Pain Management

Pain Management | Clinicians at University of Colorado Hospital are launching an initiative targeting one of the most pervasive yet elusive challenges of patient care: assessing, treating and controlling pain.

The challenge isn’t new, but it has an added urgency at UCH, which in fiscal year 2013 (which began July 1, 2012 and ends June 30, 2013) added inpatient pain management as one of the “critical success factors” it deems essential to becoming a top ten academic medical center.

To evaluate its performance, the hospital uses the federal Centers for Medicare and Medicaid Services HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, which asks patients how often their pain was well controlled and how often hospital staff did “everything they could” to help control pain. Through Dec. 31, 2012, 72.3 percent of UCH inpatients surveyed answered “always” to the questions, short of the organizational goal of 74.3 percent.

To get a clearer picture of patients’ pain experience and what staff did to manage it, a team of nurses led by the Pain and Evidence- Based Practice Champions committees plans to implement a quality improvement project that includes administering a detailed questionnaire based on one developed by researchers at the University of Pennsylvania Hospital and the University of Wisconsin Hospital and Clinics. It was published as the American Pain Society Patient Outcome Questionnaire for Quality Improvement of Pain Management in Hospitalized Adults.

The team is awaiting Institutional Review Board approval to administer the survey at UCH. That could happen as early as this month.

The survey questions focus on patients’ experience of pain in the first 24 hours following admission and surgery. The questionnaire items measure five main areas:

  • Pain severity and relief
  • The impact of pain on activity, sleep, mood and emotions
  • Medication side effects
  • Information provided about pain treatment options
  • Ability to participate in decisions about pain treatment

A sixth area asks patients whether they were offered “non-medicine methods” to relieve pain, such as meditation, walking, relaxation, deep breathing, or massage, and if so, how often.

The team will gather baseline data from the questionnaires, ask units to develop approaches to pain management, then re-administer the questionnaires and compare the data to measure results.

“We want to know if staff did everything possible to manage patients’ pain,” said Regina Fink, RN, PhD, a research nurse scientist who will help team members analyze the data collected from the questionnaire. Fink developed her own Pain Assessment Guide in the mid-1990s to help providers solicit information from patients about how their pain feels, as well as its duration, location, intensity, effects and what alleviates or aggravates it.

“It’s important that we call attention to [managing] pain. Good pain control shows patients that we care,” Fink said.

The team hopes that data from the questionnaire will increase understanding of how pain affects outcomes, including functional status – mobility and sleep, for example – and complications, such as pneumonia, said Fink.

It’s in a hospital’s interest to control a patient’s pain, said Robert Montgomery, RN, ND, CNS, an advanced practice nurse in anesthesiology who is involved in the pain management initiative. Montgomery is clinical coordinator of the Acute Pain Service at UCH, a specialty consult program that helps providers manage patients with complex post-surgical and chronic pain issues.

In addition to improving patient satisfaction, Montgomery says controlling pain allows patients to recover at a normal rate. “That helps the hospital to discharge them earlier, which decreases costs and the overall health care burden,” he said.

The questionnaire, Montgomery added, could help nurses and other providers get a better idea of how to manage pain for various procedures and in different clinical settings.

“We can start to drill down on the data to find improvements for different populations of patients,” he said.

But pain is notoriously difficult to quantify, and that makes managing it a challenge. The gold standard for assessment is still self-reporting, said Barbara Krumbach, MS, RNC, clinical nurse specialist and educator for the Post-Anesthesia Care Unit at UCH and co-chair of the Pain Champions Committee. But providers face barriers in trying to manage a patient’s discomfort, she added.

“Patients may not look like they are in pain,” Krumbach said. “It’s up to us to develop better listening skills and to be present with patients. There are different tools and signs we can use to keep patients engaged.”

A perceptive provider can pick up subtle indications of pain by looking at a patient’s facial expressions, watching for difficulty moving, and listening for sounds of discomfort, Fink noted. Her Pain Assessment Guide also includes the word for “pain” in six other languages.

Montgomery said the key to effective pain control is a detailed assessment, careful management of medications and follow-through to monitor the patient’s clinical progression. But he acknowledged that the subjective nature of pain presents a challenge to developing standardized treatment protocols.

“We have to keep in mind as an underlying premise that pain is whatever a person says it is,” he pointed out. “There is no scan, study or blood draw that will give you that person’s level of pain. And because of the variability of a patient’s response to medications, we have to be ready to adjust hour by hour in the acute-care setting.”

The Acute Pain Service, he added, can assist providers with particularly difficult cases, especially those that might call for the use of above-average doses of opioids, such as Dilaudid and OxyContin, to relieve severe and/or chronic pain. These medications can have troublesome side effects, including nausea, itching, constipation, and sedation that can interfere with recovery and delay discharge, Montgomery noted.

“Through the use of opioid-sparing techniques such as epidural infusions, peripheral nerves blocks, and select non-opioid analgesics, the Acute Pain Service can offer improved pain control with less risk,” he explained. “We’re looking to get the message to our surgical colleagues to consider using a multi-modal analgesic approach to reduce or even eliminate the use of traditional opioid medications.”

There are many reasons for providers to do their best to manage pain, Montgomery concluded, but one stands above the rest.

“We have a duty,” he said. “We can’t always minimize pain, but we must work our hardest to relieve the suffering of our fellow human beings.”