Care-related pain in hospitalized patients: severity and patient perception of management

Three-year hospital-wide pain management system implementation at a tertiary medical center: Pain prevalence analysis

We developed a pain management system over a 3-year period. In this project, "Towards a pain-free hospital", we combined evidence-based medicine and medical expertise to develop a series of policies. The intervention mainly included the development of standard procedures for inpatient pain management, the implementation of hospital-wide pain medicine education and training, the establishment of a dashboard system to track pain status, and regular audits and feedback. This study aimed to gain an understanding of the changes in the prevalence of pain in inpatients under the care of the pain management system. The subjects of the survey are inpatients over 20 years old, and who had been hospitalized in the general ward for at least 3 days. The patients would be excluded if they were unable to respond to the questions. We randomly selected eligible patients in the general ward. Our trained interviewers visited inpatients to complete the questionnaires designed by our pain care specialists. A total of 3,094 inpatients completed the survey from 2018 to 2020. During the three-year period, the prevalence of pain was 69.5% (2018) (reference), 63.3% (2019) (OR:0.768, p<0.01), and 60.1% (2020) (OR:0.662, p <0.001). The prevalence rates of pain in patients undergoing surgery during the 3-year period were 81.4% (2018), 74.3% (2019), and 68.8% (2020), respectively. As for care-related causes of pain, injection, change in position/chest percussion, and rehabilitation showed a decreasing trend over the 3-year period of study. Our pain management system provided immediate professional pain management, and achieved a good result in the management of acute moderate to severe pain, especially perioperative pain. Studies on pain prevalence and Pain-Free Hospitals are scarce in Asia. With the aid of the policies based on evidence-based medicine and the dashboard information system, from 2018 to 2020, the prevalence of pain has decreased year by year.

The Use of a Fixed 50:50 Mixture of Nitrous Oxide and Oxygen to Reduce Lumbar Puncture-Induced Pain in the Emergency Department: A Randomized Controlled Trial

Lumbar puncture (LP) is stressful and often painful. We evaluated the efficacy of a fixed 50% nitrous oxide−oxygen mixture (50%N2O-O2) versus placebo to reduce immediate procedural pain and anxiety during LP performed in an emergency setting. We conducted a randomized controlled trial involving adults who needed a cerebrospinal fluid analysis in an emergency department. Patients were randomly assigned to inhale either 50%N2O-O2 or medical air. The primary endpoint, assessed using a numerical scale, was the maximum pain felt by the patient during the procedure and the maximum anxiety and satisfaction as secondary outcomes. Eighty-eight patients were randomized and analyzed (ITT). The maximal pain was 5.0 ± 2.9 for patients receiving air and 4.2 ± 3.0 for patients receiving 50%N2O-O2 (effect-size = −0.27 [−0.69; 0.14], p = 0.20). LP-induced anxiety was 4.7 ± 2.8 vs. 3.7 ± 3.7 (p = 0.13), and the proportion of patients with significant anxiety (score ≥ 4/10) was 72.7% vs. 50.0% (p = 0.03). Overall satisfaction was higher among patients receiving 50%N2O-O2 (7.4 ± 2.4 vs. 8.9 ± 1.6, p < 0.001). No serious adverse events were attributable to 50%N2O-O2 inhalation. Although inhalation of 50%N2O-O2 failed to reduce LP-induced pain in an emergency setting, it tended to reduce anxiety and significantly increased patient satisfaction.

Pain prevalence in hospitalized patients at a tertiary academic medical center: Exploring severe persistent pain

Objective

The pain prevalence of inpatients is not a well-studied medical issue in Asia. We have aimed to evaluate pain prevalence and characterize those patients who have suffered from severe, persistent pain.

Methods

We investigated pain prevalence using a quota sampling from 19 general wards during the year 2018. Using a structured questionnaire, eight interviewers visited patients at an age ≥ 20 years, and who had been staying in general wards for ≥ 3 days. Those patients were excluded if they were unable to respond to the interview questions. If they reported pain during hospitalization, the maximum pain level and the duration of pain suffered in the past 24 hours were assessed. Care-related pain was also surveyed.

