Debra B. Gordon

Application of the American Pain Society quality assurance standards

&NA; The American Pain Societys (APS) patient outcome questionnaire was used to examine patient satisfaction with pain management in a quality assurance study of 217 adults and 31 children in a large university hospital. On a scale of 1–6, mean (S.D.) patient satisfaction with pain management provided by nurses was 5.37 (1.02) and by physicians was 5.10 (1.02). Many patients (84% of adults and 90% of children) reported that early in their hospital stay a nurse or physician had communicated the fact that treatment of pain is considered very important. The mean (S.D.) pain severity score (worst pain in the last 24 h) for adults was 6.62 (2.79) on a 0–10 scale and for children was 4.33 (0.85) on a 0–5 Faces scale. Analyses revealed little relationship between pain severity and satisfaction; even persons with high levels of pain were very satisfied with the pain management they received from nurses and physicians. Satisfaction was, however, related to whether nurses and physicians had communicated to the patient that pain management has a high priority. It appears that patients are satisfied if clinicians say they want to provide pain management regardless of whether they actually do. The data raise questions about the interpretation of patient satisfaction as an outcome variable in studies of the quality of pain management.

Acute Post-Surgical Pain Management: A Critical Appraisal of Current Practice

The Acute Pain Summit 2005 was convened to critically examine the perceptions of physicians about current methods used to control postoperative pain and to compare those perceptions with the available scientific evidence. Clinicians with expertise in treatment of postsurgical pain were asked to evaluate 10 practice-based statements. The statements were written to reflect areas within the field of acute-pain management, where significant questions remain regarding everyday practice. Each statement made a specific claim about the usefulness of a specific therapy (eg, PCA or epidural analgesia) or the use of pain-control modalities in specific patient populations (eg, epidural analgesia after colon resection). Members of the American Society of Regional Anesthesia and Pain Medicine (ASRA) were asked, via a Web-based survey, to rate their degree of agreement with each of the 10 statements; 22.8% (n = 632) of members responded. In preparation for the pain summit, a panel member independently conducted a literature search and summarized the available evidence relevant to each statement. Summit participants convened in December 2005. The assigned panel member presented the available evidence, and workshop participants then assigned a category for the level of evidence and recommendation for each statement. All participants then voted about each statement by use of the same accept/reject scale used earlier by ASRA members. This manuscript details those opinions and presents a critical analysis of the existing evidence supporting new and emerging techniques used to control postsurgical pain.

Core competencies for pain management: Results of an interprofessional consensus summit

Objective The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported. Methods An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached. Results The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain. Conclusions These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.

Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for Quality Improvement of Pain Management in Hospitalized Adults: Preliminary Psychometric Evaluation

UNLABELLED Quality improvement (QI) is a compilation of methods adapted from psychology, statistics, and operations research to identify factors that contribute to poor treatment outcomes and to design solutions for improvement. Valid and reliable measurement is essential to QI using rigorously developed and tested instruments. The purpose of this article is to describe the evolution of the American Pain Society Patient Outcome Questionnaire (APS-POQ) for QI purposes and present a revised version (R) including instrument psychometrics. An interdisciplinary task force of the APS used a step-wise, empiric approach to revise, test, and examine psychometric properties of the societys original POQ. The APS-POQ-R is designed for use in adult hospital pain management QI activities and measures 6 aspects of quality, including (1) pain severity and relief; (2) impact of pain on activity, sleep, and negative emotions; (3) side effects of treatment; (4) helpfulness of information about pain treatment; (5) ability to participate in pain treatment decisions; and (6) use of nonpharmacological strategies. Adult medical-surgical inpatients (n = 299) from 2 hospitals in different parts of the United States participated in this study. Results provide support for the internal consistency of the instrument subscales, construct validity and clinical feasibility. PERSPECTIVE This article presents the initial psychometric properties of the APS-POQ-R for quality improvement purposes of hospitalized adult patients. Validation in additional groups of patients will be needed to demonstrate its generalizability.

Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty.

PURPOSE The purpose of this study was to compare pain and anxiety in orthopaedic patients scheduled for elective total hip or knee arthroplasty who have received a kit of nonpharmacologic strategies for pain and anxiety in addition to their regularly prescribed analgesics to those who receive the usual pharmacologic management alone. DESIGN Descriptive comparative and correlational design using surveys and chart audits. SAMPLE Sixty-five patients randomized to receive usual care or usual care plus a kit of nonpharmacologic strategies. FINDINGS Patients who received the kit used nonpharmacologic measures for pain and anxiety more often than patients who did not receive the kit. The kit group tended to use less opioid and have less anxiety on postoperative day 1 (not statistically significant) and use significantly less opioid on postoperative day 2 than the patients who did not receive the kit. There were no between-group differences in pain intensity. There were significant correlations among postoperative pain intensity, opioid use, and anxiety. The coping method of diverting attention was related to lower present (now) pain scores, and ignoring the pain was associated with higher worst pain. DISCUSSION Providing a kit of nonpharmacologic strategies can increase the use of these methods for postoperative pain and anxiety and decrease the amount of opioid taken. The influence of coping strategies in acute postoperative pain needs to be examined further.

Quality improvement challenges in pain management

A great deal of attention has been paid to the quality of pain management in the last decade, with growing recognition that the under treatment of pain is a major, yet avoidable, public health problem. Studies have consistently shown poor pain control for postoperative and trauma pain, cancer pain and for many chronic pain problems not related to cancer. Major barriers to effective pain management have been identified including the inadequate knowledge of health care professionals, patients and the public; lack of institutional commitment; regulatory concerns; and limited access to and reimbursement for interdisciplinary care. Despite efforts to address these barriers and continued advances in our understanding of pain, the quality of pain management remains inconsistent at best. The need to measure and improve the quality of care is increasingly recognized by consumers, payors and health care professionals alike. Serious and widespread quality problems exist throughout American medicine. The Institute of Medicine’s (IOM) report, A New Health System for the 21st Century, highlighted the disturbing absence of real progress toward restructuring health care systems to address both quality and cost concerns or toward applying advances in information technology to improve administrative and clinical processes (Richardson et al., 2001). The report also cited the lack of careful analysis and alignment of payment incentives with quality improvement. Some have expressed concern that market forces, not good science, are driving current pain management practices (Harden, 2002). The pain community must become engaged in quality improvement efforts and act upon its responsibility to define, measure, and improve the quality of pain management.

Acute post-surgical pain management: a critical appraisal of current practice, December 2-4, 2005.

The Acute Pain Summit 2005 was convened to critically examine the perceptions of physicians about current methods used to control postoperative pain and to compare those perceptions with the available scientific evidence. Clinicians with expertise in treatment of postsurgical pain were asked to evaluate 10 practice-based statements. The statements were written to reflect areas within the field of acute-pain management, where significant questions remain regarding everyday practice. Each statement made a specific claim about the usefulness of a specific therapy (eg, PCA or epidural analgesia) or the use of pain-control modalities in specific patient populations (eg, epidural analgesia after colon resection). Members of the American Society of Regional Anesthesia and Pain Medicine (ASRA) were asked, via a Web-based survey, to rate their degree of agreement with each of the 10 statements; 22.8% (n = 632) of members responded. In preparation for the pain summit, a panel member independently conducted a literature search and summarized the available evidence relevant to each statement. Summit participants convened in December 2005. The assigned panel member presented the available evidence, and workshop participants then assigned a category for the level of evidence and recommendation for each statement. All participants then voted about each statement by use of the same accept/reject scale used earlier by ASRA members. This manuscript details those opinions and presents a critical analysis of the existing evidence supporting new and emerging techniques used to control postsurgical pain.

