and malnutrition; lead to multiple medication addressing the rights of patients (see Chapter 2). Some
use; and increase the likelihood of falls.15 Poor pain control experts go a step further and consider undertreatment of pain
can also lead to greater health care utilization, delays in to be a medical error.23
discharge, and unscheduled readmissions, which can have
financial impacts on patients and health care institutions.8,15 Patients, their families, and the public are becoming
Looking more broadly at the impact of undertreated pain, increasingly well informed about pain management and less
one could say that it increases costs to health systems overall tolerant of poor pain control. That intolerance is becoming a
and has the potential for negative workforce implications. very important driver in the improvement of care for patients
Although undertreated pain affects all types of patients, with pain.
5
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Barriers to Pain Relief effect of opioids and can thus limit the use or escalation of
At first glance, the issue of undertreated pain appears to be these important drugs.
an easy one to address. If a patient has pain, the provider
should address that pain in whatever way is necessary. Fundamentally, use of opioids for treating chronic pain is less
However, pain management is not that easy to accomplish, than optimal, suggesting that practitioners lack the necessary
and pain relief has several barriers across health care settings. knowledge, understanding, and/or skill to use opioids
Following is a brief discussion of some of those barriers. appropriately. In fact, across the health care profession,
consensus is lacking about what appropriate use should be.
Problems Arising from Health Care Providers
Inadequate knowledge about pain management principles Most patients who use pain medication, such as opioids, to
among health care providers is a significant barrier to the treat acute pain for a short period of time do not become
effective identification, treatment, and management of pain.24 addicted.26 They take the drug until their symptoms resolve,
In many cases, physicians, pharmacists, nurses, and other and then they stop. Determining addiction rates with long-
health care providers have received inadequate training in term opioid use is more challenging. Fishbain et al.
school about how to identify, assess, and respond to patient determined that in a population of patients with various pain
pain. This leads to a lack of confidence in treating long-term complaints, the rate of addiction with chronic opioid use was
chronic pain, appropriately selecting medications, and less than 1% for patients who had not taken opioids before
prescribing opioids.48 and 4% in patients who had a history of substance abuse.27
Although this research showed some risk for addiction, more
This lack of background not only can impede effective pain than 95% of patients interviewed used the pain medications
management but also can influence the provider’s perception effectively without experiencing addiction.
of the need for and importance of such management. Health
care providers who have not been educated about pain and It is important to note that addiction is distinct from
its unique psychological, emotional, and cultural triggers may physical dependence, although the terms are sometimes
underestimate the need for treatment or disregard a patient’s inaccurately used interchangeably. Addiction can be thought
complaint when it is not associated with specific physical of as a compulsive use of a substance, resulting in craving,
manifestations. In one recent study in Ireland, physicians and lack of control over the drug, and continued use despite
nurses made their own judgments about their patients’ pain harm.28 Physical dependence is a biological phenomenon in
experience rather than accepting the patients’ reports of the which abrupt discontinuation of therapy or administration
presence and intensity of pain.24 results in withdrawal symptoms. Physical dependence may
occur during chronic administration of many classes of drugs,
In addition to a lack of background about the concept of including opioids as well as benzodiazepines, barbiturates,
pain management, health care providers can have a lack of alcohol, beta-blockers, and the alpha-2 agonist clonidine. As
knowledge about current treatment options. In some cases, long as abrupt discontinuation of therapy is avoided, physical
this manifests itself as a lack of familiarity with different dependence is not a serious issue. Addiction and physical
interventions. In other cases, it manifests itself as dependence are therefore two distinct phenomena, and
misconceptions about these interventions. Physicians who are confusing them can contribute to misperceptions about pain
not familiar with different options may neglect to use them management and the undertreatment of pain.
or may avoid them because of concerns about
overprescribing, patient overdose, or addiction. For example, Another term that relates to this discussion is tolerance, which
health care providers who prescribe and administer opioid is a lessening of a drug’s effect over time. One misperception
medications are often afraid of addicting patients.25 This fear about tolerance is that it is a signal of addiction. However,
is many times based on an inadequate understanding of the this is not true and tolerance can be treated safely with a dose
increase.28
6
Chapter 1: Overview of Pain Management
Problems Arising from Health Care asked, the patient said his discomfort was bearable and he
Organizations was okay without any medication. A nurse’s repeated efforts
Although providers are primarily responsible for ensuring to discuss the patient’s pain level were dismissed. Only after
effective pain management, the health care organizations in the nurse insisted that the patient’s comfort was one of her
which providers work must also lay the groundwork for this most important responsibilities did the patient finally agree
interdisciplinary effort. Because effective pain management to take pain medication.31 Although providers must respect
requires interactive communication with patients and the wishes of these patients, they still need to provide such
families, interdisciplinary cooperation, time for assessments patients with information that will allow them to choose
and reassessments, and continual monitoring of side effects, whether to accept treatment for their pain.30 (For more on
organizations that give low priority to pain management and the subject of cultural influences on pain management, see
control can inhibit provider efforts to address this critical Cultural and Religious Issues in Pain Management in
patient issue. In one recent study conducted in Ireland and Chapter 6, pages 121–123.)
the United States, respondents identified several
organizational barriers to pain management, including an In addition to cultural influences, patients may be concerned
inability to offer analgesia until a diagnosis was made, a lack about pain medications or have misconceptions about these
of time for pain assessment and control, the need to care for types of medications. These individuals may be worried
other acutely ill patients while attending to the patients with about side effects or becoming addicted to pain medication.
pain management needs, and the inability to monitor side Although patients have access to a lot of information on pain
effects when patients leave the emergency department.24 medication because of the Internet and other media, they can
A survey of Iranian nurses showed that heavy work load, time also be influenced by others, such as friends and family
constraints, frequent interruptions, poor staffing levels, and members, who may not be as well informed. If a friend or
defective equipment all negatively affected their ability to family member whom the patient respects feels strongly
manage patient pain.29 about avoiding pain medication for fear of addiction, this
attitude can influence a patient significantly, even if the
Problems Arising from Patients patient has done his or her own research on the medication
Patients are often reluctant to complain of pain for a via the Web.
multitude of reasons. For example, many adults—in the
United States and internationally—believe that pain is simply Still other patients worry that treatment will mask other
an element of life and a normal part of the health care symptoms and thus result in inadequate focus on the
experience. These adults can be reluctant to admit to feeling underlying causes of their pain. Sometimes patients believe
pain because of fear of being labeled “complainers.” Cultural they must endure the pain and save “the strong medicine” for
and social influences may also dictate that the patient when things get really bad. These patients may be reluctant
minimize or not mention his or her level of pain. For to increase the dose of pain medication for fear that it will
example, people from cultures that value stoicism tend to hinder their process of getting better.
avoid speaking about their pain or using more emotional
responses, such as moans or screams. They may work to keep Some patients, including pediatric, elderly, and cognitively
their faces “masked”—avoiding all facial expressions of pain, impaired patients, as well as those who have other barriers to
including grimacing. Such patients may feel that providers communication such as language barriers, may not be able to
will think them weak if they admit to or show pain, and they describe their pain. Although they are suffering, they may not
may deny having pain when asked. In addition, they may show it or be able to communicate about it.
prefer to be left alone to bear their pain.30
Whatever the reason for avoiding pain discussions,
Consider the story of a middle-aged Chinese patient who minimizing discomfort, or inadequately communicating
refused pain medication following invasive surgery. When about pain, this lack of communication between patients and
7
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
providers can result in inadequate pain control, greater pain takes significant time; when this time is minimally
severity, poorer patient functioning, and depression.32 reimbursed, it lessens the appeal of such treatment.19,20
In addition, some pain medications, such as opioids, are
Another complication arising from patients is that different expensive, and patients, depending on their income levels
patients respond differently to therapy. Not all patients react and types of insurance coverage, may not be able to afford
the same way to opioids, for example, and not all patients them.
can use nonpharmacological options, such as guided imagery,
effectively. (See pages 27–28 for more information on Quality of Clinical Pain Research
nonpharmacological options.)* Consequently, even if an Many health care providers are unfamiliar with current
organization is using a clinical protocol for treating pain and treatment options for pain and the appropriate approaches to
has properly assessed and responded to the patient’s pain, the treating specific types of pain. Part of this lack of familiarity
patient can still experience pain. This continuing pain can is due to the quantity and quality of evidence on this topic.
lead to frustration, depression, and other negative symptoms. The quantity and quality of scientific evidence on cancer
pain, although improving, is not nearly equal to the quantity
Laws and Policies Restrict Pain Management and quality of evidence about treating cancer itself. The
Approaches number of patients enrolled in cancer pain trials is only a
Regulations in the United States and internationally restrict tiny fraction of those receiving care. This problem is not
the availability of opioids, a key element in managing unique to cancer pain; similar clinical research gaps have
moderate to severe pain. For example, in various countries impeded the advance of evidence-based practices in treating
around the world, more than 116 narcotic drugs and their acute pain and chronic noncancer pain as well.
pharmaceutical preparations are controlled. These include
mainly such products as opium and its derivatives— Although solid evidence shows the effectiveness of specific
morphine, codeine, and diamorphine—but also synthetic agents or therapies, guidance regarding overall approaches to
narcotic drugs, such as methadone and pethidine. Various managing a patient’s pain is still inadequate. For example,
agencies of the United Nations are involved in aspects of little research has been done on the effect of analgesics on the
drug control in health care organizations, but only the World multiple dimensions of quality of life, drug interactions
Health Organization (WHO) is specifically given a role by during long-term pain treatment, the optimal sequence of
the international drug control treaties concerning the scope adding drugs to improve pain control, how best to combine
of substances under restriction.33 drug with nondrug therapies, and individualization (such as
according to gender and ethnicity) of pain treatment. Even
Laws and policies aimed at curtailing illicit opioid use, such today, it remains unclear whether a mechanism-based
as multiple-copy prescription programs, have the potential to approach to diagnosing and relieving each component of
discourage providers from prescribing opioids for pain relief. pain in an individual is more effective in clinical practice
Such laws and policies can lead to physician fears of scrutiny than an empiric regimen in which each patient’s treatment is
and unwarranted investigations by regulatory agencies and based on pain intensity alone. In addition, few analgesic drug
can also contribute to the undertreatment of pain. trials include children, women, and elderly subjects,
populations at increased risk of having undertreated pain.
In addition to laws and regulations governing opioid use, the
lack of coverage and uneven reimbursement policies for If health care providers and the organizations in which they
health care in the United States and internationally inhibit work are to understand the nuances of pain management and
access to pain medication and treatment for millions of be familiar with treatment options that are likely to prove
people, particularly the poor, the elderly, and minorities.34 worthwhile in practice, researchers must document the
This current state of reimbursement and the lack of different etiologies and mechanisms of pain in accrued
incentives for treating patients with pain—specifically, subjects. Extended follow-up intervals are required to predict
chronic pain—can de-incentivize physicians from treating the safety of pain treatments used in daily practice, in which
patients with pain medications. Medicinal treatment often analgesic medications may be taken for years. Pain trials are
* Chapter 8 focuses on a hospital in Bangkok, Thailand, that has made nonpharmacological interventions a key part of its pain management program.
8
Chapter 1: Overview of Pain Management
Overcoming Barriers to Pain best available evidence. A complete discussion of these and
other diverse resources is available in the Online Extras at
Management http://www.jcrinc.com/APM10/Extras/.
Although significant barriers block effective pain
management, organizations can work to overcome these
barriers. Following are several specific interventions that can patient, a practitioner must consider the patient’s individual
be helpful in this effort. experience with pain and preferences for treatment, the
organization’s resources and capacities, and other factors
Use Evidence to Ensure Standardized, unique to the particular situation. In other words, to use EBP
Appropriate Treatment effectively, practitioners should not think of it as an inflexible
The field of pain management is changing every day. approach to treat every patient, but rather as a general
Keeping up with this substantial amount of information can approach that highlights which treatments are likely to be
be challenging but is also critical to ensuring the best possible more, and which are likely to be less, effective. Although an
care for patients. The pursuit of appropriate evidence is an important one, EBP is but one of the tools in an
important part of identifying and implementing the most organization’s arsenal for addressing patient pain.
appropriate and clinically proven pain treatments for
patients. Throughout this chapter, several evidence-based pain
management practices are discussed. These include, for
What is evidence-based practice (EBP, also broadly referred to example, the WHO’s three-step analgesic pain ladder for
as evidence-based medicine [EBM])? Fundamentally, it is an treating cancer pain (Figure 1-4, page 27), the Wong-Baker
approach to providing care to patients that involves the use FACES Pain Rating Scale© for assessing pain in children
of clinical research combined with clinical experience, patient (Figure 1-2, page 21), and music therapy as a
characteristics, and patient preferences to make clinical nonpharmacological option for treating patients with chronic
decisions regarding pain treatment and management. It pain (page 28). Although these and many of the other
provides an unbiased alternative to previous approaches that practices highlighted in this book may work well in an
have characterized much of traditional clinical practice. The organization, it is up to the organization and the practitioner
use of EBP is meant to help address clinical problems based treating a particular patient to weigh the evidence and
on aggregated scientific evidence rather than anecdotal determine which particular approaches are appropriate to
experience or opinion. EBP emphasizes that intuition, treat a specific individual.
unsystemic clinical experience, and belief are insufficient
grounds for clinical decision making, and stresses instead the How can an organization incorporate EBP into its pain
use of unbiased evidence from clinical research.35 management practices? The Joint Commission and JCI
standards offer a number of requirements for approaching
Although using evidence to guide practice is important, it pain management that address a variety of actions, such as
must be considered in the context of the individual patient, screening, assessing, treating, and monitoring patients for
the organization, and the treatment plan. EBP can aggregate pain. By seeking and applying the best available evidence on
and distill a significant amount of information about a how to meet these standards, organizations can get much
particular problem—such as the choice of a pain therapy for closer to comprehensive approaches that are rooted in science
a cancer patient—but before using it to treat a specific but tailored to the needs of individual patients.
9
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
EBP is especially useful in providing answers to specific comfortable with medications (see page 7). Languages differ
questions. To use EBP effectively, providers should develop in the types and number of words used to express pain. For
well-formulated questions, perform comprehensive data example, Hebrew, Chinese, and Japanese have very few
searches, interpret the data they find, and consider those data words to express pain, whereas English has 15 categories
in the context of the patient.36 With that said, accessing and with 64 words.38 Health care providers should be familiar
assessing the often large amount of clinical evidence can still with the different cultures of the patient populations they
be a challenge. It is not practical for practicing clinicians to serve so they can keep these perspectives in mind. As
access primary clinical trials to answer a specific clinical clinicians evaluate and treat their patients’ pain, it is
question. Literally hundreds of sources exist to sift through important that they recognize and respect cultural
and navigate. However, seeking information from resources differences and offer language-appropriate patient assessment
that have already organized and distilled information into the tools.38 (See Sidebar 1-2, pages 17–18, for a discussion of
form of a systematic review can be very helpful. These different assessment tools in a variety of languages.)
resources often review and assess only those studies whose • Effects of pain. Pain can affect the patient not only physically
quality has already passed critical appraisal. Searching for the but also psychologically, emotionally, and socially.
answers to a clinical question in these resources discloses • Assessment tools and techniques. These are how a provider
guidelines and recommendations a provider can consider in determines the nature, severity, and duration of a patient’s
the context of the patient and organization.37 Sidebar 1-1 on pain. (See pages 14–24 for more information about
pages 11–13 provides a brief introduction to some of the assessment.)
most frequently used EBP resources for sifting through the • Pharmacological and nonpharmacological pain
clinical research literature. interventions. These can include opioid and other
analgesics as well as less-traditional methods of pain
Again, further resources can be found in this publication’s management. (See pages 24–28 for more information
“Online Extras” (http://www.jcrinc.com/APM10/Extras/). about pharmacological and nonpharmacological treatment
options.) Education about pharmacological treatment
It can also be helpful to look at how organizations in the field options should include a discussion of potential side effects
incorporate EBP in their approaches to pain management. To associated with common treatments.
that end, we have included several case studies in this book • Any clinical care guidelines or other evidence-based
from different organizations around the world, discussing practice used in the organization
their approaches to pain management, the processes they use • How to educate patients about pain
to develop evidence-based approaches to care, and how they • Information on the benefits of and risks associated with
measure the success of those approaches. opioid prescription. Because this is an area of some
controversy, organizations should ensure they provide their
Educate Health Care Providers physicians and nurses with the most current information.
Some providers seek specific education on pain management
principles. For this reason, educating health care providers, Before beginning an education program on pain, an
including physicians, pharmacists, and nurses, on pain organization should assess health care providers’ current levels
assessment and management is critical to establishing an of knowledge and understanding about pain and should plan
organizationwide focus on pain management. educational opportunities around those assessments. For
example, recognizing that physician practice patterns may be
A pain education program includes a variety of topics to formidable barriers in improving pain management,
focus on, such as the following: organizations may want to assess the medical staff ’s
• Definitions of pain. Any discussion of pain should point knowledge and attitudes regarding pain management. The
out that pain is very personal and that the patient’s report results of the survey can be used to design pain education
of pain should be the primary identifier of pain. specifically targeted to physicians. Such education may focus
• Cultural approaches to the expression of pain. Cultural on improving patient outcomes and reducing the negative
influences can determine whether a patient speaks up about impact of prolonged pain. A baseline assessment also allows
his or her pain, is willing to treat that pain, and is for comparison after education efforts take place.
10
Chapter 1: Overview of Pain Management
PubMed
PubMed comprises more than 19 million citations for biomedical articles from MEDLINE and life science journals.
Citations may include links to full-text articles from PubMed Central or publisher Web sites. As a starting point, MEDLINE
is effective in answering queries related to pain assessment and management. One types in one or more search terms
(e.g., “cancer” and “breakthrough pain”) and then promptly receives output that can be narrowed further if desired.
Cochrane Library
The Cochrane Collaboration is an independent, noncommercial, international organization of more than 27,000
contributors across more than 100 countries. The organization provides reliable, relevant, unbiased, current
information to help providers, practitioners, and patients worldwide with their decision making. Contributors work
together to produce systematic assessments of health care interventions, known as Cochrane Reviews, which are
published online in the Cochrane Library. (http://www.thecochranelibrary.com/view/0/index.html)
The Cochrane Pain, Palliative and Supportive Care Group (PaPaS) is one of 51 review groups in the Cochrane
organization. Based in different countries around the world, PaPaS is composed of people who share an interest in
developing and maintaining systematic reviews relevant to pain management and palliative care. The PaPaS review
group was formed in 1998, and its focus is on randomized controlled trials that deal with the following topics:
• The prevention and treatment of acute and chronic pain
• The relief of symptoms resulting from the disease process and interventions used in the management of disease
and symptom control
• The support of patients and/or caregivers through the disease process
(continued)
11
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Evidence-Based Medicine
This bimonthly publication surveys a range of international medical journals, applying strict criteria for the quality and
validity of the research. It includes a wide array of clinical disciplines, including family practice, internal medicine,
pediatrics, obstetrics, gynecology, psychiatry, and surgery. Within this publication, practicing clinicians assess the
clinical relevance of the best studies. The key details of these essential studies are presented in succinct abstracts
with expert commentaries on their clinical applications. (http://ebm.bmj.com/)
12
Chapter 1: Overview of Pain Management
Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, Second Edition
(JAMA and Archives Journals)
Readers of this publication learn how to distinguish solid medical evidence from poor medical evidence, devise the
best search strategies for each clinical question, critically appraise the medical literature, and optimally tailor EBM for
each patient. In its second edition, this publication covers not only articles produced in the Journal of the American
Medical Association (JAMA) but also topics such as how to avoid being misled by biased presentations of research
findings, how to interpret the significance of clinical trials that are discontinued early, how to influence clinician
behavior to improve patient care, and how to apply key strategies for teaching EBP.
nline extras
For more sources of EBP related to pain management, see the Online Extras at http://www.jcrinc.com/APM10/Extras/.
In addition to direct care providers, nonclinical staff, management and emphasizing a receptive and responsive
volunteers, physical therapists and occupational therapists, communication style from providers.32
housekeeping staff, dietary staff, and so forth should all
receive education. To ensure comprehensive and appropriate Patient education about pain should include general
education for all staff members, organizations may need to information about pain, the importance of managing pain,
determine which staff members need basic orientation to how pain will be assessed, and treatment options, including
pain assessment and management and which need more pharmacological and nonpharmacological options. Educating
advanced content. patients about potential side effects is also important. Patients
should be able to recognize side effects of their pain
Educate the Patient and Family medications and also know that such side effects are usually
Many misconceptions in the United States and transient and can be treated.
internationally are associated with pain management, such as
“Pain is just part of the health care experience and doesn’t Many opportunities arise during the care continuum for
need to be managed” or “By managing pain, you could patient education about pain, including upon admission,
become addicted to drugs.” To dispel these and other during patient care visits, at discharge, and during follow-up
misconceptions, organizations must provide education to interactions. Education at discharge is particularly important,
patients about pain and pain management. One recent study as it can impact whether a patient takes pain medications
showed that a patient’s pain outcomes may improve by after he or she leaves the health care organization. A tendency
addressing the patient’s misconceptions of pain and pain exists to teach patients inadequately about the use of pain
13
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
program. This program may involve an interdisciplinary ssociations: Are any other signs or symptoms associated
group that spearheads pain management across the A with the pain?
organization and researches, adopts, educates providers on,
and measures the effect of clinical practice guidelines and
processes to achieve a standard of care across the
T ime course: Does the pain follow any pattern?
Assessing Pain
Comprehensive assessment provides the foundation for pain
S everity: How bad is the pain?
14
Chapter 1: Overview of Pain Management
rating scale across the organization (if possible) and have When conducting a comprehensive assessment, it is
alternative scales available for individuals unable or important for providers to remember that an individual’s self-
unwilling to use the standard scale. For certain types of report of pain is the most reliable indicator of the existence of
procedures where pain is of a limited duration, such as a pain. It should be the “gold standard” in the assessment
dental extraction, it may suffice for organizations to process, accepted and acted on. The patient’s self-report is
monitor only pain intensity and forego tracking of other more accurate than vital signs, outward behavior, or observer
aspects of the multidimensional pain experience. estimates; however, other factors should also be considered,
• Location. A patient should be encouraged to describe the such as visible cues to pain—grimacing and wincing—and
location of his or her pain as well as to show it to the reports from family members and other caregivers.
assessor, if applicable.
• Quality. In assessing pain quality, health care providers When treating individuals who are unable to self-report, it is
should use the care recipient’s own words, if possible, and particularly important to observe outward behavior and
explore any patterns of radiation. A careful description of indirect indications of pain, including facial expressions,
pain quality can provide clues to the type and nature of the body language, and other changes in behavior. An example is
pain. that a patient who is very still may actually be guarding
• Temporal characteristics. Assessing the pain’s temporal against pain that follows movement. (See page 16 for more
characteristics involves asking such questions as, “When information about assessing patients who are unable to self-
did the pain start?” “Does the pain vary with time of day report.)
or activity?” “Are there any patterns?” and “How long does
the pain last?” Family members can sometimes offer valuable perspectives
• Aggravating and alleviating factors. Aggravating and about the patient’s current pain status and can describe
alleviating factors that affect pain can be assessed by asking, behaviors that might be indicative of pain. Although not
“What helps lesson the pain—ice, medication, rest?” always reliable, information from the family tends to be more
• Present pain regimen and effectiveness. This includes any accurate when the patient’s levels of pain are at the lowest
medications—prescription, over the counter, or herbal— and highest extremes. Information from family members
the patient is taking and how effective they are. tends to err on the side of overtreatment rather than
Nonmedication interventions, such as ice, heat, and music undertreatment when it comes to pain.38 To increase the
therapy, should also be discussed. reliability of pain information from families, providers may
• Pain management history. This is the time to determine want to coach the family member before he or she provides
any previous use of pain medications, the effectiveness of his or her estimate of the patient’s pain. Telling family
those medications, and the potential for any abuse or members to put themselves in the patient’s symptom
addiction issues. More on assessing patients with substance situation can yield more accurate information.38
abuse can be found on page 23.
• Effects or impact of the pain. These could include effects Using Pain-Rating Scales
on daily function, sleep, appetite, emotions, concentration, Simple tools are commonly and successfully used to assess the
and other factors. intensity of pain, characteristics of pain, and effects of pain
• Meaning of the pain. Assessment of pain’s meaning may on functional status. These tools can help patients report,
indicate that the pain creates fear, suffering, or describe, and think about their pain. Different types of
hopelessness, or it may be a metaphor for illness or death. patients may require specific approaches to pain assessment,
• Individual goals and expectations. These should be assessed and thus tools designed to capture information from
in terms of function (for example, the individual wants to particular patients can be beneficial. To that end, several tools
sleep better or walk without pain) or achievement of a pain exist that are specifically targeted and designed to assess
scale rating of a specific value. particular types of patients and specific types of pain.
• Physical exam/observations of the site of pain. Health care Although The Joint Commission and JCI do not require
providers should examine the site of the pain and assess organizations to use pain scales to assess pain, they do
physical findings. Without direct inspection, the provider require some sort of defined methods for assessing pain.
could miss something that could provide insight into the A pain scale can be one such method and is an effective
pain’s cause. way to ensure consistent and comprehensive assessment.
15
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
(See Sidebar 1-2, pages 17–18, for a brief description of some – The Assessment of Discomfort in Dementia
of the more common pain-rating scales). – Checklist of Nonverbal Pain Indicators
– The Discomfort Scale–Dementia of the Alzheimer’s Type
Before adopting a pain scale, organizations should consider – Nursing Assistant–Administered Instrument to Assess
the characteristics of the patient populations they want to Pain in Demented Individuals
assess and keep these in mind when determining which, if – The Pain Assessment Scale for Seniors with Severe
any, scales are appropriate. The following are some Dementia
population characteristics to consider: – Pain Assessment for the Dementing Elderly
• Developmental stage – The Pain Assessment in Advanced Dementia Scale
• Chronological age • Repeat questions about pain using simple, clear language
• Functional status to prevent confusion and to reinforce understanding.
• Cognitive abilities • Frame questions about pain in the present tense.
• Emotional status • Give ample time for the patient to respond to questions
• Comorbid conditions, such as cancer, spinal cord injuries, about pain.
HIV, and so forth • Avoid overstimulation before beginning the assessment to
help the patient focus on the questions at hand.
Pain-rating scales should be used consistently throughout an
organization when possible. Obviously, the scale used to
assess cancer pain will not be the same as the one to address
pain in the pediatric outpatient clinic. However, using the
TIP
Some organizations use a special protocol to assess pain of
same scale when possible helps ensure consistency, prevents individuals with Alzheimer’s disease. Staff members use the protocol
misunderstandings, and allows for more accurate data and documentation tool when they think a pain behavior may have
collection. been triggered or when they are seeing some new behavior that
could be related to pain.
Assessing the Cognitively Impaired
Individuals with cognitive or sensory impairments or those
who are psychotic or severely emotionally disturbed require If a health care provider determines that a patient cannot self-
special consideration during assessment and treatment. report, the provider should discuss pain levels and history
Cognitively impaired patients may be at greater risk for poor with family and caregivers and look for visual cues to pain,
pain assessment and management than other adults because such as grimacing, crying, and altered body movements. It is
of their inability to communicate and their sometimes-erratic important when observing cognitively impaired patients for
behavior.40 However, these traits do not mean that they are in pain to assess at different times during different activities.
any less pain or do not have pain management needs. The pain level at rest may be different than that during
toileting or eating.
