Implementing national standards for cancer pain management: program model and evaluation

Measuring patient opinion of pain management

Pain management has been increasingly recognized as an important indicator of quality patient care. In this article, we describe the development of a measure of patients' perception of pain management. Based upon the American Pain Society's guidelines, the six-item Patient Opinion of Pain Management (POPM) scale demonstrated promising internal consistency, reliability, and validity in a sample of 241 patients from 11 hospitals. The POPM is discussed in the context of previous research on the assessment of pain management.

Improving cancer pain management using a performance improvement framework

Pain is an important issue in quality of care and is increasingly cited as an outcome used to evaluate effectiveness of nursing care. Research indicates that nurses are not well prepared to care for patients with pain. Thus many patients are inadequately assessed and treated and consequently receive less than optimal pain management. The article describes the development, implementation, and evaluation of a pain education program designed to provide clinical nurses with the knowledge necessary to use appropriate pain management techniques. Program content stresses the use of a performance improvement framework for changing clinical practice in individual clinical settings.

Improving pain management in your health care organization

Health care providers must take a systematic approach to improving the quality of pain management. Doing so enables institutions to relieve patient suffering, improve clinical outcomes, lower costs, and meet accreditation standards. The article describes the essential steps that providers should follow when planning this process and reports the progress of one health care system in this regard.

Daily pain assessment: value for nurses and patients

Current guidelines for pain management recommend systematic assessment of pain. A few standardized tools exist for the daily assessment of pain intensity, for example the numeric rating scale or visual analogue scale, yet these instruments are rarely used by nurses. In the study reported in this paper, a numeric rating scale accompanied by an educational programme for nurses, was implemented in three hospitals. The paper describes the feasibility of daily pain assessment from the nurses' and patients' perspective in multiple settings. The outcomes studied were the professional compliance of nurses with daily pain assessment, and the value of daily pain assessment for both nurses and patients. The results show that nurses' compliance with daily pain assessment is high (73.9%) and that daily pain assessment is feasible and valued by nurses; however, differences between the three hospitals and two specialties (medical vs. surgical wards) were found. Although patients have difficulty with expressing their pain by use of a number, almost all patients are able to give a pain score and a majority is positive about daily pain assessment. From this study it can be concluded that daily pain assessment is practical and appreciated by nurses as well as patients, but attuning the implementation protocol to the needs of the specific setting is necessary.

Improving Cancer Pain Management through a System Wide Commitment

Despite the well documented need for better cancer pain management there is little evidence that conventional educational approaches have improved clinical practice. This article discusses strategies to improve cancer pain management, focusing particular attention to institutional approaches that contain quality assurance (QA) and quality improvement (QI) efforts. An innovative pain management project is described that includes an in-depth evaluation of system and provider strengths and weaknesses; a system-wide commitment to cancer pain management; patient/family, nurse, pharmacist, and physician collaborative teams; use of a Washington State law allowing pharmacist prescriptive authority of narcotics and other drugs within a prescribed treatment protocol; and QA and QI efforts to improve and document performance. The authors strongly believe that the development of collaborative programs that integrate the power of the institutional process with clinical care will produce the greatest improvement in patient care not only for cancer pain, but also for other difficult domains of end-of-life.

Barriers to cancer pain relief: fear of tolerance and addiction

The purposes of this study were to (a) test the feasibility of the Cancer Total Quality Pain Management (TQPM) Patient Assessment Tool in a population of oncology inpatient and outpatients; and (b) identify factors associated with poor pain relief. The Cancer TQPM Tool was adapted from the American Pain Society's Quality Assurance Standards on Acute Pain and Cancer Pain and was tested in a convenience sample of 200 patients. The majority of patients reported that the TQPM Tool was easy to understand and to use, providing evidence for the feasibility of the tool. Factors associated with higher pain intensity included the inpatient setting, the presence of metastatic disease, hesitancy in bothering the nurse, and concerns regarding tolerance and addiction. Although there was a strong relationship between concern about addiction and concern about tolerance, fear of tolerance appeared to have a greater effect on pain intensity scores than did fear of addiction. The findings from this study suggest that the Cancer TQPM Patient Assessment Tool can be used effectively in both inpatients and outpatients to determine outcomes and the quality of cancer pain management, as well identify factors associated with poor pain control. Clinical implications include more effective education of patients and caregivers, including equivalent emphasis on tolerance and addiction.