Improving reassessment and documentation of pain management

BACKGROUND The Joint Commission standards on pain management address the documentation of assessment and reassessment. Yet, little has been published to describe when and how nurses perform and communicate reassessment of pain. In 2005, the University of Wisconsin Hospital & Clinics (UWHC) was inconsistently reassessing pain after interventions, and documented reassessments were primarily confined to pain-intensity ratings. PLAN-DO-CHECK-ACT: A large-scale plan-do-check-act (PDCA) cycle was implemented to improve the documentation of pain reassessments, including development of an evidence-based administrative policy, repetitive education efforts with bedside coaching, changes in daily bedside documentation flow sheets, and audit and feedback. RESULTS From May 29, 2006, through July 16, 2008, a cumulative rate of 94.9% appropriately documented pain reassessments was achieved. DISCUSSION Despite implementation of an evidence-based policy to clarify requirements for pain reassessment, repetitive educational efforts, changes in daily bedside flow sheets, direct and extensive leadership involvement in the form of continuous bedside coaching, combined with more timely and persistent audit and feedback and clear accountability and alignment with goals, was necessary for substantial change. Strategies to sustain improvements include daily administrative and monthly staff documentation audits with prompt feedback to clinical nurse managers and staff. Nurses are instructed on the importance of pain reassessments and on the policy and specific documentation requirements. Reassessment of pain is a routine variable displayed on unit and departmental quality dashboards. Further study should examine if the intensity of this requirement for pain reassessment documentation ultimately facilitates the safety and effectiveness of pain management.

Patients' Perception of Postoperative Pain Management : Validation of the International Pain Outcomes (IPO) Questionnaire

UNLABELLED PAIN OUT is a European Commission-funded project aiming at improving postoperative pain management. It combines a registry that can be useful for quality improvement and research using treatment and patient-reported outcome measures. The core of the project is a patient questionnaire-the International Pain Outcomes questionnaire-that comprises key patient-level outcomes of postoperative pain management, including pain intensity, physical and emotional functional interference, side effects, and perceptions of care. Its psychometric quality after translation and adaptation to European patients is the subject of this validation study. The questionnaire was administered to 9,727 patients in 10 languages in 8 European countries and Israel. Construct validity was assessed using factor analysis. Discriminant validity assessment used Mann-Whitney U tests to detect mean group differences between 2 surgical disciplines. Internal consistency reliability was calculated as Cronbachs alpha. Factor analysis resulted in a 3-factor structure explaining 53.6% of variance. Cronbachs alpha at overall scale level was high (.86), and for the 3 subscales was low, moderate, or high (range, .53-.89). Significant mean group differences between general and orthopedic surgery patients confirmed discriminant validity. The psychometric quality of the International Pain Outcomes questionnaire can be regarded as satisfactory. PERSPECTIVE The International Pain Outcomes questionnaire provides an instrument for postoperative pain assessment and improvement of quality of care, which demonstrated good psychometric quality when translated into a variety of languages in a large European and Israeli patient population. This measure provides the basis for the first comprehensive postoperative pain registry in Europe and other countries.

A role model program to promote institutional changes for management of acute and cancer pain

This report describes an 18-month project to make acute and cancer pain management an institutional priority in Southeastern Wisconsin health-care facilities. Facility-based teams, each of which included a nurse in a leadership position, were recruited to participate in a project based on the Cancer Pain Role Model Program. The project was conducted in three stages: (a) a 1-day conference focusing on basic pain management issues and clinical standards, (b) a preceptorship at the Medical College of Wisconsin, and (c) a follow-up conference focusing on institutional change. Participants completed an Action Plan, outlining activities aimed at changing practice in their facility. Participants from 17 of the 32 participating facilities partially or completely met their Action Plan goals. Lack of ongoing facility commitment, staff turnover and facility closures were cited as reasons for failure to meet goals. Nurses in key positions, provided with strong institutional commitment and given suitable educational training and nurturing, are ideally suited to help facilitate changes in institutional pain practices.