Some things providers should keep in mind when assessing a
cognitively impaired patient include the following: Assessing the Critically Ill
• Do not assume that the patient cannot self-report pain. For critically ill patients, such as those within the ICU, pain
Research shows that many patients with mild to moderate assessment can be quite challenging. For these patients, the
cognitive impairment retain the ability to report pain. ability to communicate with health care providers about pain
Consequently, cognitively impaired individuals should be may be quite limited because of the presence of breathing
given the opportunity to self-report their pain.40 apparatus, feeding tubes, and other equipment. These strike
• Use a valid and reliable pain screen to assess pain. at one of the most basic tenets of pain control: the need for
Depending on the patient, health care organizations may patient input in pain management decisions given the
be able to use the previously mentioned Numeric Pain subjective nature of pain.41 However, as with other patients
Intensity Scale or the Wong-Baker FACES Pain Rating with communication impairment, the presence of pain in an
Scale. Other scales designed especially for the cognitively ICU patient is no less real just because he or she cannot
impaired include the following: express it. Most, if not all, critically ill patients experience
– The Abbey Pain Scale (see Figure 1-3 on page 22) pain at some point during their stays, so ongoing assessment
16
Chapter 1: Overview of Pain Management
Although it is effective in measuring changes in pain intensity and the efficacy of medication, a numeric pain scale is
a one-dimensional assessment, because it does not tell the whole story of the patient’s pain experience. Other one-
dimensional scales include the following:
• Visual analogue scale. This is a number line with 100 mm markings on it. The patient marks a number on the
number line indicating his or her pain intensity. The response is scored by measuring the distance of the patient’s
mark from the left-hand end (“anchor”).
• Verbal descriptor scale. This is a scale that uses such phrases as “no pain,” “mild pain,” “moderate pain,” and
“severe pain” to help patients describe their pain.
• The Wong-Baker FACES Pain Rating Scale. This is typically used with children and has five faces ranging
from smiling to tearful. The patient picks the face that most closely represents his or her pain level. This scale
can also be helpful with adults with literacy or cognitive issues.42 (See Figure 1-2 on page 21.) A revised
version of the Wong-Baker scale is available with instructions in nearly 50 different languages at
http://www.usask.ca/childpain/fpsr/fps-r-multilingual-instructions-mar2010.pdf.
• The Brief Pain Inventory (BPI). Developed by the Pain Research Group of the World Health Organization (WHO)
Collaborating Centre for Symptom Evaluation in Cancer Care, the BPI is a common pain scale for assessing patients
with cancer pain. The multidimensional tool consists of a pain-intensity rating scale and a body diagram that the patient
can mark, showing the location and radiating tendencies of any pain. The tool also has questions about medication
efficacy and the patient’s ability to function. Although designed for use with cancer patients, this tool can also be helpful
in assessing chronic pain. To access a sample of a BPI, go to http://www.ohsu.edu/ahec/pain/paininventory.pdf.
• The Pain Self-Efficacy Questionnaire.43 Developed in Australia by M.K. Nicholas, this is a 10-item self-report
inventory that measures a patient’s beliefs about his or her ability to complete a range of daily activities despite the
presence of pain. This validated scale is used widely to assess chronic pain. Organizations can access this
questionnaire at http://www.tac.vic.gov.au/upload/pain_self_efficacy_questionnaire.pdf.
• The McGill Pain Questionnaire. This scale consists of a pain-intensity rating scale, body diagram, and list of
weighted pain descriptors. Developed by Drs. Melzack and Torgerson at McGill University in Montreal, Canada,
the tool can be used to assess and monitor patients with significant pain and to determine the effectiveness of pain
interventions over time. Translated into many different languages, this tool has been used effectively in many
medical surgical settings for postprocedural pain assessment.42 Further information about this tool can be found at
https://www.cebp.nl/vault_public/filesystem/?ID=1400.
(continued)
17
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
• The Checklist of Nonverbal Pain Indicators. This scale helps assess pain in nonverbal, cognitively impaired, or
critically ill patients. It includes the following six behaviors that indicate pain:
1. Vocalizations
2. Facial grimacing
3. Bracing
4. Rubbing
5. Restlessness
6. Vocal complaints42
A sample of this checklist can be found at http://www.healthcare.uiowa.edu/igec/tools/pain/nonverbalPain.pdf.
• The Pain Assessment in Advanced Dementia. This scale uses the following five indicators for pain:
1. Breathing
2. Negative vocalizations
3. Facial expression
4. Body language
5. Consolability
The drawback of this scale is that the caregiver infers pain rather than receiving a self-report by the patient.45
• The Pain-Related Self-Statements Scale—Catastrophizing Subscale. This is a well-validated and widely used
scale to measure chronic pain. It is composed of a nine-item self-report inventory that measures the frequency of a
patient's catastrophic thoughts and feelings, which impede the person's ability to cope with severe pain. Patients
are asked to rate the frequency with which they experience catastrophic thoughts during pain episodes.
18
Chapter 1: Overview of Pain Management
This figure shows one of several pain-rating scales from the British Pain Society that has been translated into a language
other than English. The scale consists of the foreign-language version followed by the English-language translation.
(continued)
19
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Source: British Pain Society: Pain Scales in Multiple Languages. http://www.britishpainsociety.org/pub_pain_scales.htm (accessed Jul. 12, 2010).
© 2006 The British Pain Society. Used with permission.
20
Chapter 1: Overview of Pain Management
This tool is often used to assess pain in children and the cognitively impaired.
21
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
22
Chapter 1: Overview of Pain Management
using a systematic approach is paramount. In fact, providers to substance dependency and addiction, health care providers
should err on the side of presuming pain is present when should consider the following:
assessment is not possible.41 • Use a nonjudgmental approach to assessing for a substance
abuse or an addiction issue.
Because of the critical nature of ICU patients’ conditions, • Use a multimode approach to controlling pain, including
pain levels can fluctuate significantly and frequently. For this the use of opioid medications, nonopioid medications, and
reason, ICU patients should be regularly assessed for pain. It regional anesthesia techniques, such as epidural or femoral
is important to note that it is easier to prevent the escalation blocks.
of pain by recognizing and treating it early than to manage • Remember that patients with substance abuse problems
pain after it has gotten out of control. Consequently, will require more medication than a typical patient,
providers should consider starting analgesic agents at the because they metabolize drugs and respond to pain stimuli
same time as sedative agents if they have any suspicion of differently.
pain.41 • Prevent withdrawal symptoms.
• Treat any concurrent psychological disorders, such as
anxiety, depression, or personality disorders.47
TIP • Treat an identified addiction as a primary illness, because
individuals can die as a result of the medical conditions
To help with pain assessment in intensive acre unit patients,
organizations may want to consider having laminated pain arising from their addictive illnesses. The conditions
assessment cards that include a number of different pain resulting from addiction and persistent pain are markedly
assessment methods at the patients’ bedsides. These cards may similar and include, among other things, sleep disturbance,
include the Wong-Baker FACES Pain Rating Scale, words to depression and anxiety, functional disability, substance
describe the nature of the pain, or other scales to foster abuse, and secondary physical problems.
communication.38 • Maintain open lines of communication between the
patient and all members of the care team to ensure clarity,
prevent misunderstandings, and avoid, as feasible, a
Any pain management plans for the ICU patient should be renegotiation of the opioid regimen.
based on the assessment. Pharmacotherapy may be the most
appropriate choice for this population; however, providers
should rule out potential adverse drug interactions with other
medications being used. In older patients, providers also need
TIP
To increase a provider's comfort with prescribing long-term opioid
to watch for adverse drug reactions. Older patients may be use, organizations may want to use a screening tool, such as the
more susceptible to adverse reactions, and providers should Screener and Opioid Assessment for Patients with Pain—Revised
consider starting with low doses of pain medication and and the Opioid Risk Tool. These screening tools can help identify
increasing as needed.40 Anticipating and managing side effects patients who could develop aberrant behaviors that can signal
are also important. addictions.48
23
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
When considering a specific pain scale to use with children, providers take a systematic approach to pain assessment and
providers should look at the child’s age. How a provider classification, the patient is at risk for suboptimal treatment.
assesses a 4-year-old for pain will differ from how he or she Even after an initial pain treatment plan is in place, the
assesses a 10-year-old. For example, for patients between the source and severity of the patient’s pain and the effectiveness
ages of 3 and 7, providers may want to consider the Wong- of treatment may fluctuate and therefore should be reviewed
Baker FACES Pain Rating Scale, as this visual scale can help and documented at regular intervals.
children reliably and consistently communicate the intensity
of their pain. For patients age 7 to 18, providers may want to Each organization must develop its own criteria for
consider using the same 0 to 10 numeric scale used for the assessment and reassessment based on the needs of its
general population, because these pediatric patients are able patients. For example, organization policy may call for
to count to 10 and understand the sequence and value of conducting reassessments more frequently if pain is
numbers. If providers are unsure whether a patient can use unrelieved or the method of treating a patient’s pain is being
the numeric scale, providers can ask the child) “Which changed.
number is smaller, two or four?” and “Which number is
larger, three or seven?” Providers should use the FACES scale To achieve ongoing, effective pain management, an
for children who cannot answer these questions correctly. individual’s response to pain interventions must be properly
documented. Documentation of assessment and reassessment
As with cognitively impaired patients, for children who are results helps clinicians evaluate the individual’s pre- and
verbally limited, providers must look for other clues to their postintervention pain status. (More information on
pain. These cues include facial expression, the child’s response documentation can be found in Chapter 2.)
to comforting, sleep, body movements, crying, groaning, and
changes in vital signs. A scale that can help drive these In addition to documenting a patient’s pain, health care
observations is the Faces, Legs, Activity, Cry, and providers should communicate with other caregivers about
Consolability pain assessment tool, which relies on staff the pain, treatment plan, and patient’s response to treatment.
observations of preverbal children. When using the tool, Such communication can take place during interdisciplinary
providers look at each of the five behaviors and score them rounds, care-planning meetings, shift changes, and other
using a 0–2 scoring range. A total score results when the points in time where information is shared among multiple
scores from the different behaviors are added together. This disciplines. Some topics to cover when communicating about
total score helps the provider determine the level of pain— a patient’s pain include the following:
mild (0–3), moderate (4–6), or severe (7–10).49 • Patient’s current pain level
• Patient’s current treatment for pain
Parents also help with the assessment process. Providers can • Patient’s response to treatment
ask questions of the family regarding how long the child has • Changes to patient’s pain management program
been in pain, what the child’s mood has been, whether the • Effect of the patient’s pain on daily living
child has been able to attend school, and whether pain is • Risks associated with the pain, such as the risk of falling
interfering with normal daily activities. When discussing pain • Unusual reactions to drugs
levels with parents, providers should make sure they are
aware of the importance of adequately assessing and More information about interdisciplinary communication
managing pain. If a parent feels that complaining about pain and pain management can be found in Chapter 2.
is “wimpy,” then he or she may be reticent to acknowledge
his or her child’s discomfort. Methods of Treating Pain
As a result of patient assessment, providers will have to
Ensuring Regular Reassessment determine the type of treatment to address a patient’s pain.
Once pain has been assessed, regular reassessment and follow- The cornerstone of pain management involves modifying the
up are crucial to ensure that a patient’s pain is being relieved sources of pain, altering the perception of pain, and blocking
or treated according to the care plan. Because of the multiple its transmission within the nervous system.2 Treating pain can
and evolving etiologies of pain, each time a clinician assesses involve pharmacologic and nonpharmacologic treatments.
a patient, an evaluation of pain should occur. Unless Pharmacologic treatments involve medications ranging from
24
Chapter 1: Overview of Pain Management
ibuprofen to morphine. Nonpharmacologic treatments can In addition to different routes of administration, several
include music therapy, ice, heat, distraction, journaling, and different types of pain medication are available. Following is
so forth. In many cases, a combination of therapies is used, a brief introduction to some of the more common.
with the type of treatment depending on the duration and
origin of the pain experience. NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs)
are effective analgesics and can be used to treat pain of mild
This section provides an overview of some of the many intensity. NSAIDs have central analgesic properties, can
treatment options available for addressing patient pain. reduce fever, and inhibit inflammation. NSAIDs work by
Although the scope of this publication does not allow for an blocking the production of prostaglandins—chemical
in-depth analysis of these different treatment options, this messengers that often are responsible for the pain and
section introduces several different pain management swelling of inflammatory conditions.52 The most commonly
interventions that are currently in use. used NSAIDs are aspirin and ibuprofen.
Pharmacologic Treatments Several risks are associated with excessive NSAID use,
Pain medications can take many different forms, including including risks of serious gastrointestinal bleeding,
oral medications, nasal sprays, ointments, liquids, impairment of renal function, exacerbation of hypertension,
transdermal patches, patient-controlled pain pumps, and worsening of cardiac heart failure, and bleeding. NSAIDs
injections. exhibit a ceiling effect for analgesia and so should not be
administered above the recommended dose range. At higher
Different methods will be appropriate for different patients doses, not only is there no incremental analgesic benefit, the
based on their pain histories and current pain levels, risk of side effects increases dramatically.
intensities, and durations. Oral medications are typically used
for chronic pain management because of their convenience, Selective inhibitors of COX-2. Prostaglandins—the chemical
safety, rapid onset, and low cost. Oral administration of messengers discussed previously—are formed by two distinct
drugs can manage most postoperative pain or pain of serious but related enzymes: cyclooxygenase-1 (COX-1) and
illnesses, such as cancer, HIV/AIDS, or sickle cell anemia. cyclooxygenase-2 (COX-2). Both these enzymes contribute to
Physiologic limitations, however, such as swallowing inflammation, but COX-2 is of considerable therapeutic
difficulties, nausea, malabsorption, or the need to swallow an interest because it is inducible and responsible for enhanced
unwieldy number of tablets, may dictate other routes of formation of prostaglandins during inflammation.53 COX-2
administration. inhibitors are NSAIDs that selectively block the COX-2
enzyme and not the COX-1 enzyme. Blocking this enzyme
Around-the-clock administration can be appropriate for impedes the production of prostaglandins by the COX-2
moderate to severe pain that is present continuously. enzyme. These prostaglandins often cause the pain and
Typically, this type of administration is given intravenously. swelling of inflammation and other painful conditions.
This helps improve absorption and can be supplemented for Because they selectively block the COX-2 enzyme and not the
spikes or “breakthroughs” in pain. For example, COX-1 enzyme, COX-2 inhibitors are uniquely different from
breakthrough pain during around-the-clock opioid therapy traditional NSAIDs, which usually block both enzymes.52
can be treated with supplemental “rescue” doses of a short-
acting opioid unless the breakthrough occurs frequently, and Although COX-2 inhibitors do have a reduced risk of
then the continuous dose should be reevaluated. gastrointestinal bleeding, these agents must still be used with
caution in patients with renal dysfunction or with congestive
Pain medication can also be delivered via epidural. This is heart failure, and controversy exists as to whether
particularly important in settings of acute pain, such as (presumably due to their mild hypertensive effects based on
during labor and delivery. The use of epidural opioid fluid retention) these agents may increase mortality due to
analgesia (sometimes together with a local anesthetic) offers stroke or myocardial infarction.
many benefits. It provides a better quality of analgesia and
may decrease the incidence of morbidity compared with Opioids. Opioids are very effective analgesics. They are the
similar doses of systemically administered opioids.50,51 foundation for management of moderate or severe pain and
25
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
include such drugs as morphine, hydromorphone, and misperceptions about opioid use exist and must refrain from
fentanyl. Drugs of this type have been used for thousands of avoiding these drugs out of fear of respiratory depression,
years to address significant pain, and no other therapeutic addiction, rapid tolerance, or death.
entities appear to be in development to replace them.41
Unlike NSAIDs, opioids do not exhibit a ceiling effect for Before prescribing opioids, careful consideration of the goals
analgesia as dose is increased. For that reason, it is important of treatment is important to ensure the patient only takes as
to determine effective starting doses and titrate upward as much medication as needed to achieve these specified goals.
needed.54 Opioids are commonly self-administered by When possible, opioid therapy should be easy to follow. This
patients in the postoperative setting, using small, portable clarity helps prevent patients from taking too much or too
devices, and occasionally by patients in other settings, such as little medication.
the home. This self-administration allows patients to control
the amount of analgesic they receive and promotes their As discussed earlier, carefully screening patients for possible
autonomy and satisfaction. Opioids are delivered substance abuse and depression-related issues may be helpful
intravenously within the ICU and other areas treating in preventing adverse drug events. One way to monitor
critically ill patients, thus easing drug delivery and improving opioid therapy is to make an opioid agreement with the
absorption. patient when therapy is initiated. This agreement can then be
modified when therapy is modified. These agreements often
The optimal choice of opioid depends on the pharmacokinetics set out responsibilities of the patient and provider and make
and physiochemical characteristics of the drug and the patient’s clear the potential dangers of using these drugs in any way
handling of the opioid as well as the presence of other drugs.43 other than prescribed.55
Opioids have no maximum dose or duration. Providers must
assess the benefits and potential adverse drug events when Adjuvant medications. Adjuvant medications are those that
determining how much and how long to prescribe. Concerns of augment the benefit of opioid analgesics, diminish opioid
addiction are never sufficient justification for insufficient dosing side effects, or are given by themselves to treat pain
of opioids for patients in severe pain.43 symptoms. Such medications include antidepressants and
anticonvulsants. Tricyclic antidepressants and anticonvulsants
Side effects frequently limit the dosage of opioids. are the medications of choice for neuropathic pain.
Constipation is almost universal during chronic opioid
administration, and prophylactic treatment should be used to The WHO Pain Relief Ladder
address this condition.43 Other frequent opioid side effects Despite the varying types of pain, very few new classes of
include nausea, vomiting, and altered cognitive function. analgesic drugs have been released in the past 100 years, and
These can negatively affect quality of life, so aggressive a large proportion of all pain treatment follows a formulaic
management of these symptoms is mandatory. The large approach based on a few analgesic drug classes. That
individual variation in the development of opioid-induced approach first employs an NSAID and then adds a weak
side effects dictates that clinicians monitor and inquire opioid, such as codeine, if necessary for moderate pain. For
prospectively and regularly about such side effects and be severe pain, a strong opioid, such as morphine, is substituted
ready to treat them quickly. for the weak opioid. This three-step method of pain relief, in
which such adjuvant medications as tricyclic antidepressants
Providers often have concerns about prescribing opioids due or anticonvulsant drugs may be employed at any stage to
to the potential for adverse events associated with these calm fears and anxiety, has been disseminated worldwide in
drugs. (See “Laws and Policies Restrict Pain Management the WHO’s Pain Relief Ladder. This guideline was originally
Approaches” on page 8.) The past several years have seen an developed for practitioners caring for patients with cancer
increase in overdoses and deaths associated with these drugs pain, but it can be applied to patients dealing with chronic
in the United States and internationally.55,56 Providers must be pain as well.54 (See Figure 1-4 on page 27.)
well educated in the use of opioids to treat patient pain and
must understand the risks for adverse events, such as According to the WHO ladder, to maintain freedom from
depression, respiratory issues, and substance abuse.57 With pain, drugs should be given by the clock—that is, every three
that said, they must also understand that many to six hours—rather than on demand. This approach of
26
Chapter 1: Overview of Pain Management
This figure shows the World Health Organization's three-step method for pain relief.
Freedom from
cancer pain
Non-opioid
1
+/– Adjuvant
administering the right drug, in the right dose, at the right management and control. Such therapies as acupuncture, herbal
time is inexpensive and 80% to 90% effective.54 remedies, and dietary supplements also are considered.
27
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
examined complementary therapies are music interventions instruction in self-regulatory techniques. The goals of such
and relaxation interventions. Cepeda et al. conducted a meta- care include not only addressing the patient’s pain but also
analysis of 51 randomized controlled trials related to music providing the patient with skills to cope with and manage his
therapy and concluded that although music decreased pain or her pain.5
intensity, improved pain relief, and lessened the need for
postoperative opioid treatment, the magnitude of the benefits Patients and their families are taught to report changes in
was relatively small.58 Other researchers have found that their pain or the development of any new pain so that these
relaxation therapy for treatment of chronic and postoperative changes can be assessed, treatment can be modified, or
pain can decrease pain levels significantly. A combination of diagnostic studies can be arranged.
music and relaxation therapy lowered pain scores even
further.43 An interdisciplinary approach to pain management has been
shown to be effective. For example, one recent study at
One drawback to nonpharmacological therapies is that they Baylor Medical Center5 strengthened the case for
present more reimbursement problems than pharmacological interdisciplinary chronic pain management and offered
interventions such as opioids. Many insurance carriers will evidence for the long-term effectiveness of the therapy.
not pay for any type of interventional or holistic pain Another study conducted at the University of Stavanger in
management, seeing it not as therapy but as luxury.21 To Norway showed that the use of a cognitive behavior therapy
overcome this drawback, some organizations have partnered program provided by an interdisciplinary team was able to
with education organizations that teach holistic pain improve patient quality of life, overcome pain-related
management such as massage therapy. Students in these disability, and contribute to an improvement in patient
institutions can complete their required certification hours by readiness to change.59
providing services for inpatients whose pain medication does
not suffice.21 Conclusion
Understanding of the complexity of the pain phenomenon
Interdisciplinary Therapy for Chronic Pain has grown a great deal in recent decades, and the word pain
The interdisciplinary approach to the treatment of chronic pain has now come to connote multiple distinct but related
consists of assessing and treating the physical, psychosocial, processes that unfold over time and across molecular, cellular,
medical, vocational, and social aspects of chronic pain. The individual, and societal levels. At present, many of the
International Association for the Study of Pain, among many human barriers to adequate pain assessment and pain control
other professional organizations, has long advocated that are beginning to fall. Health care providers, patients,
because chronic pain is a multidimensional condition, the regulators, and institutions are collaborating to ensure that
interdisciplinary approach is the preferred method of restoring patients receive the best available pain management.
quality of life and functionality to such patients. Nevertheless, we still need to close the gap between
preclinical research and its application to patients.
Typically, an interdisciplinary approach to pain management
involves physicians, psychologists, counselors, physical The human connection established in relieving—or better
therapists, case managers, occupational therapists, nurses, and still, preventing—the suffering of patients with pain does
other health care professionals.5 Treatment by such an distinguish it from most other fields of clinical practice and
interdisciplinary group often involves pharmacological offers those who engage in such efforts unsurpassed rewards
treatment, physical therapy, cognitive behavioral therapy, and along with challenges.
28
Chapter 1: Overview of Pain Management
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35. McNutt R.A., Livingston E.H.: Evidence-based medicine requires appropriate clinical context. JAMA 303:454–455, Feb. 3, 2010.
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37. Müllner M., Carr D.B.: Accessing and assessing medical evidence. In Shorten G., et al. (eds.): Postoperative Pain Management: An Evidence-Based
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40. Wheeler M.S.: Pain assessment and management in the patient with mild to moderate cognitive impairment. Home Healthc Nurse 24:354–359,
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48. D'Arcy Y.: Be in the know about pain management. Nurse Pract 34:43–47, Apr. 2009.
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50. Sharma M., et al.: Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m2 for off pump coronary artery
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51. Wu C.L., et al.: Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients. J Clin Anesth
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55. McLellan A.T., Turner B.J.: Chronic noncancer pain management and opioid overdose: Time to change prescribing practices. Ann Intern Med
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57. Gourlay D.L., Heit H.A., Almahrezi A.: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med
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58. Cepeda M.S., et al.: Music for pain relief. Cochrane Database Syst Rev Issue 2:CD004843, 2006.
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30
Chapter 2
Compliance with
Joint Commission
and JCI Standards
31
Chapter 2
Compliance with
Joint Commission
and JCI Standards
* Note: The standards numbers referred to throughout this chapter are applicable to The Joint Commission’s 2010 comprehensive accreditation manuals for the various programs
mentioned. Other standards numbers noted in this chapter that begin with the chapter abbreviations ACC, PFR, AOP, COP, PFE, or SQE, are from Joint Commission
International Accreditation Standards for Hospitals, Third Edition. (The fourth edition of the JCI hospital standards were published in July 2010 and are effective starting
January 1, 2011.) Refer to the most current editions of each manual for the exact wording of the standards discussed.
33
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
the patient's needs, cultural perspectives, and concerns. Those recognizes that it lacks the skill to thoroughly assess
individuals caring for a patient should be his or her best individuals who report pain, it may choose to refer such
advocate in ensuring that pain is acknowledged and individuals to a local clinic and then coordinate as a team to
addressed. address the individuals’ physical and mental health issues.
This concept is addressed in PC.8.10 for behavioral health
organizations.
34
Chapter 2: Compliance with Joint Commission and JCI Standards
For example, before initiating patient-controlled analgesia One approach to creating a pain protocol is to review the
(PCA) and epidural analgesia options for surgical and pain medications included in the organization’s formulary
obstetric patients, one hospital convened an interdisciplinary and divide them into categories for expected pain relief. For
team of physicians, pharmacists, and nurses to perform a example, pain medications used to address mild pain may
number of tasks. The team reviewed the literature on PCA; include acetaminophen, ibuprofen, and codeine. Medications
drafted policies, procedures, and standing orders; obtained to address moderate pain may include Vicodin, Percocet, and
35
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
oxycodone. Medications to address severe pain may include Addressing Pain in the Hospice Setting
morphine and hydromorphone. An organization should also
consider which pain medications would be appropriate for
(PC.01.03.01)
End-of-life care is often associated with pain and the
breakthrough pain. By segmenting pain medications into a
management of pain. For hospice organizations, which are
protocol, an organization can ensure that the appropriate
specifically charged with providing appropriate,
medication at the appropriate dose is given.2
comprehensive, and compassionate end-of-life care, pain
management is critically important.
36
Chapter 2: Compliance with Joint Commission and JCI Standards
• Accommodations for family privacy after a patient’s death and abilities. Providers should take into account a patient’s
• Décor that is homelike in design and function cognitive and physical abilities as well as his or her literacy
• Access for visitors, including small children, at any hour and cultural needs. Providers should also ensure the patient
understands the education provided. This may involve asking
Patients facing the end of life have unique needs that must be the patient to teach back the information or demonstrate the
competently addressed. By addressing patients’ pain and taught methods to confirm understanding. Regardless of its
controlling negative symptoms, an organization can help form, education must be coordinated by all disciplines
patients and their families navigate this difficult time. involved in the patient's care.
Note that JCI addresses the topic of pain management and Staff and Licensed Independent
end-of-life care in COP.7. Practitioner Training and Competency
Patient Education About Pain (HR.02.02.01, HR.01.04.01,
(PC.02.03.01, PFE.4) MS.03.01.03, COP.6, SQE.3)
As discussed in Chapter 1, the need for health care provider
As discussed in Chapter 1, patient education is a key aspect
training on pain assessment, management, and follow-up is
of effective pain management. To address misconceptions
critical to improving pain management across the
about pain, emphasize the importance of communicating
organization. The Joint Commission and JCI require
about pain, explain treatment options and side effects, and so
organizations to provide training and orientation about pain
on, organizations must have processes in place to educate
management to all health care providers, including staff and
patients comprehensively and appropriately. The Joint
licensed independent practitioners. This orientation and
Commission and JCI address patient education on pain
training should cover specific job duties regarding
management in their standards. Although JCI's requirements
recognizing the symptoms of pain, assessing pain, and
are more general, the Joint Commission gets more specific,
managing pain. It is particularly important to address barriers
necessitating a comprehensive learning needs assessment on
to pain management as well as pain assessment, equianalgesic
which the education and the methods of education and
conversions, basic pharmacology, and ethical issues in
instruction are based. Organizations complying with either
provider training. Specific information on pharmacologic and
set of standards must ensure that any education provided
nonpharmocologic treatment methods is important as well to
matches the patients' levels of understanding.
ensure proper prescribing and use of various treatment
modalities.
