Quality Improvement Project: Replacing the Numeric Rating Scale with a Clinically Aligned Pain Assessment (CAPA) Tool

Prognostic clinical prediction models for acute post-surgical pain in adults: a systematic review

BACKGROUND

Acute post-surgical pain is managed inadequately in many patients undergoing surgery. Several prognostic risk prediction models have been developed to identify patients at high risk of developing moderate to severe acute post-surgical pain. The aim of this systematic review was to describe and evaluate the methodological conduct of these prediction models.

METHODS

We searched MEDLINE, EMBASE and CINAHL for studies of prognostic risk prediction models for acute post-surgical pain using predetermined criteria. Prediction model performance was evaluated according to discrimination and calibration. Adherence to TRIPOD guidelines was assessed. Risk of bias and applicability was independently assessed by two reviewers using the prediction model risk of bias assessment tool.

RESULTS

We included 14 studies reporting on 17 prediction models. The most common predictors identified in final prediction models included age; surgery type; sex or gender; anxiety or fear of surgery; pre-operative pain intensity; pre-operative analgesic use; pain catastrophising; and expected surgical incision size. Discrimination, measured by the area under receiver operating characteristic curves or c-statistic, ranged from 0.61 to 0.83. Calibration was only reported for seven models. The median (IQR [range]) overall adherence rate to TRIPOD items was 62 (53-66 [47-72])%. All prediction models were at high risk of bias.

CONCLUSIONS

Effective prediction models could support the prevention and treatment of acute post-surgical pain; however, existing models are at high risk of bias which may affect their reliability to inform practice. Consideration should be given to the goals, timing of intended use and desired outcomes of a prediction model before development.

Using implementation science to decrease variation and high opioid administration in a surgical ICU

BACKGROUND

High doses and prolonged duration of opioids are associated with tolerance, dependence, and increased mortality. Unfortunately, despite recent efforts to curb outpatient opioid prescribing because of the ongoing epidemic, utilization remains high in the intensive care setting, with intubated patients commonly receiving infusions with a potency much higher than doses required to achieve pain control. We attempted to use implementation science techniques to monitor and reduce excessive opioid prescribing in ventilated patients in our surgical intensive care unit (SICU).

METHODS

We conducted a prospective study investigating opioid administration in a closed SICU at an academic medical center over 18 months. Commonly accepted conversions were used to aggregate daily patient opioid use. Patients with a history of chronic opioid use and those being treated with an intracranial pressure monitor/drain, neuromuscular blocker, or extracorporeal membrane oxygenation were excluded. If the patient spent a portion of a day on a ventilator, that day's total was included in the "vent group." morphine milligram equivalents per patient were collected for each patient and assigned to the on-call intensivist. Intensivists were blinded to the data for the first 7 months. They were then provided with academic detailing followed by audit and feedback over the subsequent 11 months, demonstrating how opioid utilization during their time in the SICU compared with the unit average and a blinded list of the other attendings. Student's t tests were performed to compare opioid utilization before and after initiation of academic detailing and audit and feedback.

RESULTS

Opioid utilization in patients on a ventilator decreased by 20.1% during the feedback period, including less variation among all intensivists and a 30.9% reduction by the highest prescribers.

CONCLUSION

Implementation science approaches can effectively reduce variation in opioid prescribing, especially for high outliers in a SICU. These interventions may reduce the risks associated with prolonged use of high-dose opioids.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Current Trends in Modalities of Pain Assessment: A Narrative Review

Pain is a common complaint among a spectrum of diseases. Although an ideal objective method of pain assessment is lacking, several validated tools are available for use in clinical research and practice. The tool considerations are based upon the parameters to be assessed and factors specific to patient, disease, and availability of instruments. This review classifies and brings the key aspects of currently available pain assessment tools on a single platform to ease the selection process for researchers/practitioners. The tools utilized for pain assessment were collected from articles available in PubMed and Google Scholar databases and classified into the following domains: unidimensional, multi-dimensional, investigation-based, and computerized algorithm-based tools. Their purpose of use and limitations are reviewed. The unidimensional scales are used to describe only the characteristics of pain, like intensity (e.g. numerical rating scale), type (e.g. neuropathic pain questionnaire), or pattern. In contrast, multi-dimensional tools, like Mc Gill Questionnaire, assess not only pain as an individual symptom but also its influence on physical functioning and general well-being. However, certain components like ethnicity, age, cognitive impairment, sedation, and emotion become a limiting factor in selecting the scale. In addition to these scales, a potential role of parameters such as biopotentials/markers has also been shown in pain assessment. Last, artificial intelligence is also being applied in evaluation of pain. Pain measurement is subjective in nature as assessed through questionnaires and observational tools. Currently, multi-dimensional approaches of pain assessment are available, which can lead to precision pain management.