Results

A total of 1,034 patients (M/F, 537/497) completed the survey. Amongst them, 719 patients (69.5%) experienced pain, with moderate and severe pain levels being 27.3% and 43%, respectively. Surgery was considered as it related to pain, including significantly severe pain. The top 3 care-related pain causes were needle pain, wound dressing, and change in position/chest percussion. Change in position/chest percussion and rehabilitation were associated with severe, persistent pain.

Conclusions

Pain is common in approximately 70% of inpatients, with surgery being associated with severe pain. Mobilization and rehabilitation may lead to severe, persistent pain. The periodic study of pain prevalence is essential in order to provide precise pain management.

Optimizing delivery to meet demand for integrative medicine services in an academic hospital setting: A pilot study

CONTEXT

A rapidly growing body of evidence shows the positive benefits of integrative medicine (IM) services for patients in hospital-based settings. IM therapies, such as acupuncture, massage, meditation and relaxation, and animal-assisted therapy, reduce symptom burden of pain, anxiety, and stress and increase sense of well-being and satisfaction in hospitalized patients. Current challenges facing hospitals are to move beyond proof-of-concept studies and to provide hospital-based IM therapies.

OBJECTIVE

The aim of our quality improvement project was to develop, implement, and evaluate a feasible, scalable, hospital-based "best practice" model for increasing demand for IM services and optimizing their delivery.

DESIGN

A multidisciplinary team convened to use quality improvement tools to outline a process for providing IM services.

SETTING

A large academic medical center in the Midwestern United States.

PARTICIPANTS

IM leadership staff, IM providers, nurses, hospital team members, support staff, and quality improvement staff.

INTERVENTIONS

After determining baseline levels of demand and service delivery, we sought to (1) increase nursing staff awareness of available IM services; (2) improve communication between IM providers and nurses; and (3) reinforce communication at the level of nurse supervisors, patients, and family members.

MAIN OUTCOME MEASURES

We recorded the numbers and types of IM services ordered at baseline and postimplementation and determined the new delivery rate of requested services.

RESULTS

We noted an increase in the number of IM orders, percentage of delivered IM services, and percentage of patients who reported that IM services improved their hospital stay.

Management of acute pain in dementia: a feasibility study of a robot-assisted intervention

Background: The management of pain is particularly challenging in patients with moderate to severe dementia owing to the loss of communication ability or underlying causes such as behavioral symptoms. It is often associated with health care professionals’ frustration and feeling of helplessness. The present study determined a framework and examined the feasibility of an innovative intervention using the PARO^® robot for the management of acute pain in dementia.

Method: A mixed-methods research design combining qualitative (five focus groups) and quantitative (questionnaire survey) approaches was used to define the intervention framework. We recruited 57 health care professionals from various medical and paramedical specialties (eg, nursing auxiliaries, nurses, physicians, psychologists) and with expertise in gerontology. The feasibility of the intervention was subsequently assessed with 12 patients suffering from dementia in painful situations to validate the procedure.

Results: Four main issues have been addressed: 1) the identification of a core group of painful situations associated with care (washing, dressing/change, transfer/mobilization), currently considered as inefficiently managed; 2) the selection of an appropriate assessment methodology including criteria and tools for pain evaluation; 3) the definition of health professionals' training needs and organizational requirements for their implementation; and 4) the perceived usefulness of a robot-assisted intervention for the management of pain in dementia in daily practice. The feasibility study showed that the predefined intervention framework was applicable and acceptable for the majority of professionals and patients.

Conclusion: A consistent and feasible intervention framework for the management of painful situations associated with care in dementia using the PARO robot was defined. Understanding of professionals’ needs, opinions and perceived obstacles regarding the intervention was a useful step in the preparation of the forthcoming clinical trial.

Pain among non-verbal critically Ill mechanically ventilated patients: Prevalence, correlates and predictors

PURPOSE

To investigate pain levels and factors that are predictive of pain for mechanically ventilated patients during rest and during routine nursing procedures.