A learning needs assessment can take a variety of forms,
depending on the setting. For hospitals and home care
Not everyone working in the health care organization
organizations, for example, such an assessment requires an
requires the same amount and type of education. An
examination of the patient's cultural and religious beliefs,
organization needs to determine who among its staff needs
emotional barriers, desire and motivation to learn, physical or
basic orientation to pain assessment and management and
cognitive limitations, and barriers to communication. For
who needs more advanced content. This varies by the scope
other settings, the learning needs assessment should reflect
of services provided and by which staff members are involved
organization policy and keep in mind the organization's
in the care of patients and families. For example, a long term
patient population and services provided.
care organization, which mainly serves persons on a long-
term basis, may want not only to train its direct care
Once an organization assesses a patient's learning needs
providers but also to provide an initial orientation to
regarding pain management, it must provide education based
housekeeping and dietary staff, because residents and families
on those needs. Such education may include a discussion of
may choose to confide in these particular staff members and
the risks for pain, the importance of effective pain
ask them questions about care. This orientation can empower
management, the pain assessment process, and methods for
housekeeping and dietary staff to provide supportive and
pain management. This education may take the form of one-
accurate information to residents and their families about
on-one teaching, audio and video presentations, Internet-
pain and pain management. Other employees to consider
based training options, written materials, and so on. Any
educating about pain include the receptionist who answers
education provided should be tailored to the patient’s needs
37
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
the phone to schedule visits in an outpatient clinic, Discharge education includes different information,
volunteers in a hospice program, and staff from the physical depending on the patient and his or her assessed needs. For
or occupational therapy departments of a long term care example, a rehabilitation unit of a hospital may provide
organization. information about pain management that includes general
information about pain; use of medications, if recommended;
Organizations have a variety of ways to provide education to use of nonpharmacological and behavioral interventions,
health care workers about pain, including in-services, one-on- including heat, cold, exercise, and physical therapy; and
one discussion sessions, scenarios and simulations, posters specific directions on when to call a health care professional
and fact sheets, educational videos, computerized training for additional assistance. Another hospital may provide
modules, and newsletter articles. information to all its surgical patients about pain
management, which focuses not only on the previously
Once education is provided, an organization must also ensure mentioned topics but also how on to operate any equipment
competency with pain management processes and procedures necessary for pain management, such as a PCA pump.
within the organization. For example, a long term care
facility may want to assess its staff members’ competence A key element of the discharge-planning process is written
relative to determining each patient’s physical, psychosocial, discharge instructions that the patient or those responsible
and communication needs, including determining the level for continuing care can understand. These should detail
of pain and responses to treatment. The results of the critical information about pain management, including but
competency assessment can be used to plan in-service not limited to the baseline pain assessment; any subsequent
education programs and/or to provide one-on-one staff pain assessments; any pain management instructions,
education so that competency can be maintained. including any current pain treatment; goals for pain
management; pain history or background information
Discharge Communication Regarding necessary for further treatment; follow-up treatment needs;
Pain Management and contact information for the patient to use if necessary.
(PC.04.02.01, ACC.3)
Chronic diseases pose additional pain management issues Data Collection and Monitoring
that need to be addressed. Patients are becoming increasingly To know if pain management policies, procedures, and
responsible for managing their own health at home. In education efforts are effective, organizations should collect,
addition, acute care patients are often discharged or released interpret, and respond to data about pain management.
from health care settings with instructions for self-care, Depending on the setting, this may involve collecting patient
including how and when to take pain medications, how to satisfaction information; reviewing length-of-stay information
use nonpharmacological options of care, and so on. For these regarding particular patients, such as surgery patients;
reasons, appropriate, effective, and comprehensive discharge reviewing the number of immobility-related complications;
planning is critical and required by Joint Commission and and monitoring readmissions and emergency department
JCI standards. visits for uncontrolled pain. Data collection and monitoring
may also look at the success of health care provider education
Organizations must commit to and practice effective discharge efforts or the safety of prescribing practices.
planning to help patients transition to the next level of care. For
some patients, effective discharge planning addresses how needs For example, an organization may want to survey its medical
are to be met as they move to the next level of care, treatment, staff members on their knowledge and attitudes regarding
or services. For other patients, planning consists of educating pain and its management. Surveys can occur before and after
the patients or their families on how to self-care at home and to education efforts to monitor the success and effectiveness of
access services in the future if necessary. As a result, transfer and those efforts. Likewise, if an organization prescribes opioids,
discharge must be based on the patient’s assessed physical and it may want to create specific monitoring practices to ensure
psychosocial needs and the health care organization's ability to the proper prescribing of these types of medication. For
meet those needs. example, the pharmacy department may want to review
patient records and physician orders to ensure that only one
38
Chapter 2: Compliance with Joint Commission and JCI Standards
sustained-release opioid is prescribed at a time. When practice. Traditional patterns of professional practice—
discrepant orders are noted, the pharmacist can either contact including the failure of providers to assess and document
the physician directly or coordinate with nursing staff and pain routinely, the lack of familiarity with various treatment
then take the opportunity to educate physicians and nurses options, and the common view that pain is an expected and
about appropriate and safe drug utilization. insignificant symptom—may be the most stubborn barriers
of all to change.
One specific way to collect data about performance is to
audit charts, or pain management documentation tools, for One way to address these barriers is to institutionalize pain
certain factors, including the following: management practices by making an organizational
• Documentation of a pain score at admission commitment to improving pain assessment and management,
• Follow-up in 24 hours for all admission pain scores of a thus removing the defensiveness that individual practitioners
certain score or greater may bring to the table.
• Presence of a pain management care plan
• Documented use of a pain protocol By definition, institutionalizing pain management
• Pain-intensity scores during reassessment. By looking at incorporates basic principles of pain assessment and
patients' current levels of pain, organizations can see how treatment into patterns of daily practice, including
effective their pain management strategies are. documentation systems, policies and procedures, standards of
• Length of stay practice, orientation and continuing education programs, and
quality improvement programs. In essence, standards of pain
Regardless of what information an organization collects to management are woven into the fabric of the organization.
measure the success of its pain management efforts, it should
share performance data with providers, respond to those data, Following are tips an organization can consider to achieve an
and use the data to actively and continually improve institutionalized approach to pain management:
performance. • Establish an interdisciplinary pain committee. Participants
on the committee may include physicians, pharmacists,
and nursing staff. Such a committee should include a
TIP balance of leadership and frontline providers to ensure that
any initiatives developed have the support and backing of
When auditing charts for pain management performance,
leadership and buy-in from frontline staff.
providers should examine all pain scores of 0 to determine
• Gain leadership support. For a pain management program
whether the patient or family received enough education to
to be effective, leadership must be committed to providing
understand how to use the pain-rating scale. Likewise, for the few
the resources, such as financial resources and staff time, to
cases when patients report pain higher than 10 on a 0-to-10 scale,
make the program effective. Leaders should be actively
providers should closely examine what interventions occurred to
engaged in the program and should visibly support its
make sure the patients’ pain was acknowledged and managed
work in very public ways. This is a critical step, because
effectively and efficiently.
without leadership support, any pain management program
will fall flat.
• Assess current pain management processes. This could be
done via flowcharts, care maps, and other performance
Creating an Organizational improvement tools that help diagram the process.
Commitment to Pain Assessment and Organizations should look at their current processes to
Management determine what they do well and what could be done
The importance of focusing on making pain assessment and better.
management an organizational priority—not just something • Articulate and implement a standard of practice. The goal
organization leadership or other pain “champions” take is to make pain “visible” in the organization. Establishing a
responsibility for—cannot be emphasized enough. Health standard for the assessment of pain, determining the
care provider education alone (although it is an essential part method of assessment, and identifying where the pain
of organizational change) does not in and of itself change assessment is documented are good first steps. Based on
39
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
literature review, evidence-based medicine, pain management empower patients. Unfortunately, patients and families
guidelines, and input of the interdisciplinary team, an often have low expectations regarding pain and pain relief,
organization can create a standard of practice toward which and many state that they expect to have pain during their
all providers should strive. Such a standard may involve the health care experiences. Describing the organization’s
use of pain protocols, interdisciplinary assessment tools, and commitment to pain management sends a clear and strong
multifaceted approaches to pain management— message to patients. Educating patients and families about
pharmacological and nonpharmacological. Any standard of why pain management is an important part of their care
practice should be communicated to providers, supported by and why reporting pain is essential to good pain
leadership, and regularly measured for effectiveness. management helps raise their expectations regarding this
• Make pain management easy to accomplish. If health care critical health issue.
providers have to work hard to obtain assessment tools and • Continually evaluate and work to improve the quality of
figure out proper treatment protocols, they will find ways pain management. No improvement or change is complete
not to do it. By including pain assessment as part of the without an evaluation that then feeds back into an
initial assessments or in other easily accessible locations, organization’s quality improvement process. Organizations
organizations can make effective pain management easy. should be sure to involve their quality improvement
Some ways to do this include printing pain protocols on personnel from the beginning of the change process. These
pocket-size cards and providing easy reporting tools that individuals can help guide the organization in evaluating
allow for regular and comprehensive documentation. pain management improvement efforts.
• Establish accountability for pain management. Lack of
accountability is one of the major barriers to quality pain Conclusion
management. An organization should look at its policies High-quality pain management is critical to the quality of all
and procedures, job descriptions, and competencies and health care an organization provides. By working to meet
determine whether pain assessment and management are Joint Commission and JCI standards, organizations can
part of these documents. This could include tying pain improve pain assessment and management in the short term
management to performance and compensation and and also provide the sustainable change that the public,
rewarding those individuals who effectively manage pain. patients, and their families deserve.
Organizations should work to get accountability
expectations in print. Assigning accountability ensures that Organizations should work to weave pain assessment and
pain assessment and management are the responsibilities of management into day-to-day processes. In doing so, they can
everyone who cares for patients in the organization. accomplish sustainable change and improve the quality of
• Set the tone for pain management with patients. Patient care provided within the organization.
education regarding pain management is critical to
References
1. Hasenau S.M., Roop J.C., Vallerand A.H.: The pharmacologic management of pain: A home care requisite. Home Healthc Nurse 25:260–268,
Apr. 2007.
2. D’Arcy Y., Johann D.: Using a medication protocol to improve pain management. Nurs Manage 39:35–39, Mar. 2008.
40
Chapter 3
Allegheny General Hospital
41
Chapter 3
Allegheny General Hospital’s pain management improvement process is an example of how organizational change
principles can be successfully applied to improving pain assessment and management. Note how the various
incarnations of the pain management team assessed the opportunities for improvement, agreed on an achievable
action plan that included patient and staff education, rolled out a pain management program from one unit to the
entire facility, and put systems into place to ensure that pain assessment and management would be everyone’s
responsibility. The team also ensured that information about pain followed its diverse group of patients throughout
the continuum of care and provided guidelines regarding referral to its specialty pain services.
With 900 physicians and 5,100 employees, the hospital The questions in the patient survey asked about thoughts and
annually admits more than 31,000 patients and logs perceptions of pain and pain management; 40 patients on
approximately 450,000 outpatient visits. A member of the postoperative day 1 following orthopedic surgery were
West Penn Allegheny Health System, AGH is an affiliate site interviewed. Table 3-1 on page 44 shows the patient survey
for the Philadelphia-based Drexel University School of with the results. Even though the “Agree” comments were in
Medicine. the majority, it was acknowledged that patients still needed to
be taught about pain management.
43
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Table 3-1. Orthopedic Pain Project: Patient Survey and Results (N = 40)
Don’t want to bother nurses or doctors for pain medication 83% 17%
Easier to put up with pain than side effects of drugs 61% 39%
Pain meds should be saved in case the pain gets worse 57% 43%
Patients should expect to have pain—it’s part of the disease or treatment 87% 13%
The team then developed an action plan that included the Healthcare Policy and Research (now known as the Agency
following: for Healthcare Research and Quality, or AHRQ) as a
• Reviewing the recovery room comments to see if resource. After the tool was developed, this committee
modifications of protocols were necessary implemented it by giving it to the physician’s office and
• Educating all nursing and physician staffs, both current introducing key concepts about pain. The reinforcement of
and on an ongoing basis, regarding pain management the tool occurred during the preadmission testing and
• Developing and implementing a preoperative teaching tool postoperatively on the orthopedic unit.
concerning acute pain management
The measurement of success was critical. Monitoring
The team implemented the action plan by doing the following: continued on the next quarter’s patient satisfaction surveys,
• The chair and facilitator of the team met with the chair of and it was found that the third-quarter Fiscal Year 1998
the anesthesia department and discussed the results of the efforts to manage pain increased to 81.05%. The chair and
surveys and the goals of the team. The chair of anesthesia facilitator shared these results with the team, nursing units,
suggested that the team present at the next anesthesia physician, and anesthesia department. Everyone was
department meeting. challenged to continue their efforts on improving customer
• Education of all hospital staff began with a pain satisfaction regarding pain management.
management lecture the pharmacy department gave. For
the convenience of the physician staff, residents, and On seeing the success of these efforts, it became clear to the
physician assistants, this lecture was given during a team and to AGH’s leadership that the pain management
monthly grand round. The nursing staff attended lectures program should be implemented throughout the hospital.
during in-services held on the units. Therefore, the pain management team’s focus was broadened
• A small group of nurses from the orthopedic unit, and the structure changed to ensure that it was able to work
preadmission testing, surgeon’s office, recovery room, and with every department and that the results could be tracked.
home care met twice to develop a preoperative teaching
tool on acute pain. The committee used clinical practice “The team evolved from the Orthopedic Utilization
guidelines on acute pain management from the Agency for Management Team to the Pain Management Quality
44
Chapter 3: Allegheny General Hospital
Improvement Team to what it is now: The Joint Commission called “Managing the Difficult Pain Patient, Part 1.” The
Pain Management Committee,” says Susan Leininger Hogan, survey found that many patients felt that that they were over-
R.N., M.S.N., an advanced practice nurse in the or undermedicated, and some felt that caregivers were not
Performance Improvement Department at AGH. “This name paying attention to their pain concerns. Also, differences
is to remind us of our responsibility to adhere to The Joint seemed to exist between patients who were suffering from
Commission’s standards for pain management and patient acute versus chronic pain.
and staff education.”
“Pain is a very subjective thing,” Hogan notes. “Physicians
In its early days, the team met every month to ensure that it needed to be made aware that no two patients are alike in
was meeting its targets. However, as the program grew to how they experience pain, so they need to communicate with
accommodate a wider range of patients and departments, it their patients more.”
required more flexibility.
Nurse Education
“By meeting in person less frequently, we are actually able to Education programs for nurses are open to nurses’ aides and
act more quickly, because we’re not trying to coordinate the other caregivers. “We never want to deny education to
schedules of so many busy people who have other priorities anyone who wishes to get it,” Hogan says.
as well,” Hogan explains. “We looked at our timelines and
found that if we met in person every quarter, we could do a These sessions are held throughout the year. In addition,
lot of the work over e-mail, over the phone, and in small nursing staff may receive an article or a link to a short video
group meetings. When an issue comes up that demands our about pain management, for which they can earn continuing
attention, we can meet as needed and include just those education credit.
people who are necessary to address that problem.”
Specialized Education
Regular members of the team now include the current As patient populations and medical research evolve, protocols
chair—who is a chronic pain specialist physician—and must be continually reviewed and updated. One recent
Hogan, as well as members of other departments who example is in the area of intravenous (IV) opioids (a class of
participate when their expertise is needed. These include commonly used pain medications, including morphine,
physicians, nurses, nursing education specialists, pharmacists, codeine, fentanyl, and oxycodone).
home care staff, outpatient nurses, and administrators.
In talking with other pain experts and reviewing the
Educating Staff About Pain literature, AGH staff saw a national trend regarding the safety
Management of IV push opioid therapy. According to the literature, a
“We’ve never lost sight of staff education,” Hogan says. “Even reassessment should be completed 15 to 30 minutes after
long-time staff [members] need to take part in pain administration of an IV push opioid due to the peak time of
management education to ensure that they are up-to-date on onset.1 Many hospitals are investigating ways to implement
the latest protocols and best practices.” safe patient standards when administering IV push opioids.
Physician Education To address this, the committee selected a busy surgical unit,
Twice a year, AGH attending physicians and residents must knowing that patients on that unit frequently received IV
attend grand rounds on pain management. In addition, push opioids. They then selected four nurses with different
regular presentations on pain management are mandated for levels of experience and from different shifts. Once that
residents, and attendings may participate as well. group had become compliant with the electronic
documentation, the rest of the staff were educated. The
In late 2009, the new physician chairman wanted to use a process has not gone organizationwide yet but is under
random, hospitalwide survey to gauge whether patients were discussion.
satisfied with their pain. This survey asked one question:
“How was your pain managed?” The 110 responses received “It took a lot of education and a lot of energy,” Hogan says.
were the basis for a grand rounds presentation, which was “The clinical nurse educator and manager did a wonderful
45
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
job planning the implementation and instructing the nursing rehabilitation services). All outpatient areas agreed to add the
staff. The information systems manager was a tremendous screening question to their patient histories. When patients
help by meeting with the staff weekly and listening to the answered “Yes” to the question, “Are you currently
changes that they felt needed to be made in the computerized experiencing pain?” the outpatient areas would complete a
system.” pain assessment similar to that used for inpatients. (See
Figure 3-1.)
During the time of the literature review, it became apparent
that the use of IV push opioids should be used cautiously During educational sessions, it was emphasized that all
with some high-risk populations of patients. These patients (inpatients and outpatients) needed initial pain
populations include the obese patient, the patient with assessments completed if they said “Yes” to the screening
obstructive sleep apnea, the opioid-naive patient (someone question. It was also stressed that pain reassessment be
who has received little or no opioid medication in the past), completed 30 minutes after administering parenteral pain
the patient over 65 years old, and the patient who has a medication and one hour after administering oral pain
substance abuse problem. Therefore, the committee medication. (See Figure 3-2.)
developed a list of tips regarding treatment of pain in these
patients. Education of relevant providers in pain assessment and
management. The ad hoc education committee decided that
Implementing Joint Commission pain management education would start with new-employee
Standards and new-resident orientation. A summary of the education
Involving Patients in All Aspects of Their Care for all health care providers is shown in Table 3-3 on page
On admission to AGH, each patient receives a patient 53. Starting with the nursing department, all health care
handbook that highlights services the hospital provides. providers were instructed on the pain management standard
Under the section “Rights and Responsibilities of the and received the pain management self-learning packet to
Patient,” the committee added Patient Right No. 9: “A review and complete the posttest. During the nurse’s aide
patient has the right to appropriate assessment and classes, instruction was given to report any complaint of pain
management of pain by health care providers.” The Joint to the registered nurse (RN) in charge of the patient. At
Commission steering committee approved the statement and RN/licensed practice nurse orientation, the initial pain
its addition to this section. presentation was given, along with the pain management
policy, guidelines, teaching tools, and documentation review.
Patients’ Right to Appropriate Pain Assessment At the yearly new-resident orientation, a one-page fact sheet
and Management about the pain management program was handed out, but
The initial assessment and regular reassessment of pain. In leaders found that the details were often lost in the large
discussing how initial pain assessment and regular pain volume of information received that day. Therefore, the
reassessment would occur, the ad hoc committee for nursing committee is currently developing a computerized learning
documentation decided not to reinvent the wheel but to add module for new residents to take at a later time.
the pain management questions into the charting-by-
exception documentation format. The committee used the Interestingly, instructors who conduct new-resident
reference manual written by McCaffery and Pasero2 to help orientation are finding that increasing numbers of residents
develop the pain assessment tool. The ad hoc committee have already taken courses on pain management, which
modified six forms to add the necessary descriptors for pain confirms that medical schools are starting to incorporate pain
assessment and management (for example, How does pain management into their curricula.
interfere with mobility and nutrition?) and to develop one
new form for the initial pain assessment (see Table 3-2 on Education of patients and their families regarding their
page 47). Table 3-2 refers to Figure 3-1 (pages 48–50) and roles in managing pain as well as potential limitations and
Figure 3-2 (pages 51–52). side effects of treatment. Small working groups developed
the teaching tools for acute, oncologic, and chronic pain.
Pain management documentation also applied to outpatient Each tool describes the type of pain, description of pain,
areas (gastrointestinal lab, radiology, outpatient oncology, and pain-rating scale, drug and nondrug treatment measures,
46
Chapter 3: Allegheny General Hospital
Forms Changes
1. General Database: Initial Nursing Assessment • Psychosocial information
• Emotional state: pain
• Recreational drug use
• Educational assessment: pain as a physical barrier
• Personal beliefs: fears regarding pain (i.e., fear of
addiction/cultural)
3. General Database: Initial Pain Assessment • Assessment of pain location, intensity, quality, current pain
(see Figure 3-1) management, etc.
• Assessment parameters
• Pain control: patient indicates absence of pain
common side effects of pain medication, addiction, and a quick reference guide to understanding how various
when to notify a physician. These tools are available in cultures may interpret or communicate pain differently. Of
inpatient units and outpatient areas. course, patients’ attitudes should be assessed on a case-by-case
basis, and stereotypes should be avoided. Each inpatient and
In addition, a teaching guide to help physicians and nurses outpatient unit keeps at least one of these manuals with the
educate patients and families about pain management was hospital policy manuals.
developed. (See Figure 3-3 on pages 54–55.)
Through the integrated medicine department, a
Consideration of personal, cultural, spiritual, and ethnic Complementary Therapies for Pain Management patient-
beliefs and communication to patients and families that teaching tool was developed that describes the independent
pain management is an important part of care. A cultural therapies that the nurse, patient, or patient’s family members
reference manual on managing pain was developed to provide can carry out for relaxation. Four other techniques are
47
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
The Initial Pain Assessment is part of the Initial Nursing Assessment form. The pain assessment (see page 50) is admin-
istered to all patients (inpatients and outpatients) if they say “Yes” to the question, “Are you currently experiencing pain?”
If the answer is “Yes,” the patient is asked to rate the pain. If the rating score is 4 or above, additional questions are asked.
(ID, identification; RN, registered nurse; TPN, total parenteral nutrition; PCP, primary care provider; O2, oxygen; NPO,
nothing by mouth; ADL, activites of daily living; ICU, intensive care unit)
48
Chapter 3: Allegheny General Hospital
(continued)
49
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Source: Allegheny General Hospital. Used with permission. (Wong-Baker FACES Pain Rating scale, copyright Wong-Baker FACES Foundation,
www.WongBakerFACES.org.)
50
Chapter 3: Allegheny General Hospital
This form is updated immediately before and after an intervention is carried out (30 minutes for parenteral administration,
one hour for oral administration). The document becomes part of the electronic data record, allowing the system to pro-
vide nurses with a reminder to conduct the reassessment at the appropriate time.
(continued)
51
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Source: Allegheny General Hospital. Used with permission. (Wong-Baker FACES Pain Rating scale, copyright Wong-Baker FACES Foundation,
www.WongBakerFACES.org.)
52
Chapter 3: Allegheny General Hospital
mentioned, such as massage and biodots, but these require form, the Assessment/Reassessment Intervention form, the
assistance for the nurses from the integrated medicine Conscious Sedation Flow Sheet, and the patient-controlled
department. analgesia (PCA)/Epidural 24 Hours Flow Sheet. All
physicians and nursing staff have pocket cards (see Figure 3-4
Assessing pain in all patients: Pain management policy. on pages 56–57) to show patients when they assess (and
As stated in AGH’s Pain Management Policy, “Health care reassess) patients for pain.
provider, upon patient’s entry into the health care system,
will screen all patients for the existence of pain.” All patients The specialty area of pediatrics presents unique challenges, as
are screened with the question, “Are you having pain now, or patients may not be able to describe or locate their pain
have you had pain in the last several weeks?” If the patient effectively, and because the methods by which their pain can
says “Yes” to this question, the initial pain assessment form is be treated vary widely depending on a child’s age and
completed. Physicians are instructed to include pain physical size. The pediatrics department at AGH selected the
management in their daily documentation. This information Riley Infant Pain Scale (RIPS). Clinical practice guidelines
can be included in their patient’s initial history and physical from the AHRQ were used to help select a tool for effective
and daily physician notes. When a history and physical have pain management assessment with infants and young
been completed and the patient’s self-report of pain is children. The tool consists of six categories: facial, body
known, pain management guidelines are used as a reference movement, sleep, verbal/vocal, consolability, and response to
tool. These guidelines are based on the recommendations movement/touch. Each category is given a 0-to-3 rating,
from the World Health Organization and the American Pain depending on the activity of the infant or young child. After
Society. several years of using the RIPS, the pediatrics department has
begun investigating other tools to use, especially those having
Pain assessment tools. AGH provides care to a wide variety a rating scale from 0 to10.
of adult patients and has several specialty areas, including
pediatrics. The adult medical-surgical population uses the Caring for Patients in Pain
Wong-Baker FACES Pain Rating Scale© because of the The clinician must use his or her judgment when prescribing
flexibility it provides for patients who are nonverbal or or administering medications. The pain committee decided
illiterate or who have cultural barriers that make it difficult to to break down the 0-to-10 pain-rating categories: At AGH,
rate pain. The rating scale is printed on all AGH mild pain is rated from 1 to 3, moderate pain is rated from 4
documentation tools, including the Initial Pain Assessment to 7, and severe pain is rated from 8 to 10. Mild pain
53
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 3-3. Acute Pain Management Procedures for Medical Procedures and Trauma:
A Teaching Guide for Patients and Families
This teaching guide, featuring the Wong-Baker FACES Pain Rating Scale, is provided to patients and their families as an
educational tool as part of Allegheny General Health’s pain management program.
54
Chapter 3: Allegheny General Hospital
Figure 3-3. Acute Pain Management Procedures for Medical Procedures and Trauma:
A Teaching Guide for Patients and Families, continued
Source: Allegheny General Hospital. Used with permission. (Wong-Baker FACES Pain Rating Scale, copyright Wong-Baker FACES Foundation,
www.WongBakerFACES.org.)
55
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Allegheny General Hospital physicians and nurses carry pocket cards to assist them in assessing patients’ pain. Three
copies of the card are printed on one sheet and must be separated. The next page shows the reverse of the cards.
56
Chapter 3: Allegheny General Hospital
Source: Allegheny General Hospital. Used with permission. (Wong-Baker FACES Pain Rating Scale, copyright Wong-Baker FACES Foundation,
www.WongBakerFACES.org.)
57
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
requires a nonopioid—for example, acetylsalicylic acid, After this consult is ordered, a physician from the clinic visits
ibuprofen, or celecoxib–with or without adjuvant and carries out a history and physical. After discussion with
medication. Moderate pain requires an opioid, such as the attending physician, a treatment plan is ordered, along
oxycodone and acetaminophen, oxycodone and aspirin, or with a clinic appointment when discharged. Finally, a
acetaminophen with codeine, with or without a nonopioid or substance abuse consult can be made for any patient dealing
with or without adjuvant medication. Severe pain requires an with a previous or current drug abuse issue. An inpatient visit
opioid—for example, morphine, hydromorphone, and is made daily, with outpatient referral when discharged.
fentanyl—with or without a nonopioid or with or without
adjuvant medication. One of the newest pain management services at AGH is the
Palliative Care Service (PCS), begun in the spring of 2009.
The pain management guidelines list therapeutic class, When consulted, PCS caregivers can interview the patient
generic name, adult dosage range, maximum daily dosage, and family, discuss treatment choices and outcomes, and
pediatric dosage, dosage forms available at AGH, and order treatment accordingly.
comments. For example, if a patient’s self-report of pain is 6,
the moderate category would be the starting point at which Continuum of Care
to prescribe medications. If pain continues, increases in Figure 3-5 on page 59 shows the continuum of care, starting
dosages or frequency can occur. When these measures fail, a at various entry points into the AGH system. Throughout
change to another drug in the moderate category would be the continuum of care that starts at various entry points into
the next step. The hope is that with manipulation of the AGH system, the initial pain assessment or reassessment
medications, dosages, and frequency, patients will see of pain is completed, and appropriate consults are made, if
improvement in their pain relief. Depending on the type of necessary. Inpatient and outpatient areas have included the
pain, diagnostic tests may be completed to find underlying pain management questions in the Press Ganey Patient
causes for the pain. However, when it seems that all avenues Satisfaction Survey. The results are shared with the particular
have been exhausted, consults should be ordered; any clinical area and then forwarded to the pain management
physician can order the consults at any time. committee for evaluation.