Considerations for Pain Assessments in Cancer Patients: A Narrative Review of the Latin American Perspective

Cancer incidence in Latin America is lower than in Europe or the United States but morbidity and mortality rates are disproportionately high. A barrier to adequate pain control is inadequate pain assessment, which is a relatively easy and inexpensive metric. The objective of this narrative review is to describe pain assessment for cancer patients in Latin America. Cultural factors may influence pain perception, including contextualizing pain as noble or natural suffering and aspects of what is now called "spiritual pain." Unlike other painful conditions, cancer pain may be strongly associated with existential fear, psychosocial distress, anxiety, and spiritual concerns. Pain assessment allows not just quantification of pain intensity but may elucidate pain mechanisms involved or psychosocial aspects that may color the pain. Many current pain assessment instruments capture only pain intensity, which is but one aspect of the pain experience; some have expanded to include functional assessments, mental health status evaluations, and quality of life metrics. A quality-of-life assessment may be appropriate for cancer patients since chronic pain can severely impact function, which can in turn create a vicious cycle by exacerbating pain. The incidence of cancer in Latin America is expected to increase in the ensuing years. Better pain assessment and clinician education are needed to help manage pain in this large and growing patient population.

Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists

Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.

Nurses' use of the clinically aligned pain assessment tool: A mixed methods study

BACKGROUND

Assessment of pain in the hospital has often relied on intensity rating alone. To address the gap in meeting patients' pain management expectations, a Midwestern medical center implemented the CAPA (Clinical Aligned Pain Assessment) tool for more comprehensive nursing pain assessments.

AIMS

This research described nurses' experience using CAPA on an adult general medicine unit and their documentation of the tool in the electronic health record (EHR) more than 5 years after CAPA implementation.

DESIGN

Mixed methods exploratory sequential design.

METHODS

A convenience sample of nurses (N = 8) participated in 2 focus groups to describe how they used CAPA, how well it assessed pain, how it determined pain interventions, and the challenges and advantages of using CAPA. Patient EHR data (N = 373) for a 6-month period from the same unit were analyzed to evaluate CAPA documentation.

RESULTS

Qualitative themes included: benefits of using CAPA, CAPA leads to a more comprehensive picture, variation in how CAPA is used, and challenges. Quantitative findings demonstrated most frequent documentation in the comfort domain and earlier, though still delayed, reassessment when a higher level of pain was noted. Mixed methods analysis revealed variation in knowledge and practice regarding which domains to document each shift and during reassessment.

CONCLUSIONS

As patient advocates, nurses are integral to thorough assessment and treatment of pain. Findings identified the need for methodological research of CAPA. As with any assessment tool, when using CAPA, ongoing monitoring is needed to address how it is administered, coded, and used for decision-making about pain management.

Survey of Nurses' Use of the Clinically Aligned Pain Assessment (CAPA) Tool

BACKGROUND

Limited research is available on tools for assessing pain and its effect on function in the acute care setting.

AIM

This research's purpose is to describe nurses' use of the Clinically Aligned Pain Assessment (CAPA) tool and their beliefs about its utility for assessing pain compared to the numeric rating scale (NRS) in a hospital where CAPA had been used for 6 years.

DESIGN

A cross-sectional self-report survey.

METHODS

Nurses (N = 110) from 13 adult inpatient units in an academic center participated in this survey describing frequency of CAPA and NRS use, CAPA domains documented, and how nurses asked about pain and distinguished between categories when coding for documentation. Beliefs about the tools' effectiveness were also reported.

RESULTS

Most nurses used CAPA routinely for assessments; almost half used the NRS at times. They believed both tools were effective for assessment, but CAPA was more effective to determine what intervention was needed. They also believed patient report using CAPA was more likely to match the nurse's assessment; a majority reported incorporating their observations into CAPA documentation. Most asked the patient about pain without using CAPA words, although many used the specific words. Practice varied in how nurses determined which category to select in the comfort domain and which domains were assessed routinely.

CONCLUSIONS

Although many nurses believed CAPA was effective, variation existed in how it was used to assess and document pain, increasing potential for inconsistent assessments and interpretations of pain and pain management.

