Summary Table 1Studies on methods of pain assessment (KQ1)

Author, YearStudy Design, settingSample sizeClinical condition/ baseline painIntervention/exposure of interestOutcomes measuredResults
Carey, 19971Prospective cohort26739.5% acute pain, 40.3% chronic pain.
20.9% reported no pain on admission.
Mean for pain intensity ranged from 5.09–5.75.
Patients rated the intensity of pain using each of the 3 scales once over the next 24 hours were also asked which of the scales was easiest to use, whether the scale was helpful or needed further explanation, and employment and education data.Use of 3 self-rated pain scales; questionnaire also collected demographic information and perceptions about scales.Patients most frequently selected the VAS faces scale (48.6%), followed by the number scale (35.3%) and line scale (16.1%). None of the demographic variables were associated with preference. Reliability coefficient between scales (Chronbach’s alpha) was 0.88. Most (85.8%) patients indicated that a pain rating scale helped them to describe their pain to the nursing staff.
Luger, 20032Single-site prospective study, convenience sample in Innsbruck, Austria10 EMS technicians, 10 EMS drivers, 2 ER physicians; 15 trauma patients and 36 nontrauma patients (mostly cardiovascular disease).15 trauma patients: 7 fractures or lacerations, 5 blunt injuries, 3 penetrating wounds.Pain assessment was performed at the beginning of emergency care before analgesics, during transport, and upon arrival at the hospital immediately prior to hospitalization.Severity of pain assessed by patient; EMS physician; EMS technician; EMS driver; at 3 time points (on the scene, during transport, and on arrival at hospital)The EMS physician underestimate pain 47% of the time; the EMS technician underestimated pain 53% of the time; the EMS driver underestimated pain 57% of the time. The disparity was greatest (60–68%) among patients with severe pain, and lowest (28–36%) among patients with mild pain.
The pain intensities on the VAS and VPS were highly correlated (r2=0.86, p=0.0001).
Nelson, 20043Retrospective cohort study at a suburban university-based ED521 before the mandatory pain scale; 479 after introducing the pain scale to the ED,Renal colic, extremity trauma, headache, opthalmologic trauma, or soft tissue injury. Pain varied from 0–10. 8% of patients who reported 0 received analgesia, compared with 74% who reported 9, and 69% who reported 10 as baseline pain.The standard triage form was revised to include a pain scale in the vital signs section, and the pain assessment was made at triage at the same time as presentation vital signs were assessed. ED staff and patients were not made aware of the study or alerted to the intervention.1) The proportion of patients who received oral or parenteral analgesia for their pain while in the ED; 2) the time to analgesia administrationThe proportion of patients who received analgesia after introduction of the pain scale increased from 25% to 35% (p<0.001). The mean time from triage to analgesia administration was 152 minutes before the intervention, and 113 minutes after (mean difference 39 minutes, 95%CI −7 to 84) but the difference was not statistically significant. Patients with diagnostic uncertainty who received further evaluation were less likely to receive analgesia. 34% who received no workup received analgesia, while only 27% did who underwent a workup (p=0.022). In patients with headache, 23% who underwent CT were treated for pain, whereas 62% of those who did not undergo CT were treated (p<0.001)
Morrison, 20064Controlled clinical trial in an 1171-bed hospital in Mt. Sinai Hospital, New York.3964 adults9 medical/surgical units were selected for inclusion based on similar baseline patient demographics and pain scores (3 general medicine, 2 general surgery, 2 specialty surgery, 1 oncology, and 1 mixed oncology/general medicine). 32–38% surgical pts10–16% cancer pts1.5 – 4.8% AIDS pts56% had moderate to complete relief from pain medication29–32% had moderate to severe pain at study enrollmentEducation in pain management (months 0–4) was followed by a series of additive 6 to 7-month intervention periods: 1) patient education and nursing pain assessment of current and worst pain, pain relief, and pain acceptability; 2) audit and feedback to nursing staff of patients’ pain intensity and staff compliance; and 3) a computerized clinical decision support system (CDSS) to guide analgesic prescribing.Patients were interviewed within 48 hrs of admission and then once daily. Patients were asked to rate current pain, worst pain over 24 hrs, their pain relief with analgesics, and whether their pain was acceptable to them. Pain and pain relief were rated on 4-pt scales. Outcomes included measures of pain assessment, pain severity, and analgesic prescribing. % of patients who had a daily pain assessment for each shift; % of pts wioth moderate to severe pain 72–96 hrs later, mean pain scores for the first 72 hrs or on postop days 1–3Pain documentation was improved by >80% using an enhanced pain assessment instrument combined with either audit and feedback or a computerized decision support system. The enhanced pain scale was associated with increased analgesic prescribing. Patients on units using the enhanced pain scale were significantly more likely to have their pain assessed than those on units in which the 1-item pain scale was used (p<0.001). Audit and feedback of pain results was associated with significant increases in pain assessment rates compared with units without audit and feedback (p<0.001). Adding the CSS was associated with significant increases in pain assessment only when compared with units that lacked audit and feedback (p<0.001).Overall the % of pts who received at least 1 pain assessment per day increased from 32.1% with the standard pain assessment to 79.3% when the enhanced pain scale was combined with the CSS, and to more than 80% for interventions using audit and feedback.

From: APPENDIX E, Evidence Summary Tables

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

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