In the outpatient care areas, caregivers also need to assess Improving Organizational Performance
patients for pain. Caregivers also must assess whether the The Joint Commission Pain Management Committee
pain is related to the reason for the patient’s visit: For analyzes the pain management questions on the patient
example, if a patient visiting the hospital for a follow-up to a satisfaction surveys and the open/close monthly chart audits
colonoscopy reports pain related to an arthritic knee but no report. The team looks at three parameters that are part of
gastrointestinal concerns, the patient should be referred to his the tool used for chart audits: “Pain Assessment,” “When
or her orthopedist for treatment. Appropriate, the Patient Is Educated About Pain and
Effective Pain Management,” and “Pain Intensity and
When to Refer Patients for Care in Quality.” This evaluation helps the organization develop new
Pain Management protocols when necessary and determine the success of the
Three different types of consults can be ordered, depending existing ones.
on the type of pain. First, a consult can be made to the Acute
Pain Service (APS), a service of the anesthesia department. For the last several years, AGH has also worked with a third-
After an APS consult is ordered, an anesthesiologist party firm that sends out patient surveys after discharge and
interviews and examines the patient. After discussion with collects the results for the hospital. The survey includes one
the attending physician, a pain management treatment plan pain question: “How has your pain been controlled?” The
is prescribed. Treatment plans vary, from noninterventional pain committee then reviews the scores to this question
(such as medications) to interventional (such as local blocks) overall and per unit to see if any areas need improvement.
procedures. Daily APS visits occur to assess the treatment
measure. The second consult can be made to the Chronic The committee also monitors medical records to check for
Pain Clinic, also provided by the anesthesia department. completion of the admission pain assessment, the daily
58
Chapter 3: Allegheny General Hospital
The inpatient/outpatient continuum of care consists of a continuous loop of patient assessment. For example, patients select-
ed for surgery would proceed to presurgical ambulatory care, have the required surgery, and then go through the post-op
procedures. From there, the patient would participate in consults with pain management professionals. Following this, dis-
charge or follow-up visits would occur, as required. Discharge and follow-up are surveyed so the hospital’s Joint Commission
Pain Management Committee is updated, which completes one circle of treatment.
In cases that do not involve surgery, patients go to a first visit, a second visit, consults, and then the same process of dis-
charge or follow-up visits that surgical patients receive. Surgical and nonsurgical patients complete surveys that feed back
into the pain management committee. (PIG Survey, Press Ganey Patient Satisfaction Survey; ED, emergency department;
DR, doctor)
PRE-PROCEDURE
YES SURGICAL
PMQIT ED/DR AMBULATORY CARE
ONGOING OFFICE
ED UPDATES CLINIC
NO
1ST VISIT
P/G SURVEY FOLLOW-UP
PMQIT VISIT
FLU VISIT
DISCHARGE
PLAN POST-OP
CONSULTS SURGICAL
PROCEDURE
59
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
assessment, and reassessment of pain. The scores are received “We’d like to compare our results to other tertiary hospitals
monthly for each parameter, and those units less than 90% in western Pennsylvania, but those don’t exist,” she says.
compliant are asked to review four charts weekly for one “We’re the only facility of this size with this diversity of
month. If the review finds nursing staff members who are not patients. But we still work hard to keep improving our care
compliant, the policy is reinforced in a one-on-one meeting. and improving those scores.”
References
1. Pasero C.: Assessment of sedation during opioid administration for pain management. J Perianesth Nurs 24:186–190, Jun. 2009.
2. McCaffery M., Pasero C. (eds.): Pain: Clinical Manual, 2nd ed. St. Louis: Mosby, 1999.
60
Chapter 4
Dar Al-Fouad Hospital
61
Chapter 4
In 2003, the leadership at Dar Al-Fouad Hospital (DAFH) in Cairo, Egypt, set out to establish pain management
services. The goal was to provide adequate pain relief for its patients, decrease patient suffering, and improve quality
of life. This feat may not seem noteworthy until it is understood that pain, per se, is not addressed at most hospitals
in developing countries.* Moreover, the concept of pain management is not yet well established, limited financial
resources exist to address it, and equipment and supplies are lacking. Not only were no Egyptian nurses trained as
pain nurses, the Ministry of Health, which regulates nursing job descriptions, did not even acknowledge the position.
The pain champions at DAFH overcame these obstacles, among others, by committing to the viewpoint that pain is
the fifth vital sign. In 2005, it received accreditation from Joint Commission International (JCI), the first hospital in
Egypt and Africa to do so. DAFH received accreditation again in 2008. The hospital is the first private hospital
outside the United States to collaborate with the Cleveland Clinic Foundation. In 2010, DAFH hosted its first
international Pain Management Conference in collaboration with that clinic.
* Egypt is included in a list of countries with a developing economy by the International Monetary Fund's World Economic Outlook Report for April 2010.
(http://www.imf.org/external/pubs/ft/weo/2010/01/weodata/groups.htm#oem [accessed Sep. 30, 2010])
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
• Cranial and face pain Cleveland Clinic’s pain clinic visits DAFH’s pain clinic typically
• Joint pain twice a year. He spends one to two weeks seeing patients and
• Neuropathic pain providing educational sessions for the entire staff. In addition,
some of DAFH’s consultants have received training at
Acute Pain Management Service Cleveland Clinic. Staff at Cleveland Clinic’s pain clinic provide
As part of the Pain Management Department, the Acute Pain consultations on difficult-to-treat pain cases on an ongoing
Management Service (APMS) monitors and manages acute basis.
pain in trauma, surgical, and medical patients throughout the
hospital. It covers all postoperative patients for the first 48 Pain Management Conference
hours and patients on epidurals and patient-controlled In 2010, DAFH sponsored its first Pain Management
analgesia (PCA) machines until 24 hours after weaning from Conference in collaboration with the Cleveland Clinic’s pain
the epidural or the PCA for an extended duration. Inpatients clinic to promote pain education. International speakers pre-
and ED patients require referrals (via consultations) by the sented on such topics as interventional pain management, can-
primary managing physician (PMP) to be treated in the cer pain management, neurosurgical options for chronic pain,
APMS. In addition to postoperative patients, one to two neurostimulation for chronic pain, and interspinal drug delivery
patients are referred daily. However, the PMP measures and systems. A workshop on ultrasonography guidance in peripheral
addresses their pain scores. nerve blocks and pain management was offered as well.
In 2009, 1,840 patients sought care from the APMS. Three pain management consultants in the Pain
Management Department oversee the APMS and clinic as
The Pain Clinic well as the conference.
The DAFH pain clinic is a specialized area within the
anesthesiology department in collaboration with the pain Organizational Commitment
clinic of the Cleveland Clinic in Ohio. Its physicians are In 2003, DAFH set out to establish an APMS to monitor
dedicated to the evaluation, diagnosis, and application of and manage acute pain in patients throughout the hospital.
interventional techniques for the treatment of patients Previously, pain was not specifically addressed at DAFH, as
suffering from chronic pain. in most hospitals in developing countries. In the past, pain
management consisted of the PMP’s prescribing a pain killer
Patients referred to the multidisciplinary clinic often have for patients experiencing acute pain.
pain that has been unresponsive to various treatments or are
seeking nonsurgical pain relief. Typically, these patients are In addition to modern-day obstacles, such as administrative
referred from the orthopedic, neurosurgical, neurology, and burdens, clinical care complexities, patient safety issues,
oncology departments. In 2009, 800 chronic pain patients patient expectations, and declining revenue, that plague all
were treated at the pain clinic. health care organizations, developing countries have their
own obstacles. Among them are that the concept of pain
Interventions range from epidural steroids, trigger point and management is not yet well established, limited financial
joint injections, and nerve blocks to radiofrequency ablations. resources exist to address it, and equipment and supplies
Staff members perform intradiscal interventions and (e.g., PCA machines and syringe pumps) are lacking.
intrathecal pump implants to treat various chronic pains and
spasticity that are unresponsive to other treatments. After the DAFH overcame these obstacles by committing to the
latter procedures are performed, patients are sent for viewpoint that pain is the fifth vital sign, as touted by the
rehabilitation and physiotherapy. Patients are referred to the American Pain Society, and as such should be assessed
psychiatric department, when indicated. Clinic staff also have regularly along with the other vital signs.
the capability to perform spinal cord stimulation in
cooperation with the pain clinic at Cleveland Clinic. Obtaining Leadership Support
The hospital administration approved the establishment of
The DAFH pain clinic’s collaboration with the pain clinic at the APMS based on the importance of such a service.
Cleveland Clinic began in 2002. The chairman of the Obtaining approval was made easier by the fact that the
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Chapter 4: Dar Al-Fouad Hospital
leaders at DAFH decided to seek accreditation from JCI, role of the pain nurse at the hospital, encouraging interested
which has pain assessment and management standards. nurses to attend and then apply for the position.
The leaders were instrumental in ensuring cooperation from This individual had to be Egyptian, because he or she needed
other departments within the hospital. For example, the to be able to explain the pain scores thoroughly to the patients.
committee charged with initiating the APMS had to conduct The problem was twofold: No Egyptian nurses were trained as
many long meetings with staff in the surgery department, pain nurses, and the Ministry of Health, which regulates
which was primarily responsible for prescribing postoperative nursing job descriptions, did not acknowledge the position.
analgesia—that is, until the APMS assumed that role. It was
the committee’s belief that some patients may have received In the meantime, the committee members sought to get
inadequate pain treatment as a result of the modest approval for the new job description from the Ministry of
prescribing habits the surgery department staff practiced. Health. To that end, they presented a weeklong educational
These meetings, among others, could have been much more course about pain management that the ministry’s nursing
antagonistic and less productive without the approval and leaders attended in June 2005. This course clarified that the role
support of the hospital administration. of the pain nurse was based on scientific evidence. Following
the course, the ministry approved the job description.
The leadership also supported the effort financially, as the
administration agreed to hire a pain nurse and to purchase An anesthesia nurse was chosen for the position. Given her
four PCA machines. background, she was very knowledgeable about syringes and
PCA pumps. She also was familiar with all the regulatory
Establishing the APMS issues regarding the dispensing of narcotic drugs and
In 2003, a self-appointed committee of three anesthesiologists documentation of the process.
who had witnessed acute pain management offered in hospitals
in Western countries and who wanted to emulate that at The whole process took six months from the time the job
DAFH began meeting. The pain management coordinator and description was designed until the Ministry of Health signed
the chairman and vice chairman of the anesthesia department off on the position.
composed this committee. In Egypt, pain management
practitioners are commonly anesthesiologists with a master’s Committee Expands
degree in pain. When it was announced that DAFH would have a structured
APMS based on the European model, the chief of the
The Pain Management Committee presented its idea to Nursing Office and Nurse Education Office joined the newly
initiate an APMS to the administration. It proposed the formed APMS Committee, which was appointed with the
following plan: task of rolling out the program.
• Educate all nurses about the basic principles of pain
management. As the rollout occurred, the committee continued to gain
• Incorporate the pain score measurements as the fifth vital members. It now consists of the pain management coordinator,
sign in all nursing charts. all staff anesthesiologists, senior charge nurses from various
• Adopt the European model (e.g., a nurse-based model wards, two pain nurses, three pain management registrars, and
supported by anesthesiologists). two pain management consultants. The registrars (or
• Educate the entire medical staff about the need for adequate consultants) are anesthesiologists who have an interest in pain
pain management and how it could benefit their patients. management as a subspecialty. Most of them have shifts in the
operating room (OR) as anesthesiologists and shifts in the pain
Pain Nurse management department as pain registrars.
The Pain Management Committee designed a job description
for a new position: a pain nurse. Then it sought approval for The Pain Management Committee no longer meets on a
the position from the DAFH Medical Council and Nursing regular basis. The members do, however, convene when there is
Office. After gaining approval, it began recruiting for a pain a need to upgrade the pain management service, add new charts
nurse. Committee members presented weekly lectures on the or modify existing ones, or address a performance issue.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Since 2008, the pain management coordinator has been Postoperative Pain Protocol
devoted entirely to pain management after completing a The APMS Committee decided to develop a protocol for
fellowship in pain management from the World Institute of managing postoperative pain. To that end, they met with
Pain. She is responsible for doing the bulk of the staff from various departments on a weekly basis during a
administrative work for the pain management department two-month period.
with the help of the chairman and vice chairman of the
anesthesia department and an anesthesia consultant. The committee members met with the anesthesiologists,
because they were the ones primarily responsible for pain
Different Models management in the past. They discussed the anesthesiologists’
The committee members chose to adopt the nurse-based preference for managing common types of surgery and the
European model. Having been trained in the United drug formulas available in the Egyptian market, among other
Kingdom and Italy, they were most familiar with the issues.
European model, in which the individual responsible for
acute pain management is a specially trained nurse whom They also met with the surgeons, who were previously
consultant anesthesiologists supervise.1 responsible for prescribing postoperative analgesia.
The hospital used the European model from 2003 through In addition, the committee members met with the senior
2007. Then it switched to what it refers to as the “Egyptian pharmacists to obtain a list of all the available formulas of
model,” which is an adaptation of the physician-based painkillers and adjuvant drugs as well as supplies and
American model. In the Egyptian model, a pain registrar equipment available within the hospital. They also modified
leads the APMS. A specially trained nurse assists the pain the policy for dispensing narcotics. A large number of new
registrar, who is an anesthesiologist. Under this model, the narcotics specifically used to treat chronic pain, many of
pain registrar assesses pain scores, manages treatment which were not well known in the Egyptian market, were
regimens, conducts follow-up, and modifies plans for added to the formulary. How to dispense these new drugs to
postoperative analgesia. the pain clinic’s cancer patients coming in for follow-up visits
had to be addressed in the policy as well. A new prescription
The primary reason for adopting the new model was that the form, with a duplicate special narcotics form that can be
pain clinic began experiencing greater patient volume. Some easily tracked using a serial number, was developed. The new
discussion occurred regarding hiring anesthesiologists with an paperwork expedites the prescribing process and makes the
interest in pain who could receive additional training and drugs easier to be stamped and checked by the pharmacist.
focus only on pain management, but patient volume was not The committee members routinely modify the policy when
sufficient to keep them busy. Therefore, the committee new drugs are added to the formulary or a new category of
decided to revamp the model so that pain registrars could patients with special needs is identified.
address chronic and acute pain services. This move would
offer optimal pain management services throughout DAFH The committee members discussed the key variables that
and not limit them to the surgical ward, which typically would influence the choices for oral analgesics. Among them
happens in a physician-based model. were the following:
• Patient characteristics that may impact pain control
Although the physician-based model is a costly one, • Premorbid pain status, opioid exposure, concomitant
physician salaries are lower in developing countries than in therapy
the United States, making it a cost-effective option in Egypt. • Degree of pain (e.g., mild, moderate, severe)
• Comorbidities (e.g., metabolic, cardiovascular,
Pain registrars are more knowledgeable about pain gastrointestinal, kidney/liver, central nervous system)
management than ordinary anesthesiologists and are more • Expectations of pain and pain control
familiar with the adjuvant drugs for managing pain. In • Age, gender, ethnicity, mental status, addictive behavior
addition, they are able to diagnose more complicated pain, • Degree of invasiveness or tissue damage
such as neuropathic pain, and know how to manage it • Intensity of pain (e.g., mild, moderate, severe)
effectively. • Physiologic source of pain
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Chapter 4: Dar Al-Fouad Hospital
• Type of pain (e.g., somatic, visceral, neuropathic) • Use the safest, most effective oral analgesics.
• Expected length of stay in the hospital • Close the “analgesic gaps.”
• Patient status (e.g., outpatient, inpatient) • Use a multimodal technique.
• Decrease incidence of pain by giving preemptive analgesia
The committee members chose to make the World Health when pain is expected (e.g., prior to undergoing a
Organization (WHO)’s Pain Relief Ladder the basis of the physiotherapy session).
protocol. (See Figure 1-4 in Chapter 1 on page 27.) Based on • Transfer from parenteral to oral analgesics as early as
this concept, the committee members listed various surgical possible.
procedures and the appropriate treatment modalities for each, • Use intravenous (IV) drugs for severe pain and oral
as depicted in Figure 4-1 (page 68). They felt that linking the medications for mild and moderate pain, and avoid
treatment options to surgical procedures was important for intramuscular narcotic or nonsteroidal anti-inflammatory
staff education purposes. drug (NSAID) injections, whenever possible.
• Use accurate dosage and accurate frequency.
When developing the protocol, the committee members • Monitor opioid, nonopioid, combination analgesic;
incorporated principles of pain management from evidence- analgesic adjuvant; and alternative delivery system usage.
based medicine (EBM) and best practices. As an example,
they summarized the clinical practice guidelines the By mid-2004, the committee members completed the
American Society of Anesthesiologists published as follows: protocol and were ready to begin training staff about pain
• Adequate postoperative pain control management.
– Avoid analgesic gaps.
– Use standardized, validated instruments to evaluate and
document pain intensity, the response to pain therapy,
and adverse effects. nline extras
• Education Links to pain management groups that can provide information on
– Health care provider education, training, experience evidence-based practice and medicine can be found in the Online
– Patient and family Extras at http://www.jcrinc.com/APM10/Extras/.
• Institutional commitment
– Monitor and document patients’ pain
– Promote an interdisciplinary approach
Educating Staff About Pain
The committee members also incorporated JCI’s pain Management
assessment and management standards2 by developing As part of the Pain Management Committee’s plan of action,
policies and processes that promote the notion that patients the entire nursing staff and all the anesthesiologists were
have a right to appropriate assessment and management of targeted to be educated about pain management in general and
pain. the APMS specifically. The committee took every opportunity
to educate health care providers about pain assessment and
When JCI incorporated Patient Safety Goals in 2006, they management, per JCI standards. Staff were not only made
were added to the protocol.3 For example, to improve the aware of the unique needs of patients in pain but also learned
safety of high-alert medications, DAFH standardized and interventions to manage pain and were taught to prevent
limited the number of drug concentrations available in the symptoms to the extent reasonably possible. Staff education
organization. Staff annually review a list of look-alike/sound- took various forms, including presentations, training sessions,
alike drugs used and take action to prevent errors involving one-on-one education, and courses.
the interchange of these drugs.
In every presentation, committee members frequently used
In addition, the committee members established their own the term patient rights for adequate pain management, as per
set of guidelines, as follows: JCI standards. They even had buttons created that read “No
• Improve patient care by the ward nurse, the pain nurse, Pain = No Gain” for all APMS staff to wear.
and the pain registrar.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Committee members developed a list of various surgical procedures and the appropriate treatment modalities for each
one. Linking the treatment options to surgical procedures was expected to enhance staff education. (Gyn. Lap., gynecol-
ogical laparoscopy; n. block, nerve block; NSAID, nonsteroidal anti-inflammatory drug, PCA, patient-controlled analgesia)
e Major Surgery
d ur • Thoractomy
c e • Upper abdominal
r o • Knee replacement
l p • Others
i c a
r g
S u “Moderate” Surgery
• Paracetamol
• Hip replacement
• Epidural l.a. + opioid or sys-
• Hysterectomy
temic opioids (PCA)
• Maxillofacial
• (Peripheral n. block where
• Others
indicated)
Minor Surgery
• Inguinal hernia • Paracetamol
• Varicose veins • wound inflitration with l.a.
• Gyn. Lap. and/or
• Others • systemic opioids (PCA) or
i e s
• single shot spinal with
morphine or epidural a lit
technique where indicated o d
• Paracetamol
t m
• wound inflitration with l.a.
e n
and/or
a m
• peripheal n. block
r e
• NSAID/weak opioids T
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Chapter 4: Dar Al-Fouad Hospital
Presentations
Even prior to the APMS being rolled out, committee Sidebar 4-1. Potential Benefits of
members began presenting monthly lectures on pain Effective Pain Management
management for all hospital nurses. The Nursing Education
Office monitored attendance, which was mandatory. These No matter what the educational venue, the potential
lectures emphasized the pharmacology of the drugs and the benefits of effective pain management, as follows,
anatomy of the techniques, among other issues. were always emphasized:
• Decreased chance of thromboembolic and
Committee members began conducting a series of meetings pulmonary complications
in the anesthesia department to promote the APMS to • Decreased length of intensive care unit or hospital
anesthesiologists and to stress the anesthesiologists’ roles in stay
the service’s success by appropriately prescribing postoperative • Decreased hospital readmissions for additional pain
pain medications in the OR as per the protocol. A copy of management
the protocol embedded in the WHO ladder was disseminated • Decreased suffering
to every anesthesiologist. The anesthesiologists put up some • Decreased chance of compromise to health-related
resistance, because they were concerned that the protocol quality of life
would increase the work load. However, the committee • Decreased likelihood of chronic pain syndrome
members pointed out that the protocol would improve
patient care, and eventually the resistance dissipated. Source: Dar Al-Fouad Hospital. Used with permission.
A key tool used to educate anesthesiologists was the Surgical In the beginning, surgeons who were previously responsible
Procedures/Treatment Modalities Chart (depicted in Figure 4- for prescribing postoperative analgesia demonstrated a fair
1). Using this chart, team members linked various surgical amount of resistance. Some of the PMPs crossed out the
procedures with the appropriate treatment modalities. For APMS orders from the medication sheets and wrote down
example, the WHO ladder indicates that when a patient their previously used PRN (as needed) orders. This also
experiences moderate pain, the patient should be given an occurred with a couple of consulting physicians, whom the
NSAID ± an adjuvant drug, the equivalent of a weak opioid. Medical Council promptly notified that the APMS was a
The chart indicates that moderate pain can occur when a hospital policy with which they needed to comply.
patient undergoes a hip replacement, a hysterectomy, or
maxillofacial surgery. In those cases, based on the pharmacy Lectures also were geared to pain registrars. These lectures
formulary, the patient will most likely be prescribed the NSAID stressed how the protocol was implemented rather than the
paracetamol, and an adjuvant wound infiltration can be added supporting basic science, with which they were already
± a weak opioid. Patients undergoing thoracotomy surgery familiar.
typically experience severe postoperative pain. Consequently,
the protocol calls for a strong opioid, which can be translated to Although the monthly nursing lectures are still being
be either an epidural or a PCA–parental opioid. conducted, they have evolved and are now more
sophisticated, thorough, and specialized.
Next, committee members began tailoring their message to
the various disciplines, such as intensive care unit (ICU) Training
physicians, oncologists, obstetrician/gynecologists, and The pain registrars continue to receive extensive training on
clinical pharmacists. The goal was to inform all physicians, chronic and acute pain. For starters, they do rounds in the
no matter what their discipline, how the APMS could benefit pain clinic with the pain consultant to learn how to diagnose
their patients, as cited in Sidebar 4-1, at right. Staff members chronic pain, including which tests to use. After they are
reviewed EBM studies to support the use of pain more confident, they do rounds by themselves twice a day.
management. They discussed with thoracic surgeons, for They learn various pain management interventions in the
example, the use of dorsal epidural for thoracotomy pain and OR designed for chronic pain, such as caudal epidural
its impact on postoperative lung rehabilitation and chronic steroids and transforaminal injections. They start by learning
post-thoracotomy pain. the simplest interventions and work their way up to
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
70
Chapter 4: Dar Al-Fouad Hospital
Assessing Persons with Pain OR), then every hour for the next four hours, and every four
Physicians and nurses are responsible for pain assessment, hours after that. Some patients require a more frequent
according to hospital policy. As previously stated, assessment, such as with the initiation of an epidural or PCA
postoperative patients are monitored under the APMS for the infusion. Typically, patients are reassessed as frequently as
first 48 hours following surgery. Inpatients and ED patients their vital signs are measured, as stated in hospital policy.
have to be referred by their PMP for a consult to be treated
in the APMS. The APMS team is composed of one pain All patients who complain of pain are given assessments,
nurse (of which there are two), one pain registrar, and one which are performed within 30 minutes, according to
pain consultant. hospital policy.
The anesthesiologists on duty for the day serve the surgical Documenting Pain
patients in the OR by initiating the first order for Clinical assessment of pain includes the location, severity,
postoperative analgesia and assessing for pain in the PACU radiation, duration, frequency, characteristics, precipitating
before they discharge each patient. Once the patients are factors, such complicating factors as allergies, and relief status.
discharged, they are assessed for pain in the ward by an The clinical assessment follows that cited in JCI standards.
APMS team member.
The initial assessment and reassessments are documented in the
The pain consultant assesses all postoperative patients, Nursing Assessment Pain Sheet, which is attached to the vital
focusing on the complicated cases. He also offers pain sign chart. Various labels and stickers were designed for use in
consultations to patients referred to the APMS (e.g., trauma documentation to alert other caregivers about the type of
patients waiting for operative interventions or other chronic medication the patient is receiving. (See Figure 4-2, page 72.)
and acute pain patients). Thus, the pain assessment is recorded in a way that facilitates
regular reassessment and follow-up, per JCI standards.
The pain consultant and pain registrar also visit with the
chronic pain patients in the clinic. After conducting pain The pain nurses are responsible for monitoring and recording
assessments, they implement pain management interventions. the pain scores of patients following surgery. They monitor
During that time, the pain nurse conducts a second round in the postoperative plan of care for each patient to ensure that
the hospital. In the afternoon, the pain registrar conducts his it is being provided according to the physician’s orders. The
second round, accompanied by the pain nurse, who is on her pain nurse monitors the patient’s response to variable
third round. Late in the afternoon and during nighttime, the analgesic medications and the occurrence of side effects. The
anesthesia registrar takes over pain management by pain nurse can stop, initiate, or modify epidural or PCA
responding to patients’ pain complaints. infusion pumps. However, pain nurses are not allowed to give
epidural boluses, because it is outside their scope of practice.
Recognizing Pain They can provide refills for epidural or PCA syringes.
At DAFH, all patients are assessed for pain, per JCI
standards. Specifically, all patients are screened for the In the pain clinic, a pain assessment is conducted with every
presence of pain upon admission. new episode of care. The clinic nurse documents the pain,
along with the vital signs, in the chronic pain physician chart
An assessment is done upon admission, 30 minutes after an before the patient enters the doctor’s office. This chart
intervention is implemented, and at intervals appropriate to summarizes the patient’s examination and history.
the severity of pain and the patient’s situation. The time
between assessments is individualized based on the patient’s The APMS Committee is in the process of developing a
need. For example, patients on epidurals are monitored every follow-up nursing chart that will be used during the follow-
15 minutes for the first hour (usually, this happens in the up telephone call currently being implemented. During the
call, the nurse collects information about the patient’s
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
The committee members designed various labels and stickers for use in documentation to alert other caregivers about the
type of medication the patient is receiving. These are included in the Nursing Assessment Pain Sheet, which is attached
to the vital sign chart. (R.R., respiratory rate; APMS, Acute Pain Management Service; IV, intravenous; NS, normal saline)
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Chapter 4: Dar Al-Fouad Hospital
preintervention pain status, the nature of the intervention, the pain nurse offers an alternative description, such as mild,
and the patient’s pain status one week following the moderate, or severe pain. The nurse correlates mild pain with a
intervention and prior to the follow-up visit. number of 1 to 3 out of 10, and so on. The pain-rating scale
chart, depicted in Figure 4-3 on pages 74–75, was
The APMS team members document their activity in their incorporated into the nursing charts. It includes the Wong-
own endorsement charts and in the patient file. The Baker FACES Pain Rating Scale© and the Faces, Legs, Activity,
endorsement charts are checked by their colleagues on the Cry, Consolability—also known as the FLACC—scale in
next shift to ensure the continuum of observation. The addition to a VAS. The Wong-Baker scale is used with young
endorsement chart summarizes the patient’s conditions, the children, many older children, and adults who speak a
plan of care for the next day, and any incidents or side effects different language. The FLACC scale, which is a behavioral
to be followed up, as well as documents any other remarks scale, is used with young children and incoherent patients.
about the patient’s circumstance. The nurse ending her shift
forwards the endorsement chart to the nurse coming on the Incorporating the pain scores in every patient chart ensures
next shift. Pain registrars have their own endorsement sheets that pain is assessed in all patients. The scores were recently
as well. The use of endorsement charts promotes the incorporated into the pain registrar charts as well.
continuum of care while the patient remains in the hospital.