Phase 2 Assessment of a New Functional Pain Scale by Comparing It to Traditional Pain Scales

Background

Assessment of pain has always been subjective and is commonly assessed using a numeric pain scale (NPS) or Wong-Baker faces scale. The pain intensity score is not standardized and relies on individuals’ past experiences. The disadvantage of using such pain assessment scales and treating the numbers can lead to overdosing on analgesics leading to unwanted side effects. The Robert Packer Hospital/Functional Pain Scale (RPH/FPS) was developed as a tool for the objective assessment of pain and its impact on a patient’s function. 

Aim

The study aimed to validate the RPH/FPS scale against NPS and Wong-Baker faces scale in medical, surgical, and trauma patients. The patients’ were also asked to rank the scales as one (1) being the most preferred to three (3) being the least preferred.

Design

This prospective, observational cohort study compares the two most common pain scales, the NPS and the Wong-Baker Faces, to the RPH/FPS.

Methods

Spearman correlation was used to test for correlation between the three scales, and Wilcoxon rank-sum test was used to compare means between the RPH/FPS and NPS. The study participants were also asked to rate their preferences for the scales by rating the most preferred of the three scales as one (1) and the least preferred number three (3). 

Results

The RPH/FPS had a strong correlation with both the NPS and Wong-Baker Faces scales (RPH/FPS vs. NPS R=0.69, p<0.001: RPH-FPS vs. Wong-Baker Faces R=0.69, P<0.001). As for preferences, the RPH/FPS was ranked first on 36.9% of the surveys followed by NPS on 35.9%, and the Wong-Baker Faces on 22.3%. There were 4.9% of the surveys missing the preference rankings.

Conclusion

The results validate the RPH/FPS scale against the NPS and Wong-Baker Faces scales. This gives the clinicians a tool for objective assessment of pain and its effect on the recovery process, thereby minimizing the observed disconnect that sometimes happens between the reported pain intensity level and the providers' observation of the patient.

CE: Assessing Movement-Evoked Pain

ABSTRACT

One of the most common and nuanced tasks that nurses perform is pain assessment, particularly in acute postoperative settings where frequent reassessments are needed. Most assessments are limited to obtaining a pain intensity score with little attention paid to the conditions necessitating the assessment or the factors contributing to the pain. Pain is frequently assessed during rest, but seldom during periods of movement or activity, which is a crucial omission given that acute postoperative movement-evoked pain (MEP) is intense and a common barrier to healing and restoration of function. In addition to physical limitations, MEP can impede cognitive, emotional, and social functioning in ways that can contribute to chronic pain, mood disorders, and disability. Professional and regulatory standards are moving away from a focus on pain intensity to an emphasis on its context, impact on function, and associated distress. Thus, there are many driving forces compelling nurses to integrate MEP assessments into practice to expedite the restoration of biopsychosocial functioning in postoperative patients. The authors discuss the clinical significance of a MEP assessment as well as protocols and tools for completing such assessments.

Experimental Exploration of Objective Human Pain Assessment Using Multimodal Sensing Signals

Optimization of pain assessment and treatment is an active area of research in healthcare. The purpose of this research is to create an objective pain intensity estimation system based on multimodal sensing signals through experimental studies. Twenty eight healthy subjects were recruited at Northeastern University. Nine physiological modalities were utilized in this research, namely facial expressions (FE), electroencephalography (EEG), eye movement (EM), skin conductance (SC), and blood volume pulse (BVP), electromyography (EMG), respiration rate (RR), skin temperature (ST), blood pressure (BP). Statistical analysis and machine learning algorithms were deployed to analyze the physiological data. FE, EEG, SC, BVP, and BP proved to be able to detect different pain states from healthy subjects. Multi-modalities proved to be promising in detecting different levels of painful states. A decision-level multi-modal fusion also proved to be efficient and accurate in classifying painful states.

Anesthesiologist’s role as a communication coordinator of perioperative medicine: stressing the recognition of role in the changing medical atmosphere

Background: Perioperative care process in a hospital is considerably complex, involving multiple subprocesses, healthcare professionals, and systems in support of surgical care. The perioperative process is often the primary source of hospital admissions, driving the dominant part of hospital margins and accounts for a major part of all adverse events occurring in hospitals. The recent trend stresses the importance of adopting patient-centered and quality-proven care in many medical fields. Further, the emphasis on changing from fee-for-service to fee-for-value is increasing. These changes present challenges to anesthesiologists who play a central role in perioperative medicine.Current Concepts: Anesthesiologists are in contact with many surgeons and patients and are positioned to improve clinical outcomes. They need to have up-to-date, evidence-based knowledges on perioperative clinical management and know-how to apply, organize and practice them into efficient pathways for optimal outcomes. To accomplish such purposes, anesthesiologists need to acquire communication skills to reason and convincing related personnel including surgeons and patients.Discussion and Conclusion: The recent changing climate of perioperative medicine calls upon anesthesiologists to acquire knowledges driving quality care and demands the application of communicative skills to accomplish the required tasks.

