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Helfand M, Freeman M. Assessment and Management of Acute Pain in Adult Medical Inpatients: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2008 Apr.

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Assessment and Management of Acute Pain in Adult Medical Inpatients: A Systematic Review [Internet].

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INTRODUCTION

“With the exception of the PACU, the floor will be the most common place where hospitalized patients may need acute pain management.” 1

Many guidelines and previous reviews address pain assessment and management in surgical inpatients, trauma patients, inpatients with cancer, and inpatients with sickle cell crisis. In contrast, pain in medical inpatients with other conditions has received little attention. The prevalence of pain on the inpatient medical ward is lower than that of a surgical service, but is still substantial. In one hospital survey, 43% of medical ward patients experienced pain, and 12% reported unbearable pain. Twenty per cent of elderly care and general medical patients reported pain scores greater than or equal to 6.2 In a survey of patients consecutively admitted to a London hospital, 13% had severe pain 15% had moderate pain at rest, and half had moderate or severe pain with movement.3 A few more European surveys have also tried to assess the prevalence of pain among hospital patients.4–6

On a medical service the etiology of pain is diverse, and may be hard to ascertain. Data on the course and treatment of pain in medical inpatients are absent. Little is known about how intravenous opioid therapy, considered the treatment of choice for patients with severe, acute pain, is used on a medical service. In contrast to the post-operative setting, on a medical service the patient’s course is less predictable, making it difficult to establish standards for when and how to change pain therapy and how to deliver it.

Textbooks and professional societies provide relatively straightforward guidance for managing acute pain in the perioperative setting and acute or chronic cancer pain. In contrast, in the U.S. no guidelines have not been proposed for the management of pain in acute inpatient medical care settings. Similarly, there are currently no performance measures in place to enhance pain management. The current VA Office of Research and Development pain-relevant research portfolio has no projects designed to examine the quality of pain care in the general medical or neurology ward setting.

HISTORICAL BACKGROUND

In 1986, the National Institutes of Health held a consensus development conference entitled “The Integrated Approach to the Management of Pain.” 7 It focused on causes of undertreatment of pain, in particular, excessive concern about the problems of addiction and respiratory depression. The panel endorsed the principle that the most reliable measure of acute pain is the patient’s self-report, but recognized limitations in the evidence, recommending future research on the “appropriateness of using existing research measures in clinical settings and…their validity as adjuncts to clinical judgments in pain assessment.” They also cited innovations such as patient-controlled analgesia, but noted that clinical evaluation of PCA, sustained release formulations, epidural administration, and transdermal absorption of narcotic drugs to improve pain management were inadequate.

Since 1986, it has been widely recognized that a large minority of surgical patients have moderate to severe pain throughout their postoperative hospital course. 8 Poor pain management in inpatient surgical settings has been associated with slower recovery, 9 greater morbidity, longer lengths of stay, lower patient satisfaction, and higher costs of care, suggesting that optimal pain care in these settings is of utmost importance in promoting acute illness management, recovery, and adaptation.

In February, 1992, the Agency for Health Care Policy and Research released a guideline for the management of acute pain in trauma patients and in patients undergoing surgical or medical procedures.10 In 1994, AHCPR published a guideline for managing cancer pain.11 The AHCPR guidelines brought attention to deficiencies in the quality of care and endorsed several principles that became the foundation of inpatient pain management, including

  • Clinicians should reassure patients and their families that most pain can be relieved safely and effectively.
  • Clinicians should assess patients and, if pain is present, provide optimal relief throughout the course of illness.
  • Health professionals should ask about pain, and the patient’s self-report should be the primary source of assessment.
  • Giving patients pain medicine only “as needed” resulted in prolonged delays because patients may delay asking for help.
  • Aggressive prevention of pain is better than treatment because, once established, pain is more difficult to suppress.
  • Physicians need to develop pain control plans before surgery and inform the patient what to expect in terms of pain during and after surgery.
  • Fears of postsurgical addiction to opioids are generally groundless.
  • Patient-controlled medication via infusion pumps is safe.12

The VHA National Pain Management Strategy, initiated November 12, 1998, established Pain Management as a national priority. The goals of the strategy included (1) the provision of a system-wide VHA standard of care for pain management to reduce suffering from preventable pain; (2) assurance that pain assessment is performed in a consistent manner and that pain treatment is prompt and appropriate; (3) the inclusion of patients and families as active participants in pain management; (4) the provision for continual monitoring and improvement in outcomes of pain treatment; (5) an interdisciplinary, multi-modal approach to pain management; and (6) assurance that clinicians practicing in the VA healthcare system are adequately prepared to assess and manage pain effectively. In 2000, VA published a toolkit for implementing these goals. (http://www1.va.gov/pain_management/docs/TOOLKIT.pdf)

The strategy led to rapid improvement in performance as measured by documentation of a pain assessment and pain care plans in the medical record and a lower proportion of patients with moderate or severe pain on study units.13, 14 In 2000, for example, a survey conducted in VA inpatients with cancer found that only 42% of charts showed evidence that a pain rating scale was used 15 The VA and Institute for Healthcare Improvement initiated a collaborative project that used learning sessions, monthly team conference calls, and monitoring of results and sharing of improvement methods via Internet to promote routine assessment of pain and related goals. The learning sessions emphasized reliable and standardized measurement, strategies for interval sampling, and strategies for plotting and analyzing data. From May 2000 to January 2001, when the VA-IHI Joint Collaborative was conducted; moderate or severe pain on study units dropped from 24% to 17%; pain assessment increased from 75% to 85%; pain care plans for patients with at least mild pain increased from 58% to 78%; and number of patients provided with pain educational materials increased from 35% to 62%.13, 14 By 2003, chart audit indicated that approximately 98% of veterans receiving care at a VHA facility had a documented pain score within the past 12 months.16

In July, 2002, VA/DoD developed a Clinical Practice Guideline for the management of acute post-operative pain. The basis for many of the recommendations was expert consensus rather than empirical evidence. To assess intensity, the VA/DOD CPG recommended use of a visual 1–10 numeric rating scale in the context of a complete pain history. Most of the guideline consists of site-specific recommendations for pharmacologic and nonpharmacologic therapy.

In 2003, VHA DIRECTIVE 2003–021 solidified previous accomplishments, leading to creation of a national pain management infrastructure. It requires implementation of “Pain as the 5th Vital Sign” in all clinical settings; establishment of pain management protocols in all clinical settings; and, for each patient, comprehensive pain assessment and development of a pain treatment plan.. It also encourages use of the pain reminders and dialogs sponsored by the VHA National Pain Management Strategy Coordinating Committee.

In 2004, the VHA National Pain Management Strategy Coordinating Committee issued a consensus statement on Assessing Pain in the Patient with Impaired Communication (available from http://www1.va.gov/Pain_Management/page.cfm?pg=41.)

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