Additional Pain Charts
Pain-Rating Scales Other specialized pain charts to be used with certain patients
The protocol calls for the use of various pain-rating scales to were added to the nursing chart. For example, a special chart
assess a patient’s pain. shows epidural analgesia administered to patients in labor, as
indicated in Figure 4-4 on page 76. Following this chart, the
At first, the APMS Committee members thought to use a pain nurse assesses these patients on an hourly basis in an
visual analogue scale (VAS) to document patients’ pain. effort to minimize patient risk.
However, the use of a VAS proved to be difficult because of
the translation. When the committee attempted to translate Another specialized pain chart, the epidural syringe pump
the wording into Arabic from English, the worst imaginable nursing record, details information about the medication
pain was described as so painful that it “makes you want to infused in the epidural space, including the drug name,
jump out of the window” or “feels as if you have been hit by concentration, and rate of infusion. It also indicates the
a truck.” When these concepts were translated into Arabic, it patient’s response as regards sensory, motor blocks, and side
appeared as if the caregiver was wishing the patient bad luck. effects, including pain. The pain nurse fills out this chart.
Other local hospitals had attempted to use the VAS without Caring for Patients with Pain
success for the same reason. In addition, patients refused to The protocol and hospital policy guide the care provided to
fill out the scale, because they did not want to write when patients experiencing pain. The goal is to provide adequate
they were so sick. They preferred to speak with somebody pain control, decrease patient suffering, and improve quality
about their pain. of life.
In January 2003, after several unsuccessful attempts were Although the pain nurses have three rounds per day, the pain
made to have the patients fill out the pain chart themselves, registrars have two rounds per day. During these rounds, they
the committee members decided to make the pain nurse check patients covered under the APMS.
responsible for explaining the rating to the patient and
documenting the pain scores. The pain scores are Treating Pain
documented in English but explained in Arabic. The APMS team offers a broad range of treatments to
alleviate or eliminate pain. Pharmacological interventions for
The APMS committee also added different pain scales to the acute pain and chronic pain patients include NSAIDs,
protocol. Although many of the patients found the numerical opioids, antiepileptics, muscle relaxants, and tricyclic
pain ratings more acceptable than the VAS, some still had antidepressants. Interventional treatments include epidural
difficulty gauging their pain using a number. Consequently, injections, sympathetic blocks, paravertebral and intercostal
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
This pain-rating scale chart was incorporated into the nursing charts. It includes a numerical pain rating (NPR); the Wong-
Baker FACES Pain Rating Scale; and the Faces, Legs, Activity, Cry, Consolability—also known as the FLACC—scale. (Pt.,
patient; sig., signature; APMS, Acute Pain Management Services)
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Chapter 4: Dar Al-Fouad Hospital
Source: Dar Al-Fouad Hospital. Used with permission. (Wong-Baker FACES Pain Rating Scale, copyright Wong-Baker FACES Foundation,
www.WongBakerFACES.org.)
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
The epidural record, which requires the pain nurse to assess patients who are administered epidural analgesia during
labor on an hourly basis, also contains a protocol for epidural infusion during labor and instructions for the pain nurse that
only apply to these patients. Data in the epidural charts contain information about the sensory and motor blocks, which
are of concern for patients in labor. (Bl. p., blood pressure; R, respiration)
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Chapter 4: Dar Al-Fouad Hospital
nerve blocks, joint injections, peripheral nerve blocks, muscle • The assessment process for pain and symptoms
injections, and epidural ports and intrathecal pump implants. • Methods of managing pain and other symptoms
Modalities for drug administration include PCA machines.
For acute pain patients, the most commonly used The pain nurse is primarily responsible for patient education.
intervention is the epidural infusion in addition to variable Typically, the pain nurse visits the patient prior to surgery.
nerve blocks. For chronic pain patients, interventions are She introduces herself and explains the pain management
used based on their conditions. services the APMS offers. When the patient is going to have
an epidural or IV PCA, the physician (e.g., anesthesiologist
When a patient scores greater than 4 for acute pain and or pain registrar) also explains the intervention to the patient
greater than 5 for chronic pain on a scale of 0 to 10, it is an before proceeding with it. Currently, the APMS Committee
indication that the patient is receiving inadequate pain is implementing a new dialog box in the nursing pain chart
management. Therefore, the patient’s plan of care is revised. to document this educational activity by the pain nurse.
When this occurs, the ward nurse commonly notifies the
pain nurse and pain registrar if the patient is covered under Additionally, the pain nurse is responsible for educating
the APMS. The pain registrar visits the patient, analyzes the patients and family members on the importance of
complaint, and modifies the plan of care. If the patient is not communicating any pain or discomfort the patient has. To
covered under the APMS, the PMP is notified. If the that end, the committee has developed patient education
situation is uncomplicated, the physician typically prescribes materials known as “Arabic flairs for acute pain
analgesia. However, if the patient is experiencing severe pain management.” One of the flairs introduces the pain
(e.g., a pain score higher than 7), the physician refers the management service to patients and provides general
patient to the APMS team. Then the pain registrar and the information about acute pain management and modalities.
PMP registrar meet to discuss the case. The other flair discusses epidural, from describing the
technique to listing the side effects and potential risks.
Prior to discharge, the patient meets with the pain registrar, Currently, the committee members are developing chronic
who assesses the patient’s pain management needs and pain flairs that cover every individual intervention or group
prescribes a medication, if necessary. of interventions offered through DAFH’s pain management
program.
The ED physicians, who are mostly anesthesiologists, are
responsible for discharging ED patients. If the patient is Prior to being discharged, during the last visit by the pain
experiencing pain, the ED physician writes a prescription for registrar, the patient is given a prescription for oral analgesic
analgesic drugs. If the patient is experiencing severe or drugs and a regimen to be followed once the patient is at
complicated pain, the ED physician gets a consult with an home. If the prescription contains a narcotic drug, the pain
APMS team member, who provides either a discharge registrar talks to the patient about its risks and possible side
prescription or another intervention. effects. The pain registrar also reviews what the patient
should do if he or she experiences more pain after discharge.
Similarly, PMPs treating chronic pain patients in the clinic
determine the patient’s pain management needs prior to the In addition, the pain nurses have recently started following
patient’s leaving. If the patient is experiencing severe or up with chronic pain patients by calling them one week after
difficult-to-treat pain, the PMP may refer the patient for a their last visit. The purpose of the call is to determine if the
consult with the APMS team. patient is having any ongoing pain and how to address it.
This follow-up will be documented in a chart that is being
Educating Persons with Pain developed.
Per JCI standards, patients and families are instructed about
the following: Continuum of Care
• Understanding pain and other symptoms The APMS oversees pain management for a large percentage
• The risk for pain and other symptoms of DAFH patients, whether they are having surgery,
• The importance of effective pain and symptom presenting in the ED, or visiting the pain clinic.
management
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Patients are informed about the APMS when they are Egyptian model received a combination of three drugs,
admitted to the hospital for surgery. The types of services, as compared with their counterparts treated under the European
well as interventions, are reviewed. While in the hospital, the model (45% versus 33%).
endorsement chart that is forwarded to nurses on the
incoming shift facilitates the continuum of care. Under the Egyptian model, there was a higher incidence of
lower pain scores (e.g., 0 to 3), which the APMS Committee
Prior to discharge from the hospital, the pain registrar interpreted to mean that patients were experiencing more
assesses and addresses the patient’s pain management needs. effective pain management. (See Figure 4-5 on page 79.)
For ED patients, it is the ED physician who serves that role. However, there also was a higher incidence of the very high
Before completing a visit at the pain clinic, chronic pain pain scores (e.g., 8 to 10). One explanation for the latter is
patients discuss pain management with the PMP. However, if that this is a more accurate read of the pain scores, because
any of these patients experience severe or complicated pain, under the Egyptian model, the physicians checked the pain
an APMS consult is requested to ensure that the patient scores. Under the European model, the nurses were the only
receives adequate pain control. ones documenting the pain scores, and they tended to
document lower scores for fear of being accused of poor
The recently implemented telephone calls serve as follow-ups performance. It took some time for the nurses to understand
with chronic pain patients. that pain is very subjective and can be difficult to minimize
or eliminate even after several interventions are attempted.
Improving Organizational Performance
Two types of audits are conducted at DAFH. The In 2009, one year after the Egyptian model was implemented, a
retrospective audits review types of anesthesia used and retrospective audit of the APMS found that 1,840 patients were
patient pain scores. The APMS team conducts these audits to served, 34 patients were on PCA, 252 patients were on
monitor the hospital’s pain management services and to track continuous epidural infusion, and 129 nurses were educated on
whether the goal of achieving adequate pain relief is being a one-on-one basis. As depicted in Figure 4-6, page 80, the
met. 1,840 patients displayed the following traits:
• Nearly 90% had pain scores of 0 to 3 (mild pain).
As an example, after implementing the Egyptian model, the • Almost 10% had pain scores of 4 to 7 (moderate pain).
committee conducted a retrospective audit to determine • Less than 1% had pain scores of 8 to 10 (severe pain).
which model—the Egyptian or the European—was more
effective for managing acute pain. The total number of The committee is very close to achieving its goal, with nearly
patients included in the audit was 857. The committee 90% of the hospital’s patients experiencing adequate pain
reviewed 556 patient charts from February 2007 through relief.
March 2008 during the time that the European model was
being used. The team also reviewed 301 patient charts from In 2010, the committee began to include patient satisfaction
May through October 2008 during the time that the and incidence of complication as part of the APMS’s database
Egyptian model was being used. so that it would not have to rely on the quality assurance
(QA) audits, which tend to be more global in nature.
The audit found that the majority of patients received
general anesthesia (80% of patients treated under the QA Audits
Egyptian model, compared with 72% of patients treated The QA department commonly carries out other types of
under the European model). The majority of patients audits as part of the hospital’s performance audits. The role
received parenteral analgesia within the first 24 hours of of the QA department is to ensure continuous quality
admission (85% of patients treated under the Egyptian improvement of the health care services and compliance with
model, compared with 76% of patients treated under the JCI standards and patient safety goals.
European model). The same percentage (35%) of patients in
both groups received a combination of two medications. Quality auditing for the APMS was conducted using open
However, a higher percentage of patients treated under the file review and individual tracer surveys. For the open file
78
Chapter 4: Dar Al-Fouad Hospital
Under the Egyptian model, there was a higher incidence of lower pain scores (e.g., 0 to 3), which the APMS Committee
interpreted to mean that patients were experiencing more effective pain management. However, there also was a higher
incidence of the very high pain scores (e.g., 8 to 10).
review, documentation on the pain form in the patient file is Results of the QA audit conducted in May 2008 revealed the
checked for timeliness. The pain score is checked against the following:
patient diagnosis for possible pain symptoms and pain • Based on the protocol, 30% of the pain management cases
medications. The patient also can be asked about his or her were missed.
experience. For the individual tracer surveys, if the patient is • A 78% discrepancy existed between the pain score
on pain medication, the pain nurse and the charge nurse are assessment given by the pain nurse and the ward nurse.
asked about the system for patient evaluation and follow-up. • A 56% discrepancy existed between the pain nurse’s score
For example, they could be asked about, or observed doing, indicating the patient’s pain level and the patient’s
pain medication preparation as well as narcotics ordering, interview indicating his or her pain level.
dispensing, preparation, and safety. The clinical pharmacist
can be asked about the appropriate ordering, appropriate To increase the number of cases to be managed based on the
dosage, drug combinations in this particular case, and the protocol, the committee held additional meetings with all
pharmacist’s role in notifying and educating the team. departments to reiterate the role of the APMS and
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
In 2009, one year after the Egyptian model was implemented, a retrospective audit of the Acute Pain Management
Services found that of the 1,840 patients served, nearly 90% had pain scores (the numerical pain ratings) of 0 to 3 (mild
pain), almost 10% had pain scores of 4 to 7 (moderate pain), and less than 1% had pain scores of 8 to 10 (severe pain).
80
Chapter 4: Dar Al-Fouad Hospital
indications for using the service. To decrease the discrepancy results were reported to all committee members.
between the pain score assessments and to improve the Results of the QA audits conducted in January 2010 revealed
accuracy of pain scoring overall, the pain consultants the following:
conducted training for all nurses. On the units, the pain • Based on the protocol, 10% of the pain management cases
nurses stressed to ward nurses the importance of were missed, compared with 30% previously.
incorporating the pain scores in every patient chart. As part • A 20% discrepancy existed between the pain score
of the training, they reviewed the concept of pain as the fifth assessment given by the pain nurse and the ward nurse,
vital sign, the importance of pain monitoring, the nurses’ role versus 78% previously.
in pain management, and pain management options. • An 8% discrepancy existed between the pain nurse’s score
indicating the patient’s pain level and the patient’s
In July 2009, an additional audit measuring compliance with interview indicating his or her pain level, compared with
the narcotics policies was conducted. It revealed the 56% previously.
following: • The accuracy of the narcotics ordering policy was 87%, up
• Accuracy of the narcotics ordering policy was 34%. from 34% previously.
• Accuracy of the narcotics logbook documentation was • The accuracy of the narcotics logbook documentation was
40%. 100%, compared with 40% previously.
• Accountability of the narcotics inventory was 67%. • The accountability of the narcotics inventory was 100%,
• Compliance with the narcotics discarding policy was 27%. up from 67% previously.
• The compliance with the narcotics discarding policy was
To increase compliance with the narcotics policies, an ad hoc 73%, compared with 27% previously.
committee comprising hospital managers, QA department
staff, pain consultants, and nursing supervisors was formed. In March 2010, a new auditing form was implemented. It
The ad hoc committee was charged with revising the combines all the previous items in addition to the accuracy of
narcotics logbook to be more informative and simplifying drug dosage, drug combinations, timeliness, antidote, drug
documentation, as well as revising narcotics prescriptions to preparation, administration, and vital signs. (See Figure 4-7
make them easier to use and more practical. The nursing on pages 82–83.)
supervisors were charged with providing training for all
nurses. Weekly narcotics audits were implemented. The
81
Figure 4-7. Dar Al-Fouad’s Combined Auditing Form
This auditing form, which was implemented in March 2010, combines all the items used in the previous form, plus the accuracy of drug dosage, drug
combinations, timeliness, antidote, drug preparation, administration, and vital signs. (PCA, patient-controlled analgesia; BP, blood pressure; RR, respi-
ratory rate; temp, temperature)
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 4-7. Dar Al-Fouad’s Combined Auditing Form, continued
83
Source: Dar Al-Fouad Hospital. Used with permission.
Chapter 4: Dar Al-Fouad Hospital
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
References
1. Rawal N., Allvin R.: EuroPain Acute Pain Working Party: Acute pain services in Europe: A 17-nation survey of 105 hospitals. Eur J Anaesthesiol
15, May 1998. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=460543 (accessed Jul. 2, 2010).
2. Joint Commission International: Joint Commission International Accreditation Standards for Hospitals. Oak Brook, IL: Joint Commission
Resources, 2002.
3. Joint Commission International: Joint Commission International Accreditation Standards for Hospitals, 3rd ed. Oak Brook, IL: Joint Commission
Resources, 2007.
4. Hamilton P.M.: Pain Management for Oregon Health Professionals [Online CE Course]. http://www.nursingceu.com/courses/282/index_nceu.html
(accessed Apr. 27, 2010).
84
Chapter 5
The University of Wisconsin
Hospital and Clinics
85
Chapter 5
The University of Wisconsin
Hospital and Clinics
The University of Wisconsin Hospital and Clinics (UWHC) is a recognized leader in pain management. It is not only a
Magnet Hospital but a recipient of the American Pain Society’s Center of Excellence Award. What started in 1991 as
an effort to improve pain management has evolved into a campaign to institutionalize it. The standards for pain
assessment and management for all patients are now part of routine care at all UWHC settings. Nearly two decades
later, the Patient Care Pain Team continues to keep pain management at the forefront by examining and
reexamining pain management issues and practices with the goal of continuous improvement. Key elements of the
program are the use of champions, evidence-based practice guidelines, and outcomes monitoring. Today, numerous
pain management variables are measured and monitored through a combination of daily, monthly, and annual
formats.
Clinical Services The UW Health pain clinics offer the same broad range of
UWHC pain specialists diagnose and treat pain syndromes of pain management treatments as the hospital does, only on an
all types, including muscular, skeletal, neuropathic, outpatient basis. Health care professionals must refer patients
postoperative, and cancer pain. to enter the UW Health pain clinics. Teams of physicians,
midlevel providers, rehabilitation therapists, psychologists,
A full range of clinical services in pain management is and nurses who work in concert toward pain reduction and
offered. The Inpatient Pain Consultation Management functional restoration treat outpatients. Physiatrists and
Service optimizes pharmacologic and nonpharmacologic neurologists are active participants in pain care, and
treatments. The Anesthesiology Acute Pain Service assists in interspecialty referrals are readily available when further
expertise is needed.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
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Chapter 5: The University of Wisconsin Hospital and Clinics
local health maintenance organizations and health insurers to scales used are a 0-to-10 verbal or visual analog scale, a mild-
define best practice guidelines for pain management and moderate-severe rating, a pediatric pain faces scale, the
procedure coverage. In addition, UWHC staff support University of Wisconsin Pain Scale for Preverbal and
legislation to make better pain care available for all patients. Nonverbal Children, and the Checklist of Nonverbal Pain
Indicators for cognitively impaired adults.
Staff members participate in national and international
conferences. One of the latest efforts is involvement in the Adult inpatients are screened and assessed for pain at least
development of an international acute postoperative pain once every 24 hours on general medical-surgical units and
registry. every 4 hours in critical care, or more frequently by unit
standard, patient condition, or policy, such as with epidural
Many staff members are actively involved in pain research, analgesia or intravenous patient-controlled analgesia (IV
particularly in the areas of neuropathic pain, interventional PCA). Inpatient children are screened and assessed for pain at
management, and musculoskeletal pain. Staff have received least once every 8 hours when awake.
several research grants to study, for example, innovative
nonpharmacologic pain management strategies for inpatients. As part of the assessment process, the caregiver investigates
possible mechanical causes of pain, such as immobilization,
Assessing Persons with Pain medical devices, a full bladder, or an overly tight cast.
Early on, the Patient Care Pain Team established a standard Psychosocial or spiritual aspects of pain, when appropriate,
for pain assessment and documentation to ensure that a also are investigated. As an example, patients are asked about
patient’s pain is recognized, documented, and treated their belief systems, including what the pain means to them
promptly. Hospital policies are enforced to ensure that and how it affects their emotional states and social activities.
patients receive quality pain care. (Joint Commission
Standard PC.01.02.07 requires hospitals to perform initial In addition, the caregiver reviews with the patients and their
pain assessments. See “Assessment and Reassessment” in families how and when to report and describe pain.
Chapter 2 on page 34.)
In 2007, the concept of goal-directed health care,2 touted by the
Recognizing Pain Institute of Medicine and by pain management literature in
The policy calls for an appropriate assessment, which entails general, was added to the assessment process. By identifying
screening and comprehensive initial assessments, when pain is the patient’s major life goals and connecting them with specific
present. A nurse, physician, or other caregiver performs the pain-relief goals, goal-directed health care emphasizes the
screening and assessment. reasons why the patient wants to be well and what he or she
will do once he or she obtains improved health. Goals for pain
Screening involves an initial interview to determine if the management should be specific, measurable, and patient
patient is experiencing pain. All patients are regularly centered. Pain-relief goals may include a pain-intensity rating,
screened for the presence of pain as part of routine care in a percent pain relief, or a functional goal, the latter of which
the hospital and at all clinic visits. The patient is screened for can be physical or emotional. For acute pain, treatment goals
pain on admission and with every comprehensive health tend to focus on facilitating recovery from the underlying
assessment. injury, surgery, or disease; controlling and reducing the pain to
an acceptable level; minimizing pharmacologic side effects; and
When the patient reports the presence of pain, a new pain, or preventing chronic pain. For chronic pain, treatment goals
a significant change in the location or quality of pain, the tend to focus on restoring function, decreasing pain, and
caregiver conducts an assessment, which is a more in-depth correcting secondary consequences of pain. Pain-relief goals
evaluation. The assessment includes intensity, quality, onset, focus on the needs, desires, and circumstances of individual
location, duration, aggravating and alleviating factors, and patients and are incorporated into the plan of care and
the effect(s) of pain on function. documentation system.
Pain intensity is measured using a variety of scales based on Clinic patients and those receiving home health visits are
population and individual patient preference. Among the routinely screened as well. The UW Home Health has its
89
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
own policy. Specifically, clinical staff screen pain status at Caring for Patients with Pain
each visit for return or symptom visits; specialty clinic visits; UWHC staff recognize that pain control is a high priority
and physicals or health promotion visits. Typically, the and can be accomplished in the majority of patients.
patient is asked if the pain is related to the reason for that
visit or specialty. In some of the clinics, such as in the pain, Treating Pain
spine, and sports medicine clinics, the physician or provider UWHC staff offer a broad range of treatments. Among them
provides a specialty-focused pain assessment. Pain screenings are medications, interventional procedures, physical and
may not be conducted when the patient is there for a blood occupational therapy, and behavioral/psychological
pressure check; specific education/counseling; a blood draw treatments. Caregivers involved in making such decisions
or diagnostic test; an injection, immunization, or skin test; or may include a nurse, physician, pharmacist, physical
a pacemaker and other device checks. therapist, chaplain, or social worker, as relevant and within
the scope of his or her individual practice, licensure,
Documenting Pain privileges, and/or job description.
The caregiver documents pain systematically, including
location(s), intensity, quality, onset, duration, aggravating and Pain control options are selected based on the most
relieving factors, and presence and severity of side effects appropriate combination of techniques for the individual
from pain medications, as warranted by the patient’s patient, family, caregiver, and setting. The patient is educated
condition and the clinical setting. At a minimum, location, regarding the risks and benefits of options chosen and others
quality, frequency, and severity of pain are documented. that may be relevant.
Over the years, numerous forms have been revised, added, or Prescribed analgesics are administered, and interventions are
deleted to improve documentation. delivered in a timely, logical, and coordinated manner. When
possible, a balanced, multimodal and rational approach is
In 2008, a customized electronic medical record (EMR) was used, combining analgesics with differing mechanisms of
implemented. The full set of pain reassessment parameters action with nonpharmacological strategies. The patient is
was built into it. Documentation screens were customized to educated regarding the plan of care and the potential
distinguish pain screening, assessment, and reassessment after outcomes and side effects of treatment.
intervention, including a measure of pain relief, impact on
function, side effects, and patient satisfaction. Rather than The caregiver explores the patient/family concerns about the
simply recording a change in a patient’s pain rating, the EMR use of opioids. The caregiver also provides information—or
contains a new feature that prompts documentation of “pain alerts those who can provide information—to address these
relief ” using a validated scale (e.g., none, slight, moderate, concerns.
lots, complete) shown to provide an acceptable surrogate
measure of patient-determined clinically important response.3 The patient is educated about the use of nonpharmacological
The purpose of the prompt is to determine how effective the approaches, when feasible. If the patient opts for a
intervention really was in reducing pain. nonpharmacological intervention, such as therapeutic
massage, distraction, heat/cold, positioning/immobilization,
Electronic documentation has provided a single, longitudinal guided imagery, relaxation, or focused breathing, as clinically
record, integrating inpatient and outpatient assessments to appropriate, its use is facilitated. In 2008, three types of
help ensure that treatment decisions are based on the most patient-specific television channels aimed at helping relieve
current information. In addition, the implementation of the pain were added to television programming throughout the
EMR has provided continued support for improving hospital.
documentation of pain reassessment and maintaining
performance. By 2009, all UW Health clinics were linked to The caregiver ensures that attention is paid to the patient’s
the EMR. psychosocial, spiritual, and cultural values and beliefs,
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Chapter 5: The University of Wisconsin Hospital and Clinics
because they affect how the patient responds to care. Patients • The stock of multiple dosage forms of meperidine on all
and their families are allowed to express their spiritual beliefs inpatient units made the drug an easy choice for first-line
and cultural practices. treatment of pain.
• Several preprinted physician orders included meperidine as
The caregiver monitors the ongoing effectiveness of the a first-line agent, again leading to its use as a first-line
analgesic regimen and other interventions. Medication treatment.
administration and effectiveness of analgesic and • The common misconception persists that meperidine
nonpharmacologic regimens are documented. causes less sphincter of Oddi spasming, making it a first
choice for many patients with abdominal pain or
pancreaticobiliary disease.
nline extras
A short overview of a non–U.S. hospital offering a range of both
Working with several members of the hospital’s Center for
pharmacologic and nonpharmacologic treatments is available in
Drug Policy and Clinical Economics, the team developed a
the Online Extras at http://www.jcrinc.com/APM10/Extras/.
guidelines draft that restricted the use of meperidine on
inpatient nursing units. The Drug Use Evaluation and
Pharmacy and Therapeutics Committees approved the
The caregiver documents the care plan, interventions, and guidelines, depicted in Figure 5-1, pages 92–95.
outcomes. When a patient’s response to routine interventions
is inadequate because of the complex pain management The guidelines note that meperidine does have some
situation, the caregiver ensures the patient’s access to the full therapeutic applications, even if it should not be used as a
range of interdisciplinary resources and processes. first-line analgesic. Appropriate indications may include
treatment of postanesthesia, drug, or blood-induced
Finally, pain management is included in the discharge plan. shivering; management of brief procedure pain; and
management of acute pain when it is administered via the
Meperidine Use epidural route.
Early on, the Patient Care Pain Team targeted the use of
meperidine, which was a widely used opioid analgesic for the The guidelines were mailed to all medical, pharmacy, and
treatment of moderate to severe pain and is now discouraged house staff along with a memo listing available pain
as a first-line agent for most painful conditions. management resources in the hospital. The guidelines were
then posted on UConnect, the hospital’s intranet.
An evaluation of meperidine use from January to July 1995
revealed that more than 1,500 patients were administered the Shortly after the guidelines were published, the oral tablet
drug. Although the average prescription administered was and IV PCA syringe dosage forms of meperidine were
well within the limits of APS guidelines, the data suggested removed from the hospital formulary.
that meperidine was being used as a first-line opioid therapy,
a practice contrary to APS recommendation and clinical An interdisciplinary case-based conference on meperidine use
practice guidelines issued at the time by the Agency for was convened. Participants included medical staff from the
Health Care Policy and Research (now known as the Agency gastroenterology and surgery departments as well as the pain
for Healthcare Research and Quality). clinics. Structured with open discussion, cases were presented
and a critical literature review was discussed.
The team implemented a Plan-Do-Check-Act (PDCA) cycle
to reduce the inappropriate use of meperidine. With the use Approximately 18 months after the release of the formulary
of an Ishikawa diagram and a flowchart, the team identified guidelines, a drug utilization evaluation showed that only 2%
the following root causes of meperidine use: of total hospital admissions received meperidine at some
• No clear mandates or standards were related to meperidine point in their hospital stays, compared with 12% one year
use. earlier.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 5-1. University of Wisconsin Hospital and Clinics (UWHC) Guidelines for the
Use of Meperidine
The Patient Care Pain Team developed guidelines for the use of meperidine, which is now discouraged as a first-line agent
for most painful conditions.