Medical-Surgical Patients' and Registered Nurses' Satisfaction and Comprehensiveness of Patient Assessment Using the Clinically Aligned Pain Assessment Tool

BACKGROUND

The pain experience is complex, and nurses are challenged to objectively assess and document patients' subjective reports of pain. There is a clear need for an assessment tool that is easy to use and provides meaningful, actionable information for patients and nurses.

AIMS

This study explored nurses' and patients' satisfaction with the Clinically Aligned Pain Assessment (CAPA) as well as nurses' charting.

SETTING AND PARTICIPANTS

A convenience sample of adult patients and nurses on four medical-surgical units in one community hospital.

METHODS

A quantitative, two-group comparison design between patients and nurses using questionnaires to determine satisfaction and a retrospective chart review to determine comprehensiveness of nurse charting.

RESULTS

No significant differences existed between patients' and nurses' responses to seven of eight satisfaction questions The median score for seven of eight questions was 5 (using a 6-point Likert scale with 1 = strongly disagree and 6 = strongly agree), which demonstrated more than 80% agreement (somewhat agree, agree, strongly agree) among both groups that CAPA was superior to the NRS, based on individual responses. The one significant difference (p = 0.03) revealed patients were more likely to respond "agree or strongly agree" compared to nurses regarding the nurse thoroughly addressing patients' needs using CAPA. Inter-rater reliability using CAPA was determined to be 89.5%, and a panel of clinical experts determined CAPA had strong content validity of 88.33%. In addition, 70.41% of nurses charted comprehensively using CAPA.

CONCLUSION

As a result, CAPA was determined to be convenient, accurate, and valuable in guiding intervention decisions.

The IPA, a Modified Numerical System for Pain Assessment and Intervention

The objective of this study was to (1) construct a pain scale that improves communication between healthcare providers and patients (Interventional Pain Assessment [IPA] tool) and (2) to validate this new pain scale with the numeric rating scale of 0 to 10 Numerical Rating System (NRS).

Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series

BACKGROUND

Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use.

OBJECTIVE

To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG).

METHODS

Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests.

RESULTS

The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117).

CONCLUSION

Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

Pain Information Model and Its Potential for Predictive Analytics: Applicability of a Big Data Science Framework

PURPOSE

To describe the application of a big data science framework to develop a pain information model and to discuss the potential for its use in predictive modeling.

DESIGN AND METHOD

This is an application of a cross-industry standard process for a data mining adapted framework (the Applied Healthcare Data Science Framework) to build an information model on pain management and its potential for predictive modeling. Data were derived from electronic health records and were composed of approximately 51,000 records of unique adult patients admitted to clinical and surgical units between July 2015 and June 2019.

FINDINGS

The application of the Applied Healthcare Data Science Framework steps allowed the development of an information model on pain management, considering pain assessment, interventions, goals, and outcomes. The developed model has the potential to be used for predicting which patients are most likely to be discharged with self-reported pain.

CONCLUSIONS

Through the application of the framework, it is possible to support health professionals' decision making on the use of data to improve the effectiveness of pain management.

CLINICAL RELEVANCE

In the long term, the framework is intended to guide data science methodologies to personalize treatments, reduce costs, and improve health outcomes.

A Paradigm Shift for Movement-based Pain Assessment in Older Adults: Practice, Policy and Regulatory Drivers

BACKGROUND

The profession of nursing has been on the front line of pain assessment and management in older adults for several decades. Self-report has traditionally been the most reliable pain assessment method, and it remains a priority best practice in identifying the presence and intensity of pain. Although advances in technology, biomarkers, and facial cue recognition now complement self-report, it is still important to maximize self-report of pain and to gather understanding of the total pain experience directly from patients. Practices in pain assessment in older adults have evolved over the past 25 years, and current research and quality improvement studies seek not only to detect the presence of pain, but also to determine the best protocol for assessment and most important pain characteristics to assess. Increasing data are now supporting two emerging practices: (1) consistently assessing the impact of pain on function, and (2) measuring pain during movement-based activities rather than at rest.