Assessing clinical outcomes: patient satisfaction with pain management

The problem of unresolved pain in hospitalized patients is costly both in monetary terms and in patient comfort. Concern about patients' satisfaction and well-being led to a study to determine the characteristics of the pain experience as reported by the hospitalized patients. This study also examined the recently revised American Pain Society Patient Outcome Questionnaire (APS-POQ), particularly in regard to results from newly added items and overall reliability and validity. The data provide a cross-sectional description of patients' experience with pain in a large, urban teaching hospital. One hundred fifty-seven adult subjects reported moderate to high levels of current pain intensity, worst pain, and general level of pain in the last 24 hr, as well as moderate to high rates of pain-related interference with care activities. While patients indicated that they were satisfied with their pain management and with the responses of physicians and nurses to complaints of pain, patient satisfaction was inversely and significantly correlated with pain now and general level of pain in the last 24 hr. When patients with high pain intensity (> 7) were separated into satisfied and dissatisfied groups for analysis, no significant differences were found regarding pain-related interference with various activities including mood, relationships, sleep, etc. The majority of patients indicated that they were still in pain, but 41% did not wish to receive a stronger dose of pain medication. Significant differences between those who did and did not want more pain medication were found in that younger patients were more likely to want more pain medication. Additionally, analysis of these two groups found that patients who were still in pain and desired more pain medication reported significantly higher levels of pain-related interference with activity and sleep. The inverse correlation of current pain intensity and general level of pain with overall satisfaction with pain management differs from findings of previous studies. One added item queried patients regarding approaches they had used to manage pain in the last 24 hr. Oral pain medications, prayer, intravenous and intramuscular injections were the top-ranked methods. The findings guide further analysis of the APS-POQ questionnaire. Recommendations of items to be retained in the questionnaire are made based on data analysis. Refining the questionnaire will allow health-care providers to increase their understanding of issues related to pain management. The findings provoke several questions for further study, such as what are age and ethnic differences regarding pain intensity and satisfaction, as well as the predictors of aversion of receiving more pain medication when pain persists.

A survey of the nature and perceived impact of quality improvement activities in pain management

We surveyed members of the American Pain Society (APS) to determine if they were engaged in quality assurance or improvement (QA/I) activities. If so, we queried them about the characteristics of these activities and their perceptions of whether their data appear to show improvements, decrements, or no change in pain outcomes. Of the 222 respondents from at least 180 institutions, 201 (91%) reported that their institutions had a continuous improvement program. One hundred forty-three respondents reported having data on at least one of six pain outcomes at two points in time. The majority reported that their data revealed improvements in outcomes. A large number, however, had not collected data on important outcomes, such as pain intensity and patient functioning. Many APS members are collecting longitudinal data, and interpreting the data as revealing improvements in outcomes. There is a need for rigorously controlled assessment of the effects of QA/I programs on pain outcomes.

Severity and impact of pain after day-surgery

PURPOSE

To assess the intensity, duration and impact of pain after day-surgery interventions. Predictors of pain severity were also evaluated along with the quality of analgesic practices and patient satisfaction.

METHODS

Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0-10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods.

RESULTS

Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51%) reported that instructions about pain control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain > or = 4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects.

CONCLUSION

The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.

Symptom management outcomes. Do they reflect variations in care delivery systems?

OBJECTIVES

Symptom management is increasingly recognized as a critical element of patient care, particularly in managing chronic illness. However, research on outcomes related to symptom management is in its infancy, except for the symptom of pain. This symptom was therefore chosen as a prototype to review the state of the science regarding relations between organizational variables and symptom management outcomes and to illustrate the issues regardless of the symptom managed. This article discusses pain outcome measures appropriate for acute and cancer pain, proposes attributes of the care delivery system that may affect outcome measures, and identifies challenges associated with this type of research.

METHODS

Review of quality assurance studies raises issues concerning the adequacy of currently used outcomes for pain and satisfaction with pain management. Although considerable effort has been expended in developing pain measurement in adults and children, critical issues for examining pain management outcomes include deciding what perspectives should be used as the most valid indicator of the pain outcome and when the measures should be obtained.

RESULTS

Critical concerns are raised about the measure of satisfaction with pain management and its appropriateness as the end-result outcome. A key issue is whether respondents actually disentangle satisfaction with pain management from satisfaction with other aspects of care, including caring dispositions of health-care providers. Finally, the question is raised: Are pain outcomes affected by organizational context?

CONCLUSIONS

Although the answer to this question is unknown, a few research studies suggest that organizational context is likely to influence pain outcomes. It is clear, however, from ongoing work that until several conceptual, methodological, and analytic challenges are resolved, research is unlikely to capture the influence of variations in care delivery systems on symptom management outcomes.

Pain Management

Postoperative pain management is essential and must be approached as an integral part of the perioperative care. It should be systematic and based on sound physiological and pharmacological principles. The intra operative management of pain is crucial, because there is perhaps an important role for preemptive analgesia. Because of its unique nature, pain is difficult to assess; for good results, adequate and repeated assessment are vital. The literature also points to the detrimental ef fects of inadequate pain control. There are a variety of methods available for pain management. In choosing a method, various factors need to be considered includ ing: (1) physician skill, (2) knowledge of analgesics and routes of administration, (3) patient and clinically re lated circumstances, (4) the availability of an environ ment supportive of effective pain management, and (5) the knowledge and skill of staff to assess and monitor patients. These need to be considered along with the risk-benefits and cost-benefit of the various drugs and techniques. The cornerstone of therapy is opioids, which can be administered by a variety of routes. The use of thoracic epidural analgesia (TEA) with opioids and local anesthetics is highly beneficial, especially in high-risk patients. The aim should be to provide all patients a balanced analgesic regimen based on the identification of multiple mechanisms involved in postoperative pain.