92
Chapter 5: The University of Wisconsin Hospital and Clinics
Figure 5-1. University of Wisconsin Hospital and Clinics (UWHC) Guidelines for the
Use of Meperidine, continued
(continued)
93
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 5-1. University of Wisconsin Hospital and Clinics (UWHC) Guidelines for the
Use of Meperidine, continued
94
Chapter 5: The University of Wisconsin Hospital and Clinics
Figure 5-1. University of Wisconsin Hospital and Clinics (UWHC) Guidelines for the
Use of Meperidine, continued
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
In 2000, the hospital converted to a new computerized unit- Institutions are encouraged to develop policies surrounding
based medication cabinet–dispensing system, enabling the team “as needed” range orders. Because of this and the fact that,
to have access to monthly reports of meperidine usage. This through Standard MM.04.01.01, The Joint Commission
system enabled the team to spot trends in meperidine usage requires organizations to specify requirements that ensure the
more quickly, which helped prevent the use of meperidine from safety of how medication range orders are written, carried
rising, especially as new physicians joined the staff. out, and administered to inpatients, the Patient Care Pain
Team addressed this issue by developing a list of
Meperidine utilization was reviewed on a regular basis considerations for writing and interpreting “as needed” range
through 2005. Its use dropped to less than 2% and remained opioid orders. These considerations are shown in Figure 5-3
stable, as depicted in Figure 5-2, page 96. Ongoing on pages 97–98. In 2010, these guidelines were incorporated
monitoring since 2005 has no longer been necessary and has into the UWHC’s medication administration policies.
enabled the team to turn its attention to other matters.
Today, if a physician tries to order meperidine for pain, a A range order requires nursing staff to exercise judgment in
unit-based pharmacist quickly intervenes to help counsel for determining the most appropriate dose for a given clinical
a better, safer agent. situation. Still, the intent of the order should be clear. It
should specify an appropriate dose range and frequency of
“As Needed” Range Orders administration based on the pharmacokinetics of the opioid,
The use of “as needed” range orders for opioid analgesics is a the patient’s characteristics, and the circumstance. However,
common clinical practice. Range orders provide flexibility in orders that require nurses to administer specific doses based
dosing to meet a patient’s unique analgesic needs and allow on pain-intensity ratings are inappropriate. The order should
dose adjustments based on his or her individual responses to neither be prescriptive nor vague. If the order is unclear,
treatment. The problem is that introducing two variables clarification should always be sought from the prescriber.
(e.g., dose and frequency range) into a single order promotes
ambiguity. Moreover, range orders have been demonstrated to Team members also developed a quick guide called Pain Care
be a common source of medication errors. Physicians have Fast Facts on how to write, interpret, and carry out “as
been shown to underprescribe opioid analgesics, and nurses needed” range orders properly, distributed it to the entire
have been shown to administer inadequate doses, both of staff, and posted it on UConnect.
which result in the undertreatment of acute pain.4
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 5-2. Use of Meperidine and Intramuscular (IM) Route for Analgesia
Note that the population of patients was not all from the University of Wisconsin Hospital and Clinics but rather from var-
ious subgroups examined for different studies.
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
Reassessment of Patients with Pain The task force conducted a more thorough evaluation of
After a patient receives treatment or undergoes an current practices the month following the accreditation
intervention for pain, the caregiver conducts frequent survey to examine baseline performance. A medical record
reassessments to determine the patient’s response. Prior to audit on 85 open charts revealed that only 24% of timed
2005, the hospital policy stated that, with exceptions,* no reassessments were made within one hour after any
predetermined standard of care specifies exactly when intervention.
reassessment after intervention must be performed. Rather,
bedside critical pathways (plans of care) were to be As part of an evidence-based process to define practice
individualized every 24 hours to provide the frequency of expectations related to pain reassessments, the task force
assessments tailored to the nature and severity of pain, the gathered and critiqued the relevant literature. Pain
level of intervention, and the care setting. management guidelines offered the following
recommendations5,6:
However, in 2005, during a Joint Commission survey, it was • Pain should be reassessed after each pain management
noted that the reassessment of pain after interventions was intervention, once sufficient time has elapsed for the
conducted inconsistently. Despite the hospital policy, plans of treatment to reach peak effect (for example, 15 to 30
care termed critical pathways were found to have rarely been minutes after a parenteral medication and one hour after
completed or individualized for pain management. Although oral medication or a nonpharmacologic intervention).
numerous documented pain-intensity ratings were in the • Reassessment should include whether the patient’s goal for
medical records, individual patients were found to have pain relief was met (for example, pain intensity, effect on
undocumented gaps in the time periods between high levels function [physical or psychosocial], patient satisfaction
of reported pain, intervention, and reassessment. with pain relief, whether side effects had occurred and were
tolerable).
In response to these findings, a task force comprising staff
nurses from three councils (e.g., Nursing Practice, Nursing PDCA
Research, and the Unit Council Chairs) was formed. The The task force implemented a series of interventions and
task force was charged with implementing a PDCA cycle to communications efforts, as shown in Figure 5-4 on page 99.
improve the documentation of pain reassessments.
* Exceptions included, for example, IV PCA epidural and intrathecal analgesia, moderate sedation, and a number of specific invasive treatments, such as nerve blocks,
or drugs (such as DHE [dihydroergotamine mesylate] for migraine).
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Chapter 5: The University of Wisconsin Hospital and Clinics
Figure 5-3. Considerations for Writing and Interpreting PRN (“As Needed”) Range
Opioid Orders
The Patient Care Pain Team developed a list of considerations for writing and interpreting “as needed” range opioid orders,
which was subsequently incorporated into the medication administration policies of the University of Wisconsin Hospital
and Clinics. (CNS, central nervous system; NSAID, nonsteroidal anti-inflammatory drug; IV, intravenous).
(continued)
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 5-3. Considerations for Writing and Interpreting PRN (“As Needed”) Range
Opioid Orders
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
98
Chapter 5: The University of Wisconsin Hospital and Clinics
This figure presents the major activities and communication points with nursing staff that occurred between the time of
The Joint Commission’s survey and achieving full and stable compliance with performance. Problems with vendor produc-
tion of new forms delayed implementation. (RN, registered nurse)
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
Specifically, the “plan” stage called for an administrative To educate the nursing staff about the new flowcharts, they
hospital pain management policy, which was developed and were given an in-service training session and a staged release
implemented in 2006. The policy clearly stated the of revised flowcharts using a one-page Pain Care Fast Facts
requirements for pain screening, assessment and reassessment, guide outlining the new policy and requirements. Unit-based
and the management of pain across all care settings. pain resource nurses also discussed the changes at unit-level
council meetings. Policy and practice changes were reviewed
The vital sign section in all daily nursing flowcharts in the and discussed at nursing practice, nursing research, nursing
inpatient settings was expanded to accommodate a table with quality, nursing education, and the unit chair council
several variables rather than a row of pain-intensity ratings. meetings on several occasions.
The table includes pain relief, side effects, impact on
function, and patient satisfaction, all of which are expected to With regard to the “check” stage, the following performance
facilitate more comprehensive documentation of pain measure was created: the number of reassessments
reassessment after “as needed” intervention. Today, all this documented within the specified time interval (30 minutes
information is included in the EMR. after parenteral drug or one hour after PRN oral analgesic or
nonpharmacologic intervention) divided by the number of
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
PRN interventions (either nonpharmacologic or analgesic) A daily audit from May 29, 2006, through May 29, 2010,
administered in a 24-hour period. This new pain assessment revealed compliance above the 90% performance measure, as
performance measure was added to the monthly shown in Figure 5-5 on page 101.
documentation compliance audits routinely performed by all
registered nurses (RNs). However, with longitudinal data continuing to show daily
fluctuations just above the 90% compliance goal, there was
An audit for February through April 2006 revealed an concern that the UWHC was vulnerable to another Joint
improved compliance rate of 72%, up from the baseline of Commission Requirement for Improvement. More
24%. However, the target compliance rate of > 90% was not importantly, no evidence suggested that the more stringent
achieved. policy had helped improve the quality or safety of pain
management. The additional nursing burden the policy
The task force came to the realization that the monthly audit caused was also a factor.
and feedback process was too slow to provide timely feedback
to evaluate the effectiveness of pain reassessment Policy Modification
interventions. The communication and educational activities From the time the policy was first implemented, questions
were insufficient to effect a practice change of this about the benefit to patients and impact and potential
magnitude. In addition, numerous systems issues served as burden on nursing practice were raised. Many nurses argued
barriers. The latter included a slow production and that they had been reassessing pain and communicating with
distribution schedule for the new forms, communication gaps team members and that the new policy only created an
of the new requirement, and lack of staff goal alignment. additional documentation burden. Many nurses continue to
report that the policy’s requirement is burdensome and
Upon hearing that the target compliance rate was not interrupts their work flow. But the audits captured only “as
reached, the chief nurse executive and two nursing directors needed” pain interventions provided during the first 24 hours
developed a plan that called for the reeducation of the after initiation of a new or changed pain management
clinical nurse managers and nursing directors to emphasize regimen, which accounts for an estimated 30% of all pain
the severity of the problem. A 24-hour-a-day/7-day-a-week interventions. The total number of “as needed” interventions
initiative to provide visible, interactive nursing leadership at requiring documentation provided by UWHC staff is more
the bedside was implemented. Clinical rounds were than 300 per day.
implemented every 2 hours on all patients, during which
members of the nursing leadership team reviewed bedside Consequently, by the end of 2009, an alarming trend of
flowcharts and interacted directly with the nursing staff to fewer documented pain management interventions was
address any implementation questions. These rounds identified on some nursing units, perhaps an unintended
occurred around-the-clock for two weeks, including consequence of the policy discouraging documentation—
weekends. that is, if the nurse does not document an “as needed”
intervention, then documenting a timed reassessment is
During rounds, discussions were held with nurses to bring not needed.
any potential problems to their attention. Nursing
administrators, clinical nurse managers, and CNSs educated The pain management CNS alerted the chief nursing officer
individual nursing staff members by using a form of one-on- and director of Patient Care Services about this trend and
one bedside coaching. Coaching is a means of interacting obtained administrative support to develop a policy
with staff which promotes the alignment of goals and modification. To that end, the CNS invited 18 key nursing
supports adaptation for sudden shifts in health care.7 During and pharmacy personnel from adult and pediatrics medical,
these coaching sessions, which often occurred right outside surgical, and intensive care units and the ED to participate in
the patient’s door, staff frustrations were acknowledged and a policy modification task force. Members included bedside
obstacles were identified. The intent was to have staff focus staff nurses, CNSs, nurse managers, the nursing directors of
on the potential value of the documentation of reassessments Practice Innovation and Quality, and the hospital and
to patients as opposed to simply meeting a Joint Commission pharmacy Joint Commission compliance officers.
accreditation requirement.
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Chapter 5: The University of Wisconsin Hospital and Clinics
Figure 5-5. Percent of PRN (“As Needed”) Pain Interventions (Adult) with Appropriately
Documented Reassessment
Daily audits between May 2006 and May 2010 have shown stable sustainment beyond the target rate of 90%. The cumu-
lative rate of “as needed” pain interventions that have an appropriate time reassessment is 93% (422,644 documented
reassessment for 454,282 interventions).
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
Prior to the task force meeting, several peer hospitals often overlooked interventions that were scheduled or
were polled on the elements of requirements for nursing administered for chronic pain conditions. Based on the
practice and documentation in their hospital policies. available evidence and task force member feedback, the
The National Association of Clinical Nurse Specialists following draft language was developed and circulated to the
(http://www.nacns.org/) e-mail list also was queried for task force in March 2010 to modify the policy:
comments about pain reassessment policies that passed a • The reassessment of pain is ongoing and not simply a one-
Joint Commission accreditation survey. Additionally, advice time event. Response to pain interventions is reassessed in
was garnered through personal communication with a a manner appropriate to the route and method of pain
nursing leader who serves as a liaison between The Joint control. Dependent on the situation, reassessments include
Commission and the American Society of Pain Management pain relief, side effects, impact on function, and patient
Nurses on pain management standards issues.8 satisfaction with treatment.
• Response to pain interventions (pharmacological and
Task force members unanimously agreed that pain nonpharmacological) is used to monitor effectiveness and
reassessment is more than a single event and should occur on to determine whether further intervention is needed.
an ongoing basis that is often global in nature. It was noted • In the inpatient setting, an RN performs a documentation
that although the EMR included space to document a of ongoing reassessments for each patient receiving pain
comprehensive reassessment, the current policy was focused treatment of any kind minimally three times within 24
on “as needed” interventions only. Consequently, the EMR hours (approximately 8 hours apart), such as at times of
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
shift handoff, transfer to another unit, or change in communications and laminated wall posters located in
therapy. In other words, any inpatient who is receiving various nursing units.
either nonpharmacological or pharmacological treatment,
whether scheduled or “as needed” for either acute or Nurses are now instructed on the importance and benefits of
chronic pain, should have a reassessment documented pain reassessments and on the policy and specific
minimally three times within 24 hours. documentation requirements during hospital orientation.
Pain reassessment is a routine variable displayed on all unit
The revised hospital policy was subsequently approved and and departmental quality dashboards.
implemented in June 2010. The policy modification was
shared with unit-based pain resource nurses for discussion at
unit nursing councils. Overall, feedback to date has been Educating Staff About Pain
positive. An extensive communication and education plan Management
was developed to inform staff of the final new requirements Over the years, Patient Care Pain Team members have met
using e-mail, nursing orientation and continuing education with a variety of hospital committees and opinion leaders to
forums, and unit-based peer champions (e.g., pain resource educate them about pain management efforts and to ensure
nurses). CNSs who interacted directly with nursing staff to that pain management is integrated into the QI process.
address any implementation questions conducted clinical
rounds daily for two weeks. Nursing administrators, Vehicles for staff education include various types of training
managers, and CNSs provide ongoing coaching. sessions and one-on-one coaching opportunities as well as
written materials and tools. The pain champions are the pain
Returning to the hospital policy regarding reassessment, if resource nurses and pain CNSs. Other presenters include
any of the following scenarios occur, they are reported to the nursing administrators, clinical nurse managers, team
appropriate health care practitioners: The patient’s pain is members, and other colleagues in leadership positions.
unrelieved, the intervention(s) is insufficient to reduce pain
to an acceptable level according to the patient, the initial Ongoing Sessions
planned interventions do not manage side effects, or new or Early on, the team members presented open-forum, monthly
unexplained pain develops. Next, the caregiver reviews the pain case conferences to gather staff from across the
pain assessment, current analgesic effectiveness, prior organization to discuss patient scenarios and topics of
analgesic history, and present medical situation with a interest.
physician. They identify the problem and discuss the need for
adjusting the treatment plan. Today, the team hosts two interdisciplinary monthly pain
journal clubs that follow the core curriculum of the
Leadership Role International Association for the Study of Pain. One of the
Direct and extensive leadership involvement in the form of clubs is clinical in nature; the other focuses on basic science.
continuous bedside coaching, combined with clear Both draw an audience mix of scientists, professors, Ph.D.
accountability and alignment with goals, was critical to ellicit students, and residents, along with nurses, psychologists,
substantial change. pharmacists, and physicians.
Communication and follow-up with all stakeholders, In 2008, monthly nursing grand rounds were implemented.
including clinical nurse managers, directors, nursing councils, At least one nursing grand round a year addresses a pain
staff nurses, and other nurse leaders, also were essential. topic.
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Chapter 5: The University of Wisconsin Hospital and Clinics
serving as a change agent, role modeling best practices, The team routinely develops and contributes to the pain
coordinating unit-based QI projects, providing an interface management resources section of UConnect used for on-time
with the team, and facilitating integration of evidenced-based interdisciplinary pain education. This section includes pain
practice at the bedside. They are required to undergo a clinic referral forms; an Opioid Treatment Agreement form
formal annual reappointment process as well. Currently, 45 (aka opioid contract); contact numbers for pain services; an
pain resource nurses cover the ED, Mohs micrographic Opioid Equivalency Table; an Opioid Titration Guideline;
surgery, oncology, otolaryngology, radiotherapy, and all resources for neuraxial analgesia for acute and chronic pain;
inpatient units. In 2008, the Resource Nurse Connection other pain guidelines, including one for sickle cell crisis and
newsletter was launched. Its purpose is to connect resource chronic pain; migraine resources; and links to Internet Web
nurses, including those in pain management, with others sites of professional pain societies.
throughout the hospital and provide a source to learn more
about how the role works. Educating Persons with Pain
According to hospital policy, the effective relief of pain
A physician-nurse team regularly provides in-service training requires professional expertise and patient/family
to various medical departments’ teams of residents and involvement. As part of the UWHC’s effort to educate
interns, offering an overview of UWHC’s principles and patients about pain, a pain-rating scale is displayed in every
resources for pain management. In 2009, the team completed inpatient room on the dry-erase board. Posters entitled Are
the development of electronic competency on pain You in Pain? are placed in every clinic examination room.
management for resident physicians.
Clinicians at the UWHC have written more than 50 patient
With regard to pediatrics, the team developed a pain educational materials addressing a variety of pain topics. In
management rotation for first-year pediatric residents as part 2009, new Health Facts for You were written about topical
of their community rotation with an emphasis on a systems lidocaine, nondrug pain control for kids, regional block for
approach. Pediatric nurses in the more than 12 local, satellite outpatient surgery, and upper extremity block. The Health
pediatric clinics were trained on techniques for analgesia IV Facts for You can be found on the hospital’s Web site
starts, including distraction, holding, and use of topical (http://www.uwhealth.org). A couple of these have been
lidocaine. translated to Spanish as well. But patients do not have to
access them on their own. The EMR automatically generates
A session on pain management is presented in all nursing a list of Health Facts for You for each patient, as appropriate.
orientation programs, including those for nursing assistants, The clinician simply prints it and hands it to the patient,
nurse residents, and RNs. reinforcing the content with verbal teaching.
Written Materials Patients can visit one of eight Patient Learning Centers
Written materials take a variety of forms. Among the first located in the UWHC facilities, where nurses conduct one-
were clinical practice guidelines and pocket-size pain on-one education for patients and families. Patients can drop
management reference cards, which were widely disseminated in during business hours or schedule an appointment with a
among physicians, pharmacists, and nurses. In 2009, the nurse educator to learn about any health care issue.
team distributed an updated pocket guide on pain Additionally, some centers offer organized preoperative
management, as depicted in Figure 5-6 on pages 104–105, to education group sessions for common elective surgeries, such
all UW Health physicians. as joint replacement, at which techniques for perioperative
pain management are discussed.
Pain Care Fast Facts: 5-Minute Clinical In-Service sheets are
evidence-based summaries addressing important pain topics, If patients access the Web site at http://www.uwhealth.org/pain,
such as opioid conversion and cultural views of pain. they find more pain care information, such as self-help
Currently, 33 Pain Care Fast Facts are available. The one- to documents, support groups that meet at a UWHC facility, and
two-page summaries are e-mailed to all Patient Care Pain referral instructions. The video library addresses specific pain
Team members and pain resource nurses in addition to being conditions, such as headache, or offers a glimpse into patients’
posted on UConnect. experiences at the UW Health clinics.
103
Figure 5-6. University of Wisconsin Hospital and Clinics (UWHC) Pain Reference Card
In 2009, this updated pocket-size pain management reference card was disseminated to all UW Health physicians. (prn, as needed; PO, by mouth; IV,
intravenous; PCA, patient-controlled analgesia, RN, registered nurse)
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 5-6. University of Wisconsin Hospital and Clinics (UWHC) Pain Reference Card, continued
105
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
Chapter 5: The University of Wisconsin Hospital and Clinics
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
UWHC staff routinely give lectures at local venues on pain immunization or other needle-related procedure and about
topics geared for laypersons. For example, a headache methods for distraction during painful procedures.
symposium addresses how to manage these difficult disorders.
In the UW Health pain clinics, providers use exercise and
Continuum of Care rehabilitation, medications, injection techniques, relaxation
Pain management has been integrated across the UWHC and mind-body treatments, and integrative medicine to help
system and throughout the patient’s lifespan. Patients are patients feel better and function better once they return to
screened for pain on every visit, whether to a clinic or as an their daily lives. With regard to patients with chronic pain,
inpatient at the hospital. If the screening is positive, a staff focus on helping them regain control of their lives;
thorough pain assessment is completed. An interdisciplinary function better at work, in the community, and at home;
plan of care is completed for each patient who is admitted to cope more effectively with pain when it cannot be cured; and
the hospital. Although plans of care are individualized based reduce their pain whenever possible. In addition, UWHC
on patient need, each plan has a section on pain that includes pain specialists avail themselves for telephone consultations
specific interventions and goals. Upon discharge from the from local and regional providers.
hospital or clinic, discharge instructions are tailored to
address needed follow-up issues. If pain is persistent upon Chapter 8 discusses newer palliative care strategies that are
discharge, instructions are included, such as follow-up showing positive results for patients with pain in one
appointments, analgesic regimen, or whom to contact for international hospital setting.
questions and follow-up.
Improving Organizational Performance
Many tools are available to encourage and assist all staff at The Patient Care Pain Team began its QI efforts by using a
the UWHC to address pain across the continuum. The patient outcomes questionnaire and a medical record audit
Health Facts for You sheets are available to be used at any tool for ongoing annual outcomes monitoring studies. Unit-
time during a patient visit but are especially encouraged to be based monthly audits were added to increase the proximity
used at discharge from the ED or the hospital or between and frequency of data feedback to staff. The unit’s pain
outpatient visits. Topics include coping with chronic pain, resource nurse initially performed these audits to monitor
avoiding the ED for headaches, reducing pain medicine after peer practice and provide regular feedback to staff about pain
discharge, and completing home care after various types of assessment, documentation, and pain intensity experienced
injections and procedures. Given the prevalence of migraine by specific populations of patients. Later, this was
headache and its impact across the continuum of care, a incorporated into monthly documentation audits performed
headache toolkit was created with materials for patients by every staff nurse as a form of learning and discovery
and staff. This kit includes patient education materials, exercises to promote visibility of pain as a quality issue and to
diagnostic criteria, and medication and nonmedication improve all areas of documentation.
recommendations for pediatric and adult patients.
In addition, collaborative drug utilization review studies have
Order sets are another method used to remind staff of pain been conducted with the hospital’s Pharmacy and
control measures and to make them more readily available. Therapeutics Committee to address analgesic prescribing,
All pediatric admission and postoperative order sets include resulting in the development of clinical practice guidelines
the use of a topical lidocaine cream for all IV starts and regarding the use of meperidine, continuous opioid infusions,
blood draws. This program has been so successful in the and pharmacological management of migraine headaches.
pediatric population that its use is being expanded to the
adult population, and the options of medications for Key Quality Indicators
pretreatment are being expanded. Staff are encouraged to use Today, numerous pain management variables are measured
these medications for other painful needle-related procedures, and monitored through a combination of daily, monthly, and
such as blood draws, accessing ports, and prior to lumbar annual formats. The pain management quality indicators
punctures. A Health Fact for You sheet was created to monitored at the UWHC address all aspects of quality,
educate parents about how to obtain and apply topical local including organizational structures, processes, and patient
anesthetic products prior to clinic visits that may include an outcomes.
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Chapter 5: The University of Wisconsin Hospital and Clinics
In 2009, the most frequent diagnostic category of patients seen was medical-surgical (noncancer). Seventy-six percent of
consults had histories of chronic pain, consistent with the previous four years of data.
Surgical Cancer
5% Psychiatry
Surgical Non-cancer
31% 6%
Medical Cancer
6% Medical Non-cancer
52%
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
Medical record audits and patient surveys are conducted to pain relief recorded within 24 hours of admission for patients
examine staff practice patterns and patient outcomes. As an seen between September 2009 and May 2010.
example, in 2009, the most frequent diagnostic category of
patients seen was medical-surgical (noncancer), as depicted in Documentation of pain reassessments is monitored daily. The
Figure 5-7, above. Seventy-six percent of consults had data are fed back to nurse managers and CNSs to share with
histories of chronic pain, consistent with the previous four unit-based pain resource nurses so that they can work
years of data. Medical record audits are used to track the together to address practice deficiencies. On a monthly basis,
nature and frequency of documented pain assessment and the types of pain interventions being provided and levels of
analgesic prescribing as well as staff administrative practices. pain relief reported by patients are summarized in graphic
For example, Figure 5-8, page 108, shows the percentage of displays by level of nursing unit and are available in an online
pain interventions recorded within 24 hours of admission for shared network file. These data—along with quarterly
patients seen between September 2009 and May 2010. In summaries of Press Ganey, Inc., patient satisfaction surveys of
addition, patients are routinely surveyed regarding their pain care and results from specific QI projects—are shared
experience of pain intensity and relief, the impact of pain on annually with nursing and medical leadership in the form of
their function and mood, the helpfulness of information they a pain management report card. Indicators for utilization of
received about pain treatment, their ability to participate in pain services, which measure the volume and nature of
pain treatment decisions, their satisfaction with pain inpatient pain consults, also are provided as an annual report
management, and their use of nonpharmacological strategies. to track trends in the nature of pain management issues and
As an example, Figure 5-9, page 109, shows the percentage of as secondary referrals to pain specialists.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
This measure is the percentage of pain interventions recorded within 24 hours of admission for patients seen between
September 2009 and May 2010. The unit arrival date/time is used if present. Population includes inpatient direct care units
only. It excludes first-day surgery, ED, and all ambulatory care areas. (IM, intramuscular; IV, intravenous; PCA, patient-
controlled analgesia; subcu., subcutaneous)
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
Examples of more specific ad hoc measures obtained in nurses, who are expected to disseminate the information to
focused pain QI studies performed in 2009 include time-to- their colleagues.
analgesia in the ED, the methods of analgesia provided for
reduction of dislocation and fracture in the ED, the types of The Nursing Quality Council now tracks and reports
goals patients had in watching specialized television Nursing Sensitive Outcome indicators, including patient
programming designed to help alleviate pain and anxiety, and satisfaction with pain management, in a newsletter titled
the impact of using this programming. Focus on Quality, which is shared with all nursing staff.
Progress on all avenues of pain improvement is reflected in The Pain Service CNSs and pharmacist review and report all
monthly team meeting minutes, which are distributed to Patient Safety Net events related to analgesics to the
approximately 50 interdisciplinary staff and 45 pain resource Medication Safety Committee on a quarterly basis.
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Chapter 5: The University of Wisconsin Hospital and Clinics
This measure is the percentage of pain relief recorded within 24 hours of admission for patients seen between September
2009 and May 2010. The unit arrival date/time is used if present. Population includes inpatient direct care units only. It
excludes first-day surgery, emergency department, and all ambulatory areas. (PRN, as needed)
Source: The University of Wisconsin Hospital and Clinics. Used with permission.
References
1. Gordon D.B., et al.: American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain
Society Quality of Care Task Force. Arch Intern Med 165:1574–1580, Jul. 2005.
2. Waters D., Sierpina V.S.: Goal-directed health care and the chronic pain patient: A new vision of the healing encounter. Pain Physician
9:353–360, Oct. 2006.
3. Farrar J.T., et al.: A comparison of change in the 0–10 numeric rating scale to a pain relief scale and global medication performance scale in a
short-term clinical trial of breakthrough pain intensity. Anesthesiology 112:1464–1472, Jun. 2010.
4. Paice J.A., et al.: Efficacy and safety of scheduled dosing of opioid analgesics: A quality improvement study. J Pain 6:639–643, Oct. 2005.
5. Management of Postoperative Pain Working Group: VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain. Veterans
Health Administration, Jul. 2001. Updated May 2002. http://www.healthquality.va.gov/pop/pop_fulltext.pdf (accessed Aug. 5, 2010).
6. Registered Nurses’ Association of Ontario: Assessment and Management of Pain. 2002. http://www.rnao.org/Page.asp?PageID=924&ContentID=720
(accessed Mar. 31, 2010).
7. Waddell D.L., Dunn N.: Peer coaching: The next step in staff development. J Contin Educ Nurs 36:84–89, Mar.–Apr. 2005.