OBJECTIVE

The purpose of this article is thus to discuss the shifting paradigm for movement-based pain assessment in older adults, as well as the practice, policy, and regulatory drivers that support this practice change.

∗Surgical patients' and registered nurses' satisfaction and Perception of Using the Clinically Aligned Pain Assessment (CAPA©) Tool for Pain Assessment

Pain management is a significant issue in all health care systems. Pain is often mismanaged because of lack of a comprehensive pain assessment. This often leads to inappropriate medication administration, inadequate pain relief, negative patient outcomes, and delayed discharges. There is an opportunity for developing a more comprehensive pain assessment. The Clinically Aligned Pain Assessment (CAPA©) pain tool was developed by the University of Utah.. It assesses 5 dimensions of pain: comfort, change in pain, pain control, functioning, and sleep. The purpose of the study was to determine if the patients and nurses were more satisfied discussing pain with CAPA© or the numeric rating scale (NRS) and words to describe pain, intensity, location, duration, and aggravating and/or alleviating factors (WILDA) tool. This study had a 2-group comparison design with mixed methods approach. One group comprised patients and the other group comprised nurses. There were 63 nurses and 95 patients enrolled in the study at two perioperative hospitals. The results demonstrated that the patients and nurses were more satisfied with using the CAPA© tool than the NRS/WILDA. The CAPA© tool allows for a more comprehensive way to assess pain which has the potential to create more effective treatments for pain, improve discharge time, and positive patient outcomes.

Multidimensional Pain Assessment Tools for Ambulatory and Inpatient Nursing Practice

BACKGROUND

One of the critical components in pain management is the assessment of pain. Multidimensional measurement tools capture multiple aspects of a patient's pain experience but can be cumbersome to administer in busy clinical settings.

AIM

We conducted a systematic review to identify brief multidimensional pain assessment tools that nurses can use in both ambulatory and acute care settings.

METHODS

We searched PUBMED/MEDLINE, PsychInfo, and CINAHL databases from January 1977 through December 2019. Eligible English-language articles were systematically screened and data were extracted independently by two raters. Main outcomes included the number and types of domains captured by each instrument (e.g., sensory, impact on function, temporal components) and tool characteristics (e.g., administration time, validity) that may affect instrument uptake in practice.

RESULTS

Our search identified eight multidimensional assessment tools, all of which measured sensory or affective qualities of pain and its impact on functioning. Most tools measured impact of pain on affective functioning, mood, or enjoyment of life. One tool used ecological momentary assessment via a web-based app to assess pain symptoms. Time to administer the varying tools ranged from less than 2 minutes to 10 minutes, and evidence of validity was reported for seven of the eight tools.

CONCLUSIONS

Our review identified eight multidimensional pain measurement tools that nurses can use in ambulatory or acute care settings to capture patients' experience of pain. The most important element in selecting a multidimensional pain measure, though, is that one tool is selected that best fits the practice and is used consistently over time.

Topical Review: State of the Field of Child Self-Report of Acute Pain

OBJECTIVE

Children experience acute pain with routine and emergent healthcare, and untreated pain can lead to a range of repercussions. Assessment is vital to diagnosing and treating acute pain. Given the internal nature of pain, self-report is predominant. This topical review reflects on the state of the field of pediatric acute pain self-report, and proposes a framework for acute pain assessment via self-report.

METHOD

We examine self-report of acute pain in preschool-age children through adolescents, and we detail a three-step process to optimize acute pain assessment.

RESULTS

The first step is to decide between a pain screening or assessment. Several 0-10 self-report scales are available for pain screenings. Assessment requires specification of the goals and domains to target. Core criteria, common features, modulating factors, and consequences of acute pain provide a framework for a comprehensive pain assessment. Whereas there are some measures available to assess aspects of these domains, there are considerable gaps. Last, it is important to integrate the data to guide clinical care of acute pain.

CONCLUSIONS

Self-report of acute pain is dominated by single-item intensity scales, which are useful for pain screening but inadequate for pain assessment. We propose a three-step approach to acute pain assessment in children. However, there is a need for measure development for a comprehensive evaluation of the core criteria, common features, modulating factors, and consequences of pediatric acute pain. In addition, there is limited guidance in merging data found in multifaceted evaluations of pediatric acute pain.

Low back pain: critical assessment of various scales

PURPOSE

To study the various pain assessment tools based on their psychometric properties and ease of use.