MATERIAL AND METHODS

Pain levels were assessed using Behavioral Pain Scale (BPS) and physiological measures among 247 mechanically ventilated patients.

RESULTS

At rest, 33.2% of patients suffered pain, with a BPS > 3; of these, 10% presented significant pain levels (BPS ≥ 5). Variables that correspondingly predicted resting pain were age (β = -0.010, p < 0.001), sedation score (β = -0.153, p < 0.01), and method of ventilation (β = -0.281, p = 0.021). During the procedures, 90% of patients suffered pain, with a median BPS of 6 (IQR: 4-8), and 83% of patients experienced significant pain levels. Age (β = -0.022, p = 0.001), sedation score (β = -0.355, p < 0.001), receiving sedation and/or analgesia in last hour (β = 0.483, p = 0. 01), resting pain levels (β = -0.742, p < 0.001) and the type of painful procedure (β = -0.906, p < 0.001) were significant predictors of procedural pain.

CONCLUSIONS

Many mechanically ventilated patients suffer resting and procedural pain. Many variables were found to play a role. Clinicians need to consider these variables and intervene to decrease pain among patients at risk.

Effect of Integrative Medicine Services on Pain for Hospitalized Patients at an Academic Health Center

BACKGROUND

Pharmaceuticals such as opioids have routinely been prescribed for pain management. However, there has been an increasing epidemic of prescription opioid abuse, causing demand for nonpharmacologic complementary and integrative therapies for pain management.

OBJECTIVE

To determine if integrative medicine services provided to inpatients could help reduce pain posttreatment. In addition, this study aimed to track total services requested and performed over the fourth quarter of 2017.

DESIGN, SETTING, AND PARTICIPANTS

This prospective study analyzed documented integrative medicine services requested, indications for the requests, and pre- and posttreatment pain scores. A paired t test was used to determine significance. The study population was inpatients, from October 1, 2017, through December 31, 2017, at Mayo Clinic's Methodist and St. Mary's Hospitals in Rochester, Minnesota.

RESULTS

During the study period, 1220 integrative services were provided with a majority being massage therapy (1,064; 87.2%), followed by acupuncture (112; 9.1%). Massage therapy and acupuncture were highly significant (P < 0.00) at reducing pain scores posttreatment to inpatients. Over one-third of patients fell asleep during their therapy service time.

CONCLUSION AND RELEVANCE

Integrative therapies are appropriate modalities to help alleviate pain and other symptoms for the inpatient population. Due to the effectiveness of these modalities, integrative therapies may be a complement to opioids prescribed for pain. In addition, with over one-third of the patients falling asleep during therapy, our results suggest that integrative therapies can promote a state of relaxation. Future studies are warranted to determine the impact of integrative medicine therapies on sleep deprivation and other common symptoms of hospitalized patients.

[Improving the quality of cancer pain management in palliative care unit: Targeted clinical audit]

Goal This study aims to assess the quality of the cancer pain management in Palliative care unit.

METHOD

The method used was the targeted clinical audit. The audit grid was built according to the recommendations of the pilot Committee, and tested until the final version with 19 items was obtained. In this retrospective study, 60 consecutive patients were studied on 2 periods of time. The first one (T1) shows the gap between the patient's chart and the expected standard, and proposes corrective measures. The second one (T2) re-assesses, using the same items list, the efficacy of these measures.

RESULTS

After the corrective measures, the patients' medical record documentation was significantly improved at T2 for: neuropathic pain assessment improved, from 3% (T1) to 67% (T2) (P<0.001), so did pain assessment during the titration, from 6.7% (T1) to 90% (T2) (P<0.001). The overdoses symptoms assessment improved from 17% at T1 to 93% at T2, (P=0.002) and breakthrough pain evaluation improved from 3% at T1 to 73% at T2, (P<0.001). The pain reassessment after the rescue doses improved from 10% at T1 to 73% at T2 (P<0.001). The other points improved but not significantly.

CONCLUSION

The quality of the pain cancer management was improved during the audit, but some points (patient education and in patient medical record documentation) can be improved. We need to continue to implement the improvement measures in our unit.