8. Personal communication, Dec. 18, 2009.
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Chapter 6
Montefiore Residential and
Community Services for
Seniors
111
Chapter 6
Montefiore Residential and
Community Services for Seniors
As stated in Chapter 1, pain is common among the elderly. Yet it is not, as widely believed, an inevitable consequence
of aging. Elderly persons, the most frail and vulnerable of whom reside in nursing homes, are at greatest risk for
undertreatment for pain and, thus, decreased functioning and quality of life. No one disagrees that pain should be
addressed in the elderly, but many perceived and real barriers exist to improving pain assessment and management,
including the wide variation in medical status (cognitive impairment, for example) throughout the population. This chapter
describes a comprehensive pain management improvement effort, including engagement and education of residents and
their families, use of an interdisciplinary palliative care consultation team, staff education, consideration of religious and
cultural factors, and availability of a wide range of integrative therapies and comprehensive performance improvement
efforts. Montefiore Residential and Community Services for Seniors, in Beachwood, Ohio, has been successful in
institutionalizing pain assessment and management by making it everyone’s responsibility.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
community-based hospice services. The Weils of Bainbridge, including physical, occupational, and speech therapy, is
an assisted living facility located in Bainbridge, Ohio, is part available based on resident need. All residents/patients
of the Montefiore care continuum. It offers luxury senior receiving therapy are assessed for pain throughout the therapy
housing with an emphasis on independence, safety, and treatment plan. For example, residents on the subacute unit
wellness. Recently, the Weils opened a 21-bed skilled specifically receive rehabilitative services postsurgery for total
rehabilitative unit and an 8-bed assisted living wing knee and/or hip replacements.
specializing in dementia care. The Weils of Bainbridge
follows the same pain practice as the Montefiore care Residents on this unit often experience pain as the therapy
continuum. Throughout all services offered by Montefiore, regimen is increased. Therefore, a variety of pain
registered nurses (RNs) conduct preadmission, admission, management techniques is implemented to allow the resident
and ongoing pain assessments. The nurse manager works to progress with the therapy program. For all therapy
with the resident, family, and primary care physician to carry programs—including home therapy—pain medications and
out the prescribed pain protocol. therapy techniques focusing on strengthening, flexibility,
posture, ultrasound, massage, application of heat and cold,
The short-term skilled unit at Montefiore and the Weils and stretching are part of the pain management plan.
provides 24-hour skilled care for postacute care residents. The Patients with chronic back pain problems, for example, begin
short-term nursing and therapy team members are specialists with the basics of using proper body mechanics, posturing
trained in treating and meeting the needs of residents with with appropriate spine alignment, proper use of adaptive
problems that include orthopedic rehabilitative, surgical, and equipment, strengthening, stretching, and often application
stroke or neurological complications; congestive heart failure; of heat and cold.
and vascular disease. The long term care beds are staffed with
24-hour nursing care, under the guidance of primary care Montefiore’s home care program, Montefiore at Home,
physicians and a full-time medical director. The dementia provides skilled and nonskilled nursing, aide, and therapy
care unit is staffed with 24-hour nursing care for residents services in the patient’s home or assisted living facility. The
with Alzheimer’s and other dementia-related illnesses. The home care program is nonsectarian and offers a team of
dementia care unit provides a homelike atmosphere in a specialists in the areas of geriatric assessment and care,
secure environment. All activities on the dementia care unit palliative care (prehospice) services, infusion therapy,
are specific to the dementia population. rehabilitative services, and safety as well as a Russian
interpreter who assists with a growing Russian immigrant
The National Council of Jewish Women (NCJW)/Montefiore population. (For more on this subject, see “Cultural and
hospice program oversees the care on the inpatient unit with Religious Issues in Pain Management” on pages 121–123.)
six dedicated hospice beds at Montefiore and focuses on
specialty end-of-life care. The nonsectarian community-based With the home safety assessments, which are carried out in
hospice program follows patients in their own homes or at the senior’s home or assisted living suite, the emphasis is on
contracted external nursing facilities. The hospice staff are creating a safe environment. The occupational therapists are
trained in meeting the medical, psychological, and spiritual also trained in low-vision rehabilitation, which offers an
needs of patients and their families in a comfortable homelike additional dimension to the promotion of a safe
setting. The NCJW has supported the hospice program since environment.
its inception in 1992 and continues to have an active role in its
successful operation. In recognition of palliative care as an integral component of
the care continuum, in 2009 Montefiore Hospice received a
Range of Programs and Services grant from the Mt. Sinai Foundation to launch a palliative
An RN nurse manager supervises all inpatient units and care consultation program.
programs within the Montefiore care continuum and
coordinates all aspects of physical, psychological, and spiritual “The reality is that people often wait too long to seek
care for residents and their families. The nurse manager symptom management through palliative care, and the pain
ensures the highest level of comfort for each resident or is out of control by then,” says Diane Korman, R.N.,
patient cared for within the continuum. A full therapy team, M.S.N., C.H.P.N., director of hospice and palliative care.
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Chapter 6: Montefiore Residential and Community Services for Seniors
“This program is part of the continuum of care. It fills the For example, on admission, residents or patients receive pain
gap for patients and families who need to know what their management information specific to their right to be
choices are, particularly for those who are not quite ready for comfortable at all times. Residents receive verbal and written
hospice care.” information, including the You Have the Right to Have Your
Pain Assessed and Treated handout and various pain booklets
The palliative care program is headed by a palliative specific to the type of pain or disease process that is present
care–certified physician and palliative care administrative (see Figure 6-1 on pages 116–117).
director and also includes a social worker, a spiritual care
worker, and registered nurses certified in palliative care. A Ongoing reinforcement regarding all aspects of comfort
rabbi and a Christian pastoral care provider are available for promotion takes place across all care settings. More
patients who wish to consult on religious concerns with importantly, residents are informed of their rights to be cared
regard to pain management. for by staff who are knowledgeable in all areas of current pain
management practice.
The team can be called at any time to assist staff in caring for
residents who may be experiencing atypical or more complex Montefiore employees are educated about pain management
pain problems. The team collaborates with the inpatient staff, issues beginning at orientation. Staff knowledge about pain
functioning in an educative role and assisting with all areas of management are monitored and reinforced throughout the
pain management practice. competency evaluation process. Staff members are trained in
the areas of observing signs and symptoms of pain and
Team members also go to other organizations, hospitals, and utilizing verbal and nonverbal monitoring systems. To begin
community centers to educate the public and other caregivers with, staff are trained by way of pain assessment questions,
about pain management. utilizing comprehensive assessment tools and pain-scale
rulers.
“There is always a good audience, including caregivers, social
workers, discharge planners, and patients’ families,” says Assessing Persons with Pain
Prosser. “We educate them about potential care options and The single most important pain management issue that
discuss the common concerns about narcotics, sedation, and Montefiore management and educators stress with staff is
addiction. This team helps overcome a lot of biases.” that pain assessment includes much more than using a pain
measurement scale. The home care and hospice staff have
Organizational Commitment to Pain developed a user-friendly pain assessment tool that is used
Management with each visit or when a telephone call is placed to the
Montefiore’s pain program is based on strong support from patient. (See Figure 6-2 on pages 118–119.)
its board of directors on down to the direct care staff.
“Without support from leadership, these programs would Pain assessment findings are documented on the home care
have been impossible to implement,” Korman says. online assessment tool. The section that addresses pain
management is standard across the United States for home care.
All programs within the Montefiore care continuum adhere to
Joint Commission standards that recognize patients’ rights to At Montefiore, it is a practice standard that pain is
pain assessment and management, to receive medication for considered the fifth vital sign on this form. If the patient
their pain, to be cared for by staff trained in pain assessment reports a pain level of 3 or greater on a scale from 0 to 10,
and management, and to be educated on their and their the pain assessment tool (Figure 6-2) is used to reassess the
families’ roles in obtaining adequate pain management. pain on a follow-up visit and/or in a telephone call,
whichever is planned or warranted according to the plan of
See Chapter 2, “Compliance with The Joint Commission and care, as shown in Figure 6-3 (see page 120).
JCI Standards,” for a discussion of the requirements that
apply across all programs, including long term care Regardless of the tool used, the intensity, quality, and effect
organizations. of pain on the resident’s overall performance status and
quality of life are always measured. If a resident cannot
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 6-1. You Have the Right to Have Your Pain Assessed and Treated
All patients receive the You Have the Right to Have Your Pain Assessed and Treated handout upon admission. (NCJW,
National Council of Jewish Women; IV, intravenous)
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Chapter 6: Montefiore Residential and Community Services for Seniors
Figure 6-1. You Have the Right to Have Your Pain Assessed and Treated, continued
Source: Montefiore Residential and Community Services for Seniors. Used with permission.
perform activities of daily living because of a pain problem, a For nonverbal or cognitively impaired residents, staff focus
care conference is carried out. The pain scale measures on signs and symptoms that may or may not be related to
intensity of pain and includes sad and happy faces (which pain problems. For example, a resident may suddenly start
coincide with numeric ratings) for use with nonverbal or acting out or may have behavior changes, restlessness,
cognitively impaired residents. Separate scales are used that irritability, and even depression, which are all symptoms of a
focus on facial expressions and other physical cues in larger problem. Pain, which is frequently under- or untreated
nonresponsive patients. Staff are educated to differentiate in this population, often leads to an escalation of other
what answers and findings indicate what type of pain a symptoms. Residents who have underlying medical problems
resident is having. For example, is the resident experiencing often have exacerbations of their diseases when pain is
burning, aching, electrical shock sensations, or a deep visceral untreated. “Depression is very common in patients when
pain? Staff understand the difference between acute and pain is not getting adequately controlled,” Prosser notes.
chronic pain and nerve or inflammatory pain.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
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Chapter 6: Montefiore Residential and Community Services for Seniors
Source: Montefiore Residential and Community Services for Seniors. Used with permission.
Ancillary staff training sessions have been developed, with they participate in the pain management competencies. The
emphasis on what signs and symptoms should be reported to existing tool incorporates the basics of pain assessment,
the charge nurse or case manager. Montefiore has realized including location, intensity within a scale, quality, and other
that many of the pain management programs have been contributing factors. The tool is easily understood, and any
geared toward licensed practical nurse and RN audiences, layperson can use it. If a home care staff member identifies a
even though aide, dietary, therapy, and social work staff pain problem, an individualized pain care plan is developed
interact with residents regularly and may detect signs of pain and is updated regularly. Montefiore utilizes pain assessment
problems when the nurse is not present. Ancillary staff need guidelines (see Table 6-1 on page 122) in its everyday pain
to understand what symptoms they may need to report to a management practice.
nurse or physician.
The Montefiore organization realizes that pain comes in
Montefiore has emphasized the basics with staff to promote many forms. Each patient or resident is assessed for a baseline
consistent use and compliance across disciplines. Staff are level of pain upon admission. Residents are reassessed (hands
exposed to many different types of assessment tools when on) with any new onset of pain. The licensed practical nurse
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Inpatient staff assess patients for their levels of pain and their understanding of pain management. Appropriate interven-
tions are ordered on the basis of staff findings.
Source: Montefiore Residential and Community Services for Seniors. Used with permission.
and nursing assistant monitor residents each shift to detect workup, an addition to or a change in the patient’s current
any pain problems. Pain assessments are conducted and medications, and a physician or emergency room evaluation.
documented on the pain assessment tool and communicated
between caregivers. Caring for Persons with Pain
Montefiore understands that many barriers with residents
Unit-based housekeeping, activity, and dietary staff also and families impede the achievement of effective pain
provide continuity of care for residents. Including these staff control. Typically, health care workers are faced with residents
members in the pain management regimen allows for easy and families who display behaviors of stoicism, learned
and early detection of any discrepancies in resident behavior coping mechanisms with a “fight the pain” mentality, and an
that may or may not be related to a pain problem. Early overall lack of knowledge in the area of pain management.
detection and assessment result in timely follow-up. Additionally, many health care workers frequently lack the
necessary assessment skills and overall education on pain
For home care and hospice patients, pain is assessed with management practice. Regulatory agencies offer added
each nursing or therapy visit. A verbal and hands-on scrutiny in the area of pain medication prescriptions,
assessment is carried out on each visit, and pain assessment is resulting in physicians’ reluctance to write necessary
incorporated directly into the visit documentation notes. If prescriptions.
the pain is rated at 3 or greater, the plan of care is reassessed
with input from the patient, staff, family, and physician, Montefiore has observed that each of its residents or patients
followed by a reassessment within 24 hours. This process is perceives his or her pain differently, exhibits fluctuating
repeated on an ongoing basis to assure effectiveness of the tolerance levels, and has different cultural beliefs in the area
plan. Unresolved pain may result in further diagnostic of pain management. Although the clinical team at
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Chapter 6: Montefiore Residential and Community Services for Seniors
Montefiore can manage the majority of pain problems facing hospice philosophy and care strategies that are consistent
its resident population, it also understands that some with Jewish law is a challenge for even the most adept
residents may need more aggressive therapy regimens. If a clinician.
resident does not respond to conservative pain management
approaches, he or she is referred to outside experts. According to Jewish law, pain management is a delicate
Montefiore realizes that residents with chronic pain who do balance between controlling suffering and hastening death.
not receive appropriate assessment and treatment typically Although it is not permissible to commit acts to hasten
use more health services than others. death, it is permissible to ease the symptoms of the dying
process.4 However, due to the lack of education regarding
Community pain clinics manage a small number of hospice services and philosophy relative to Jewish law, the
Montefiore residents. The consultation information and Orthodox community looks to hospice services far too late
treatment plan developed by the pain clinic or outside within the disease trajectory, sometimes within just days or
experts is incorporated into the facility plan of care, and the hours of death.
primary physician follows it. If conservative or traditional
methods of pain control are ineffective, patients are referred To ensure that these patients understand the hospice and
to pain clinic specialists who have extensive backgrounds in palliative care program and can get care at the appropriate
the use of different combinations of medications and time, a full-time Orthodox rabbi who is expert in Jewish law
treatment modalities with which a typical health care and hospice philosophy is a member of the hospice and
professional may or may not be familiar. The clinics palliative care team. The rabbi works closely with hospice
incorporate high-tech approaches to achieve pain clinicians, attends weekly team meetings, and provides
management, including intraspinal or intrathecal medication guidance, interpretation, and solace to patients and their
injections, corticosteroid injections, and transcutaneous families concerning Jewish medical ethics and treatment
electrical nerve stimulation unit application. The nursing decisions. Because Montefiore provides this Jewish-centered
home staff are instructed on what to observe and what effect approach to hospice care, patients from the Orthodox
the treatment will have on the resident from all care aspects. community can consider using hospice services before
imminent death for symptom management and psychosocial
The World Health Organization (WHO)’s Pain Relief support.
Ladder3 is used as an integral part of Montefiore’s pain
practice. Similar to Montefiore’s pain assessment guidelines Holocaust survivors (from all levels of religious observance)
(see Table 6-1), the pain treatment protocols, as shown in also present unique concerns, because many have a deep
Table 6-2 on page 123, are kept very simple and are easy to distrust of systemic health care and medications—particularly
follow. those that could alter a person’s mental status. In addition,
their families tend to be profoundly protective of those
The hospice team consists of a collaboration of inpatient and individuals.
community-based staff members who are experts in the area
of pain and symptom control. Montefiore offers its patients “There needs to be a building of trust between the patient
alternatives to traditional pain treatments. A Russian and the clinical team to make the patient feel comfortable
interpreter, a layperson who translates for the non-Russian- with his or her plan of care,” Prosser says.
speaking staff members, visits the sites/homes to assist with
translation for Russian-speaking seniors. In the Russian culture, people are reluctant to discuss death
and hospice care, feeling that they should do whatever
Cultural and Religious Issues in Pain necessary to prolong life. In addition, it is important to
Management remain stoic, suffer through pain, and take minimal pain
A unique challenge of Montefiore’s hospice and palliative care medication. As a result, these patients tend to have many
program is the community that it serves. A large Orthodox tests and treatments late in the care process. The Russian-
community within the eastern suburbs of Cleveland remains speaking interpreters and clinical staff focus their efforts on
an untapped patient population for hospice and palliative educating patients on the pathophysiology and appropriate
care. Educating the Orthodox Jewish community of the treatment of their pain. Repeated education is given to ensure
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
This list shows the pain assessment guidelines Montefiore uses in its everyday pain management practice. (UTI, urinary tract
infection; DVT, deep vein thrombosis; ADL, activities of daily living)
Source: Montefiore Residential and Community Services for Seniors. Used with permission.
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Chapter 6: Montefiore Residential and Community Services for Seniors
Montefiore’s pain treatment guidelines are similar to the World Health Organization (WHO)’s pain ladder, a three-step guide
to the administration of analgesia and adjuvant medication for the treatment of pain (see Chapter 1, page 27).
Source: Montefiore Residential and Community Services for Seniors. Used with permission.
the patients of the safety and efficacy of pain medication use. meeting. Staff also receive a written pain management test as
Many forms have also been translated into Russian. a part of their clinical competencies. The staff development
department administers the test annually during the staff
“Sometimes, with all of these groups,” Korman adds, “we just competency evaluations. Newly hired hospice and home care
have to accept that we don’t have control. Patients and staff take the test at the beginning and at the end of their
families are in charge of their own lives, and while we can probation periods.
provide information and guidance, ultimately, they make the
decisions about their care.” Needs assessments help Montefiore administrators determine
the staff ’s educational needs regarding pain management. For
Educating Staff About Pain example, a recent needs assessment about pain control and
The pain management education process for staff, residents, end-of-life care found that some staff were uncomfortable
and physicians begins on admission for residents and in administering pain medications, particularly for those
orientation for staff. Physicians caring for the residents patients nearing the ends of their lives.
actively participate in care conferencing and review of pain
management treatment plans to promote the highest level of “Some staff had the same biases, the same religious and
comfort for the resident. The education process continues as cultural ideas that our patients have,” says Korman. “Others
an ongoing intervention throughout the resident’s stay. Staff were afraid of giving the patient the last dose before the
members and residents in all care settings, including the patient died, because they would feel as though they had
Weils of Bainbridge, understand early on that residents have ‘caused’ the death.”
a right to receive appropriate pain assessment and treatment.
Staff members receive ongoing education in all areas related Therefore, the organization launched an education program
to safe medication prescription and ordering procedures and focusing on those issues to help staff feel more connected to
pain assessment and treatment techniques. the process of providing care and more open to the idea of
contacting the palliative care and hospice teams.
Montefiore is a continuing education provider on the topic
of pain management. Education takes many forms, such as “We wanted everyone to feel free to express any fears or
lectures and handouts in orientation and during annual staff concerns,” Prosser explains. “They needed to know that it’s
competency evaluations and quarterly (or more frequent) in- okay to worry about these things and that they can call the
services by internal and outside lecturers. Hospice staff palliative care and hospice team to problem solve and put
discusses pain management of patients at a weekly team interventions in place.”
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Montefiore promotes an environment of open discussion and pain tolerance and which methods of pain management have
communication regarding all pain treatment plans and has worked best for the resident.
been able to achieve full physician collaboration in the area
of pain management. All the physicians on staff truly buy Social work and spiritual support are available for residents
into the importance of appropriate pain management. The and family members who may be experiencing complex pain
chief executive officer, medical director, and vice president of problems, cultural differences, or variances in outlook
nursing emphasize the importance of good pain management between the resident and a family member. Montefiore
practice. The medical director is the mentor to the other believes in whole-patient assessment, which applies directly to
physicians. The medical director intervenes with outside whole-pain assessment. Residents and families come to
physicians in all areas of pain management and supports the Montefiore with rich histories and beliefs. Pain is not just a
nursing staff. If education is needed, he intervenes verbally physical problem; it can be spiritual, practical, and
and provides copies of current literature. emotional. Staff at Montefiore deal with residents and
families who are in pain emotionally, and that pain worsens
Staff members have learned to use the pain assessment and their physical pain. Residents who are angry or anxious and
treatment guidelines as a part of routine patient and resident have unresolved feelings or fears on any topic experience pain
care. Management and professional staff understand that a at many different levels. In an effort to help residents and
key part of their roles is to help patients and residents achieve their families work through all their fears and anger, the
good pain control, in spite of the many barriers. Staff psychosocial team conducts support groups, provides
members have learned the difference between addiction, individual counseling, and teaches relaxation techniques. The
pseudoaddiction, tolerance, and dependence to opioids that psychosocial team can help the residents and families make
are commonly used for pain management. Staff also have the difficult transition from home to a facility, which can
become familiar with the side effects seniors may experience represent a monumental adjustment, especially for residents
when commonly prescribed anti-inflammatory medications struggling with basic communication or cultural differences.
are used for pain control. The psychosocial team can help in reinforcing the
importance of treatment plan compliance. Unresolved
Educating Residents and Families spiritual issues can be addressed among the resident, family,
About Pain and a clergy member. Addressing questions regarding life
Family involvement is key to a successful pain management review and quality of life can help residents achieve higher
program. Family members can be important providers of comfort levels.
information and assistance, so they are included in all
resident care conferences so they, too, may learn about pain Improving Organizational Performance
management practices. The multidisciplinary team approach Montefiore is committed to continually providing its
helps identify physical and emotional factors that may be residents and staff with the latest in pain management
affecting adequate pain management. The team understands information. It includes specific pain management issues
and utilizes a “whole patient or resident” assessment process, within its quality management and ethics program. The
with the understanding that psychological or spiritual pain nursing facility analyzes data included on the Minimum Data
can exacerbate physical pain and at times may be the only Set, with emphasis on residents who trigger elements J2 (pain
pain that exists. Dementia, speech and hearing difficulties, symptoms) and J3 (pain site), which can be indicators of
and hypersensitivity to side effects of medication often make chronic pain and are monitored for trends over time.
pain assessment difficult.
A performance initiative monitored within the nursing
Montefiore staff assist the family in understanding pain and facility pertained to the use of x-rays for complaints of pain.
its management, resulting in overall stress reduction. In the A three-month data collection revealed that most of the x-
case of memory-impaired, nonverbal, or cognitively impaired rays ordered resulted in diagnoses of chronic pain as opposed
residents, the family may be able to communicate with the to acute pathology. In response to this finding, the facility
resident more effectively about pain management. More reeducated the nursing staff in all areas of acute and chronic
importantly, the family can provide a history of the resident’s pain symptoms and pathology, and the use of x-rays has
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Chapter 6: Montefiore Residential and Community Services for Seniors
decreased, having been replaced with more appropriate organization has learned that a successful pain management
medical management for pain. campaign requires support from top leadership. Caregivers
have learned that patients, even those who are nonverbal,
Pain management quality indicators and important aspects of always communicate in some way that they are experiencing
care are monitored each month within the home care and pain, so Montefiore staff does not ignore any possible signs of
hospice quality program. Pain levels for home care and potential pain problems with residents. Psychological and
hospice patients must be maintained at a rating of 3 or below spiritual pain problems do not go undetected or untreated,
on a scale of 0 to 10 within 48 hours of admission to the either, because they are as important as physical pain
program. A patient who rates pain at 3 or greater on syndromes. Montefiore and its management team are grateful
admission receives a follow-up visit or telephone call within to accreditation and regulatory organizations that have
24 hours of the admission visit, with reassessment of pain “stepped up to the plate” to support best pain management
and possible treatment plan changes. If 100% compliance is practices and overall improvements in quality of life.
not achieved for this pain management indicator,
management staff are required to document an action plan
with reasons for noncompliance.
nline extras
Conclusions Behavioral health organizations face unique challenges in their
Montefiore’s commitment to providing the highest level of efforts to assess and manage pain for those under their care. Find
pain management across its care continuum has become part out how one organization in New York state met these challenges by
of its daily practice. Montefiore has successfully implemented establishing a program of pain assessment, staff and client
pain assessment as the fifth vital sign; however, ongoing education, and advocacy on behalf of its patients. Review its story in
education and reevaluation of all pain management practice the Online Extras at http://www.jcrinc.com/APM10/Extras/.
areas is an essential part of its operational success. The
References
1. Catananti C., Gambassi G.: Pain assessment in the elderly. Surg Oncol 19:140–148, Sep. 2010. Epub Dec. 16, 2009.
2. Barkin R.L., Barkin S.J., Barkin D.S.: Perception, assessment, treatment, and management of pain in the elderly. Clin Geriatr Med 21:465–490,
Aug. 2005.
3. World Health Organization (WHO): WHO’s Pain Ladder. http://www.who.int/cancer/palliative/painladder/en (accessed Aug. 5, 2010.)
4. Dorff E.N.: End-of-life: Jewish perspectives. Lancet 366:862–865, Sep. 2005.
125
Chapter 7
The Stone Center of
New Jersey
127
Chapter 7
The mission of the Stone Center is to do the following: Obtaining Medical Staff and Budgetary Support
• Provide accessible, high-quality, cost-effective urological The entire staff strongly embraced the pain management
services in a clean, safe, and comfortable atmosphere. initiative. The medical staff were well versed in Joint
• Promote individualized care for all patients as well as a Commission standards, including the pain assessment and
feeling of cohesiveness among staff. management standards, because of the organization’s
affiliation with Joint Commission–accredited hospitals.
Organizational Commitment
Prior to the introduction of The Joint Commission’s pain Administrative leaders, the medical director, Medical
assessment and management standards in 2000, pain Advisory Council members, and the Board of Governors all
management at the Stone Center focused primarily on supported the pain management initiative, as reflected in the
postprocedure pain related to the patients’ kidney stones. approved budgetary items outlined in Table 7-2 on page 130.
After the standards were published, the leaders at the center
realized that they needed to take a more comprehensive Policy Revisions
approach to pain assessment and management. As an example of policy revisions made after the Pain
Management Program was implemented, a statement about
129
Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
The Stone Center of New Jersey, LLC, is a health care facility dedicated to promoting and providing optimal care to
patients with pain, whose philosophy is to improve the quality of care for patients who are in pain through patient
education and professional collaboration. Pain can be a common part of your experience: Unrelieved pain has adverse
physical and psychological effects. All patients’ rights to pain management are respected and supported.
• Develop and produce a pain brochure and pain algorithm; designate existing staff to do this.
• Create a pain management presentation for staff and for staff orientation.
• Create a pain assessment scale.
• Make the necessary revisions in the medical records to support documentation of the pain assessment (e.g., changes to the
nursing flowchart form and discharge instructions).
• Revise existing policies to include pain and reflect Joint Commission standards.
• Purchase relaxation tapes.
• Make further revisions after the pain management program is initiated.
patients’ rights and responsibilities regarding pain was added requirements that apply across all programs, including
to the Stone Center’s policy on the rights and responsibilities ambulatory care organizations.)
of patients. It now includes the following statement:
Staff follow established procedures when assessing patients for
The patient has the right to appropriate assessment and pain. Perioperative nurses perform initial assessments and
management of pain. The patient has the right to expect reassessments. The attending anesthesiologist assesses patients
that his/her report(s) of pain will be believed and [that for pain preprocedure, postprocedure, during recovery, and at
he or she] will receive effective pain management. the time of discharge. Additionally, the urologist performs a
pain assessment prior to treatment, during treatment, and
Also, pain assessment was incorporated into the preprocedure after treatment.
telephone call. During the call, which is made three to four
days before the procedure, the perioperative nurse performs a To effectively manage pain, determine the degree of pain
pain assessment using a numerical pain scale. The patient is relief, and direct subsequent pain management, a pain-rating
asked to rate his or her pain on a scale of 0 to 10, with 0 scale is used. The center adapted three of the most widely
being no pain and 10 being the worst pain imaginable. used pain-rating tools in the United States for its own use, as
Appropriate follow-up is performed for complaints of pain. follows:
• Numerical rating scales, which require patients to rate their
Assessing Persons with Pain pain between 0 and 10
The Stone Center plans, supports, and coordinates activities • A simple descriptor scale that lists descriptions of pain
and resources to ensure that all patients’ pain is recognized intensity, such as “no pain,” “moderate pain,” and “severe
and addressed appropriately. This entails initial assessment pain”
and reassessments of pain at regular intervals, as per Joint • A faces-style rating scale, which was developed for the
Commission standards. (See Chapter 2, “Compliance with pediatric population and depicts graphics of facial
Joint Commission and JCI Standards,” for a discussion of the expressions representing various pain intensities
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Chapter 7: The Stone Center of New Jersey
Recognizing Pain
Understanding that pain is perceived differently by all
patients is an important element in the Stone Center's
approach to patient care.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Caring for Persons with Pain evaluate a patient’s status in the recovery period. The criteria
The Stone Center staff maintain that an aggressive approach include activity, respiration, circulation, consciousness,
to pain assessment and management can reduce pain, oxygenation, treatment site, ambulation, feeding, urine output,
increase patient comfort and satisfaction, and improve and pain. Each criterion is scored between 0 and 2. A score of >
patient outcomes. Staff stress that the Pain Management 18 is required at the center for discharge.
Program is not just about assigning a rating to a pain score
but rather about developing a pain management plan with The Joint Commission Team also created a pain algorithm, as
each patient. depicted in Figure 7-2 on page 133, for the perioperative
nurse to follow for patients who experience pain in the
A perioperative nurse performs the following steps as part of recovery period.
all patients’ pain management plans:
• Uses the pain assessment scale to assess the level of pain Most patients who receive lithotripsy remain free from
• Determines the location and duration of pain complications in the postprocedure period, although pain
• Ensures that the patient had pain medication at home and does occasionally occur. The pain can be related to the
was taking it as prescribed crushing of the kidney stone and particles of stone moving,
• Offers the patient an opportunity to come earlier to the soft tissue injury at the entry site of the shockwave, a ureteral
center to obtain more intensive pain management or stent that is not properly aligned, or bleeding around the
ensures that the patient is obtaining adequate relief from kidney.
prescribed medication
• Communicates the patient’s score to the anesthesiologist When a patient reports pain, a thorough assessment is
and urologist when the patient is at the center completed to determine the source of the pain. The pain is
• Continues to assess pain using the pain scale and follows commonly related to stone fragmentation and/or stone
the pain algorithm during recovery movement or stent migration. If either of these is the pain
• Reassesses pain at discharge source, the nurse follows the aforementioned pain algorithm.
• Reassesses pain during the postprocedure phone call The patient is given pain medication along with fluids and
positioning comfort measures. The patient is assessed
Treating Persons with Pain periodically to determine if he or she has any pain relief. If
Nurses at the center know that patients have their own the patient experiences pain relief, he or she is then
unique experiences of pain and that their descriptions of pain discharged. If the patient does not have relief, he or she
are the most reliable indicators for determining the presence receives more pain medication or a different type of pain
of pain. Patients who say that they have pain are offered pain medication and continues to be monitored and reassessed. If
medication, music therapy, and/or relaxation techniques. the patient’s pain worsens or is not relieved, he or she will be
transferred to the hospital for further pain assessment and
Specifically, if a patient complains of pain during the management.
preprocedure call, the perioperative nurse conducts
appropriate follow-up, such as the following: If the stone has fragmented and is moving, the nurse
• Encouraging the patient to take pain medication encourages fluid intake to flush the particles of stone out
• Having the patient (or a staff member) call the urologist if through the urinary tract as well as percussion of the affected
the patient does not experience pain relief kidney. Positioning can help eliminate stone particles. In
• Consulting with the anesthesiologist addition, pain medication helps alleviate the discomfort.
• Having the patient come earlier for his or her procedure to
provide pain management techniques The nurse assesses the area on the body where the entry of
• Rescheduling the patient’s appointment for an earlier date the shockwave occurred, especially when the patient
complains of soreness in the back or flank area. The patient’s
Once at the center, the patient’s pain is continuously evaluated skin is assessed, because this treatment typically causes
using the pain scale and the Aldrete Scoring System, the latter blotches, redness, or even a bruise mark where the shockwave
of which assigns a predetermined score to objective criteria to repeatedly hits or enters the skin. This process causes
minimal discomfort; usually an over-the-counter pain
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Chapter 7: The Stone Center of New Jersey
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
prescribed pain medication, what regimen is being followed, “not to be superheroes and wait out the pain.” This message
and if the patient has obtained any pain relief. The nurse is relayed during the preprocedure call, during discharge
then notifies the doctor. instructions, in recovery, and then again during the
postprocedure call.
The urologist also schedules a follow-up office visit with the
patient one to two weeks after the treatment to check the Pain management information also is shared with the
patient’s progress and to discuss whether the patient’s level of patient’s family or other caregivers. The center incorporates
pain has improved. family members and/or others close to the patient into the
day’s activities by requiring that an adult accompany the
Educating Persons with Pain patient to and from the procedure. These friends or family
Patient education begins with the first patient contact. members also listen to instructions the patient receives and
During the preprocedure phone call, the perioperative nurse are present when the nurse tells the patient about the center’s
discusses what type of pain can be expected from kidney commitment to pain management.
stones and possible postprocedure pain. For example, the
nurse tells the patient that flank, groin, and lower abdominal Because approximately 25% of the center’s patient
pain are common with kidney stones on the affected side. In population is Hispanic, the center provides all patient
addition, pain can occur when the stone is moving down the information, including brochures, pain scales, and discharge
ureter, and, with this movement, spasms and cramping may instructions, in Spanish. For individuals who cannot speak
occur. If the doctor inserts a stent to allow for easier passage English, the center has Spanish-speaking staff to translate.
of the stone, this procedure may feel uncomfortable at first
until the body adjusts to it. The stent may cause spasms in Educating Staff About Pain
the ureter. Pain management techniques also are discussed at Staff receive ongoing education regarding pain assessment
this time. and management. A pain management presentation is given
each year as a staff in-service. The pain in-service is followed
Upon arriving at the Stone Center, patients are given copies by a posttest that attendees are required to pass. The
of Pain Management Techniques for Patients, a brochure presentation also is used as a competency assessment for the
created by center staff. They also are given copies of the clinical staff. The annual competency assessments performed
Patients’ Rights and Responsibilities. In 2010, the patient for all staff include the domain of pain. In addition, this
brochure was uploaded to the center’s Web site, enabling presentation has been incorporated into orientation for all
patients to access it prior to arriving at the center. The new medical, anesthesia, and nursing staff members. In 2010,
perioperative nurse reviews the discussion about the type of the pain in-service was uploaded to the center’s Intranet site
pain that can be expected following the procedure and so the clinical and medical staff can access it online. This
treatment options. half-hour lecture, as outlined in Figure 7-3 on page 135,
keeps staff up to date on pain management issues.
Discharge instructions also teach patients about pain
management. They include a pain assessment scale, a list of When the 2009 Joint Commission pain management
pain medications to take, what to expect after the procedure, standards began requiring orientation for licensed
and how to address pain after discharge. independent practitioners (LIPs), the Stone Center’s Joint
Commission Team developed an orientation specific to LIPs.
Because some patients do not take their prescribed pain It consists of a slide show and packet. In addition, this
medications or do not take them correctly, educating patients orientation packet has become part of the credentialing and
about the importance of taking prescribed medications and reapplication process for LIPs.
not waiting until the pain is overwhelming is critical to
effectively managing their pain. Consequently, the Finally, the clinical staff routinely circulate articles on pain
perioperative nurse must convey that if the pain medication topics in current journals. To ensure that staff members read
is not taken with the onset of pain, it will be ineffective once these articles, they must sign a sheet indicating that they
the pain becomes intense. The nurses encourage the patients have.
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This pain assessment presentation, represented here in part, is used as an in-service, at staff orientation, and as a
competency program for employees.
* These are not The Joint Commission’s verbatim standards for ambulatory organizations but are the Stone Center’s interpretation for their internal
presentation. Please refer to the most recent edition of the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) for the specific
requirements.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
When changes are made to pain management processes as a However, the Stone Center’s overall performance
result of quality assurance (QA) audits, staff are educated improvement efforts focus on its monthly QA studies and
about them through several venues: competency assessments, annual pain studies. Both of these studies are used to evaluate
staff meetings, and e-mail. Reminders of the newly the appropriateness of the center’s pain management
implemented processes are posted in the staff lounge, techniques and to identify when improvements in policy and
procedure rooms, newsletters, and e-mails. procedure can be made.
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Medical record audits conducted between 2007 and 2009 show that nurses are 100% compliant with documenting pain
scale ratings.
patients the type of pain previous patients experienced after administration of pain medication. This information was
the procedure. shared with the medical staff, the medical director, the
Medical Advisory Council, and the Board of Governors, the
Tracked Annually latter of which approved the recommendations.
The data from the monthly medical record audits are trended
on an annual basis and disseminated in the form of a yearly The Joint Commission Team continued to monitor patient
pain study. complaints of pain during recovery while obtaining more
specific information, such as how many patients experienced
One of the first pain studies revealed an increase in the pain, how patients rated their pain, and how many patients
number of patient complaints of pain during recovery. The received pain medication. The team noted that the rise in
QA Committee made recommendations to increase the complaints occurred after the installation of a new lithotripsy
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
machine. Although the new machine targeted kidney stones In 2009, 21% of patients experienced mild to moderate pain,
more effectively and efficaciously, it also resulted in patients’ whereas 5% experienced moderate to severe pain in the
experiencing more pain because of how much more powerful recovery room following the procedure, as depicted in Figure
it was than the previous machine. 7-5, page 139. These figures fall significantly below the
threshold the center uses of “less than 40% of patients
In addition, the team conducted a literature search on pain complain of pain in the recovery room.” This is an internal
management medications to ensure that the most appropriate threshold the center established due to a lack of national
pain medications were being administered. benchmarks.
The team analyzed the data collected on pain complaints as Additionally, 8% of patients experienced mild to moderate
well as the information on pain medications and presented all pain, and 2% experienced moderate to severe pain 48 hours
of it to the QA Committee for evaluation. The team’s postprocedure, as depicted in Figure 7-6 on page 139. These
proposed revisions to the center’s policy and procedure were figures fall significantly below the threshold the center uses of
approved and subsequently implemented. “less than 32% of patients complain of pain in the recovery
room.”
As a result, the nursing staff and the anesthesiologists
perform more intense follow-up. For example, patients’ The QA Committee is considering lowering both thresholds
complaints of pain are continually monitored. The nurses to be consistent with what is occurring in the patient
complete daily audit forms for any patient who indicates the population.
presence of pain before, during, or after the procedure. The
nurses also indicate what steps were taken to alleviate the Conclusion
pain. Today, the Stone Center’s Joint Commission Team and the QA
Committee continue to play lead roles in monitoring the
The center’s policy now calls for the following medications to center’s pain management efforts. The committee consists of
be used: the directors of Special Projects, Clinical Operations, and
• Morphine: 1 to 2 mg intravenously for severe pain Quality Assurance and Research, as well as the Board chair, the
• Fentanyl: 50 mcg intravenously times two doses every 10 director of Anesthesia, and the chief of Radiology, working
minutes as needed for moderate to severe pain closely with the center’s chief operating officer. In 2009, when
• Oxycodone with paracetamol/acetaminophen: 5/325 mg The Joint Commission revised its pain management standards
orally is prescribed for mild to moderate pain. This dose for ambulatory care settings, the center’s Joint Commission
may be repeated if pain is not relieved. Team reviewed the updated standards and revised the center’s
policies and procedures accordingly.
In addition, the center no longer administers meperidine to
patients for complaints of pain in the recovery phase. A Through its statement of purpose, the Stone Center's Pain
literature search revealed several studies demonstrating that Management Program resolves to do the following:
the analgesic effects of meperidine are not pronounced and • Introduce the topic of pain at the time of initial patient
that unique side effects complicate its use. Consequently, contact.
meperidine was replaced with more efficacious and less toxic • Reduce the incidence and severity of patients’ acute
opioid analgesics. postprocedure pain.
• Educate patients about the need to communicate
Data collected about patient complaints of pain postprocedure unrelieved pain so they can receive prompt evaluation and
between 2002 and 2009 demonstrate that the percentage of effective treatment.
patients complaining about pain has steadily decreased. • Enhance patient comfort and satisfaction.
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The pain studies track patient complaints of pain following the procedure in the recovery room.
The pain studies track patient complaints of pain following the procedure within 48 hours.
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Reference
1. Allred K.D., Byers J.F., Sole M.L.: The effect of music on postoperative pain and anxiety. Pain Manag Nurs 11:15–25, Mar. 2010.
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Chapter 8
Wattanosoth Hospital/
Bangkok Cancer Hospital
141
Chapter 8
Wattanosoth Hospital/
Bangkok Cancer Hospital
A cancer diagnosis is the beginning of an emotionally and physically painful journey for patients and families.
However, treating the physical pain can ease the mental stress, and providing emotional and spiritual support can
make the physical pain more tolerable. Knowing this, caregivers at Wattanosoth Hospital/Bangkok Cancer Hospital
sought to create a program that treated the whole patient, helping him or her to manage his or her pain through a
combination of traditional medicine, complementary therapies, and mood elevation and moral support. The result is a
program that addresses medical and emotional needs for inpatients and outpatients. Patients not only feel less pain,
they feel that their caregivers are listening to them and answering their concerns, and they feel empowered to make
their own pain management decisions.
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
2005 received accreditation from Joint Commission • A variety of magazines and books in a variety of languages as
International. It became the first hospital in Egypt and well as puzzles, such as crosswords or Sudoku. A selection of
Africa to do so. Buddhist, spiritual, and inspirational books is also available.
• A particular brand of sour hard candy, a Thai specialty
Palliative Care Service treat that offers a blend of sweet, sour, and salty flavors to
Most cancer patients suffer from pain, so the palliative care help reduce nausea and vomiting (not offered to patients
department plays an important role in treatment. The with diabetes or kidney problems)
department includes traditional pain management therapies
along with complementary medicine, as well as programs Aromatherapy
designed to educate patients and families about their Aromatherapy is the treatment or prevention of disease by the
treatments so they may take control of their health care. use of essential oils. Two basic mechanisms are offered to
explain the purported effects. “One is the influence of aroma
The Pain Management Program includes the following: on the brain, especially the limbic system through the
• Acute and chronic pain assessment of symptoms olfactory system,” Maripolsky explains. “The other is the
• Patient-controlled analgesia consultation direct pharmacological effects of the essential oils. Because
• Medication and adjuvants many essential oils are potent antimicrobials, they can be
• Pharmacy consultation useful in the treatment of infectious disease.”
• Symptom management
• Nutrition management The modes of application of aromatherapy include the
• End-of-life care following:
• Aerial diffusion: For environmental fragrance or aerial
Additionally, says Virginia Maripolsky, assistant chief disinfection
executive officer, Nursing Affairs, for Wattanosoth • Direct inhalation: For respiratory disinfection,
Hospital/Bangkok Cancer Hospital, the pain management decongestion, and expectoration as well as psychological
program includes nonpharmacological established therapies, effects
such as acupuncture, exercise, and massage, as well as the • Topical applications: For general massage, baths,
following newer strategies that have given patients positive compresses, and therapeutic skin care
results in pain management.
Following are the benefits that aromatherapy is believed to
produce:
nline extras • Aromatherapy massage helps increase basal metabolic rate;
A short overview of another non–U.S. hospital offering a range of
induce relaxation; increase excretion of toxic products;
both pharmacologic and nonpharmacologic treatments is available
increase circulation and lymphatic drainage; reduce anxiety,
in the Online Extras at http://www.jcrinc.com/APM10/Extras/.
stress, and pain; and increase skin integrity.
• Inhalation helps respiratory problems, promotes expulsion
of secretions from respiratory infections, reduces stress and
Distraction anxiety, and promotes a good feeling.
Palliative care providers have found that distraction, or taking • Aromatherapy baths help promote relaxation, reduce stress
a patient’s mind off the pain, can be very helpful, particularly and anxiety, reduce heat and inflammation, increase
while the patient is undergoing chemotherapy. Some of the circulation and lymphatic system, and reduce pain and
distractions provided include the following: inflammation.
• Craft kits for patients to work on while they receive • Topical application reduces fluid and serum; reduces heat,
chemotherapy; they may continue the crafts during their pain, and stress; and promotes relaxation.
next scheduled visits. Nurses are trained to teach the crafts. • Sitz baths and soaking help infections of the urinary and
Most popular are crystal embroidery beads that make key genital area.
chains, toy animals, and other small items. • Creams promote healing, act as lubricants, and maintain
• Individual televisions and headsets for each patient humidity.
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Chapter 8: Wattanosoth Hospital/Bangkok Cancer Hospital
• The diffusion of essential oils is used for longer duration to bundle to the patient when the cancer diagnosis was made.
reduce pain and promote relaxation. The materials were meant to fully prepare the patient for all
possible experiences in the months to come; the goal was for
Therapeutic Music a better educated and well-prepared patient, but this goal was
The use of music as therapy is an interpersonal process in not the outcome of these well-intentioned efforts.
which music is used in all its facets—physical, emotional,
mental, social, aesthetic, and spiritual—to help patients “Patient feedback both verbally and through the written
improve or maintain their health. Music primarily helps patient perception survey indicated that a bundle of
patients improve their observable level of functioning and education material on the day of diagnosis was too
self-reported quality of life in various domains (e.g., cognitive overwhelming in light of everything else the patient was
functioning, motor skills, emotional and affective processing,” Maripolsky says. “The material would be quickly
development, behavior and social skills) by using a variety of laid aside for another day and eventually lost in the stressful
music experiences. It is considered one of the expressive routine of a cancer patient.”
therapies, and it is grounded in the belief that everyone can
respond to music, no matter how ill or disabled. The unique At the monthly Cancer Pathway meeting, the
qualities of music as therapy can enhance communication, multidisciplinary team discussed methods to improve the
support change, and enable people to live more resourcefully timing of the delivery of educational material, and JITE was
and creatively. born. All patient instruction materials are now available
through the hospitalwide e-Document system; all staff can
Although many countries, such as Great Britain and the access these materials, which BMC leadership have been
United States, have university-based programs for music approved. In addition, the team has closely aligned the
therapists, the profession is not yet developed in Thailand. receipt of educational materials to correspond to the timing
However, caregivers at Wattanosoth chose to incorporate this of the care and treatment.
therapy to help promote health and quality of life for their
patients. The Breast Center at Wattanosoth had the most developed
educational materials and served as the role model for other
Benefits of therapeutic music include the following: cancer departments to improve the quality and quantity of
• Distraction from uncomfortable treatments patient instruction. The breast care coordinator and
• Decrease in depression, improved mood, and a reduction education project manager gathered, organized, and
in the state of anxiety formatted educational materials with the cooperation of the
• Increased relaxation and decreased stress multidisciplinary team, which included the following
• Possible improved perception, memory, and learning members:
• Supported spirituality, empowering the will to fight the • Medical director of the Breast Center
disease • Nurse manager
• Stimulated body movement • Nutritionist
• Nurse educator, cancer
Education and Support • Chemotherapy nurses
“Another important part of the palliative care program is • Chemotherapy pharmacist
education of the patient and family as well as support to ease • Radiologists
stress during this difficult time,” Maripolsky says. • Radiopharmacist
• Radiology technicians
Following are some of the programs designed to help in these • Physical therapy
areas. • Surgeons and anesthesiologists
Just in Time Education The complete educational package includes the following
Before the Just in Time Education (JITE) program, the seven sections:
patient and family instruction materials were given as a 1. Introduction to Breast Cancer
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
2. Patient and Family Preparation for the Pre- and discharged to outpatient care, so staff members conducted a
Postsurgical Phase gap fit analysis. They discovered the following:
a. Pathway categories • Few community resources for cancer have been developed
i. Assessment in Thailand.
ii. Investigation • Physicians are still adjusting to outpatient pain
iii. Medication management.
iv. Patient/family education • Few books in Thai bookstores feature the topics of pain or
v. Discharge planning cancer.
vi. Expected outcomes • Thai culture does not encourage complaining to an
b. If the patient is in the breast cancer conserving therapy authority held in high esteem, such as a physician, high
pathway, she is given an additional booklet detailing government official, or Buddhist monk.
the activities of each day pre- and postop.
c. A section on activities of the health care staff and More-developed countries feature networks of support groups
activities of the patient where members provide each other with various types of
3. Essentials of Chemotherapy help, usually nonprofessional and nonmaterial, for a
4. Oncology Imaging particular shared, usually burdensome, characteristic. The
a. Nuclear medicine help may take the form of providing and evaluating relevant
b. Bone scan information, relating personal experiences, listening to and
c. PET scan accepting others’ experiences, providing sympathetic
5. Radiotherapy understanding, and establishing social networks. A self-help
a. Simulator support group is fully organized and managed by its
b. Linear accelerator members, who are commonly volunteers and have personal
6. Palliative Medicine—Your Options experience in the subject of the group’s focus. Few self-help
7. Hormonal Therapy groups exist in Thailand, and the quality of these meetings
has not been established.
The packet also includes two video CDs on how to perform
breast self-examinations and stretching exercises after surgery Therefore, the team chose to develop a free support group
as well as a handbook on cancer nutrition. Figure 8-1 on that would be facilitated by professionals who do not share
pages 147–149 shows some of the materials provided. the problem of the members but are involved in the care and
treatment of cancer patients. The facilitator would organize
Patients have indicated their satisfaction with JITE, which the meeting, control the discussions, and provide other
gives them the knowledge and materials to understand and administrative services.
be involved in the decision-making process in a timely
fashion. The information is fresh in their minds, allowing The result was the Think Positive Club, which offers all
them the time to form questions for their physicians. With cancer patients a monthly link to the staff and is focused on
the increase in international patients, the material has been topics that increase knowledge on pain management and
translated into English, with Arabic and Japanese to follow. provide alternatives easily accomplished in the home setting.
Figure 8-2 on page 150 shows the improvement in patient All patients who are in active treatment are informed of this
perception scores after the changes were implemented. monthly meeting.
The Think Positive Club “Many cancer patients have difficulty adapting to their new
As more and more care is relegated to the outpatient compromised circumstances and giving up their previous
oncology clinics and ambulatory chemotherapy, cancer pain active lifestyle,” Maripolsky says. “The group provides
management becomes more of a challenge. How can the staff distraction, helps patients develop an attitude of thinking
anticipate the pain management needs of a targeted yet positive, and above all, offers sanuk, the cherished Thai
diverse population of cancer patients in outpatient treatment? concept of having fun. Many staff are involved at each
It is important to continue the relationship with the inpatient meeting, developing rapport with patients and enjoying
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Chapter 8: Wattanosoth Hospital/Bangkok Cancer Hospital
This is an example of the JITE materials provided to English-speaking breast cancer patients. This includes pre- and post-
operative instructions. (CA, cancer; DM, diabetes mellitus; HT, hypertension; p.r.n., as needed)
(continued)
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
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Chapter 8: Wattanosoth Hospital/Bangkok Cancer Hospital
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Figure 8-2. Patient Satisfaction Scores Before and After Just in Time Education
This bar graph shows the changes in patient perception scores (the higher the score, the better) during the first three
months of 2010 once the distribution of educational materials was realigned to correspond to the timing of care and
treatment. (SE, side effects; D/C, discharge)
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Chapter 8: Wattanosoth Hospital/Bangkok Cancer Hospital
Every day of the year, approximately 40% of BMC patients Foot Reflexology During Chemotherapy
are foreigners—expatriates and fly-ins. Therefore, the facility Therapeutic massage has a long history in Thailand, with the
has other religious accommodations as well. Very near the techniques having passed largely unchanged down the
intensive care units are a Muslim praying room, a Buddhist centuries. Knowledge of massage in Thailand has been
praying room, and a separate, quiet devotional room. handed down by word of mouth across the generations.
Customer service personnel are prepared to respond to any Because of this tradition, Thai patients tend to be quite open
religious, devotional, or cultural requests with connections to the idea of massage and other touch therapies.
and resources in the community. In times of need, stress, and
crisis, responding to spiritual needs may be as effective and Foot reflexology is a simple, noninvasive method to help
consoling as any pain management intervention. balance the body. It is the physical act of applying pressure to
the feet and hand with specific thumb, finger, and hand
For another view of spiritual concerns and pain care, see techniques with or without the use of oil or lotion. It is based
“Cultural and Religious Issues in Pain Management” in on a system of zones and reflex areas that reflect an image of
Chapter 6. the body on the feet and hands, with a premise that such
work effects a physical change to the body.
More Recent Initiatives
Two newer programs added to the palliative care program The oncology physicians, the multidisciplinary team, and the
include healthy cooking and foot reflexology. hospital leadership support this new program. The hospital is
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
Since the implementation of the palliative care program, patient satisfaction scores rose nearly every month in 2009
when compared to the same months in 2008. (The higher the score, the better.)
in the process of writing policies and securing staff with the Patient Satisfaction
proper training. Thai massage is also being considered for Since the palliative care program was begun in 2007, patient
cancer inpatients. Both of these relaxing approaches are quite satisfaction scores have risen nearly every month, as compared
popular throughout Thailand. with the same month in the previous year. Figure 8-3, above,
shows the scores for 2008–2009.
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Chapter 8: Wattanosoth Hospital/Bangkok Cancer Hospital
References
1. Boon H.S., Olatunde F., Zick S.M.: Trends in complementary/alternative medicine use by breast cancer survivors: Comparing survey data from
1998 and 2005. BMC Womens Health 7:4, Mar. 2007.
2. Yates J.S., et al.: Prevalence of complementary and alternative medicine use in cancer patients during treatment. Support Care Cancer
13:806–811, Oct. 2005.
3. AARP, National Center for Complementary and Alternative Medicine: Complementary and Alternative Medicine: What People 50 and Older Are
Using and Discussing with Their Physicians. 2007. http://www.aarp.org/health/alternative-medicine/info-2007/cam_2007.html (accessed Aug. 6,
2010).
153
Index
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
G N
Geriatric patients. See elderly/geriatric patients. National Coordinating Center for Health Technology Assessment, 12
National Guideline Clearinghouse, The, 12
H Neuropathic pain, 4, 26, 63, 66, 89, 133
HIV, 4, 12, 16, 25 Nocieptive pain, 3, 4
Holistic remedies. See nonpharmacological methods. Nonpharmacologic treatments, 15, 27–28, 144–145
Hospice setting, 36–37, 113–115, 120–121, 123 drawbacks vs. opioids, 28
deemed status, 36 Nonverbal patient assessment tool
Wong-Baker FACES pain rating scale, 21f, 73
I NSAIDs, 25, 26, 73
ICU patients, 3, 23 Nursing education specialists, 45
Improving organizational performance, 58, 78, 106, 124, 136
quality assurance (QA) audits, 78–83, 136–138 O
time line of pain reassessment improvement activities, 99f Online Extras, 9, 10, 13, 67, 91, 125, 131, 144
Injuries, musculoskeletal, 4, 12, 16, 18 Opioid treatments, 6, 8, 23, 25–27. See also pharmacologic
Institutionalizing pain management, 39–40 treatments.
Interdisciplinary therapies, 28 addiction vs. physical dependence, 6
Interventional treatments, 73, 77. See also nonopharmacologic laws and regulations, 8
treatments. side effects, 26
156
Index
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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition
U
Undertreatment consequences, 5, 113
University of Wisconsin Hospital and Clinics (UWHC), 87–109
action plan development and implementation, 88
goal-directed health care, 89
Joint Commission standards, 95
meperidine use, 91, 92f–95f, 106
patient assessment, 89–90
patient care, 90–102
patient education, 103,106
performance improvement, 106–109
staff education, 102–103, 104–105
Users’ Guides to the Medical Literature, 13s
W
Wattanosoth Hospital/Bangkok Cancer Hospital, 143–153
complementary medicines/therapies, 143, 144
palliative care, 144–145, 151–152
patient/family education, 145–151
Wong-Baker FACES Pain Rating Scale, 9, 16, 17s, 21f, 23, 24, 53,
54f, 73, 74, 75, 136
World Health Organization’s (WHO’s) Pain Relief Ladder, 26, 27f,
67, 121, 123t
158