METHODS

Published articles on psychometric properties of pain tools were accessed and data collected for low back pain (LBP)-specific tools, generic tools, neuropathic LBP tools, tools for cognitively impaired patients, and tools for acute LBP.

RESULTS

Among the LBP-specific tools, Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) have good construct validity and reliability, and responsiveness over short intervals. Quebec Back Pain Disability Scale (QBPDS) gauges only disability and sleep. Among the generic tools, McGill Pain Questionnaire (MPQ), West Haven-Yale Multidimensional Pain Inventory (MPI), and Brief Pain Inventory (BPI) show good responsiveness, but BPI is the only tool validated for LBP. Neuropathic Pain Scale (NPS) and Short Form-MPQ-2 (SF-MPQ-2) are both reliable tools for neuropathic LBP. For cognitively impaired patients, Pain Assessment in Advanced Dementia (PAINAD), Abbey Pain Scale (APS), and Doloplus-2 are all reliable tools, but PAINAD has good construct validity. For acute pain, Clinically Aligned Pain Assessment (CAPA) is reliable and responsive, but presently, unidimensional tools and SF-MPQ-2 are the tools most preferred.

CONCLUSION

Based on psychometric properties and ease of use, the best tools for LBP seem to be RMDQ/ODI (among LBP-specific tools), BPI (among generic tools), SF-MPQ-2/NPS (for neuropathic LBP), PAINAD (for cognitively impaired patients), and unidimensional tools and SF-MPQ-2 (for acute pain). Overall, BPI seems to be a tool that can be relied upon the most. These slides can be retrieved under Electronic Supplementary Material.

Pilot Testing the Clinically Aligned Pain Assessment (CAPA) Measure

BACKGROUND

Pain is one of the most common symptoms experienced by patients in acute care hospitals and acutely ill patients experience both acute and chronic pain. Unrelieved pain can have a profound negative impact on individuals' functional status, well-being, quality of life, and satisfaction with care. For providers, managing pain can be challenging. While the numeric rating scale is widely accepted and used, it measures only pain intensity. CAPA® pain assessment offers an alternative approach in which providers have a conversation with patients about pain and how it impacts five key areas.

AIMS

The purpose of this pilot project was to evaluate provider and patient satisfaction with the CAPA® measure as compared to a numeric rating scale when evaluating patients' experience with pain.

DESIGN

A mixed methods qualitative design was employed.

SETTING

This study was conducted at a 247-bed community teaching hospital in Providence, RI.

PARTICIPANTS

The target sample included patients admitted to the study units and providers who delivered care to patients on the study units and used the numeric rating scale and the CAPA® method of assessment.

METHODS

In focus groups, nurses and physicians were asked about satisfaction with evaluating patients' pain with the numeric rating scale as compared to CAPA®. During a one-to-one interview, patients were asked to describe their impressions of the two assessment measures.

RESULTS

Nurses, physicians, and patients were satisfied that CAPA® effectively evaluated pain and provided more information about pain than the numeric rating scale.

CONCLUSIONS

CAPA® is recommended as a supporting assessment to evaluate patients' pain experience in acute care.

More than pills: alternative adjunct therapies to improve comfort in hospitalised patients

Discomfort in the hospitalised patient continues to be one of the healthcare system’s greatest challenges to positive patient outcomes. The patients’ ability to focus on healing is impaired by discomforts such as pain, nausea and anxiety. Alternative, non-pharmacological therapies have shown to be effective in reducing discomfort and managing pain, complementing analgesic agents and optimising pain therapy modalities. This multi-cycle project is aimed to assess the effect of alternative therapies on inpatient, progressive care patients who reported discomfort or little to no relief in discomfort from prescribed analgesics and adjuvant agents. In the first Plan Do Study Act (PDSA) cycle, patients who reported discomfort were offered aromatherapy or visual relaxation DVDs. In the second PDSA cycle, patients were offered a comfort menu that consisted of multiple alternative interventions such as aromatherapy, ice or heat and ambulation. During each cycle, participants completed a survey measuring comfort levels before and after patient-selected alternative intervention(s) were administered. In the first PDSA cycle, 88% of patients reported an increase in comfort level after the intervention, and 97% reported an interest in using alternative therapy again. In the second PDSA cycle, 47% reported increased comfort, and 89% indicated a willingness to try alternative therapies again for improvement of comfort level. Overall, the quality improvement project increased the level of comfort reported by hospitalised patients, creating a gateway to comfort with less emphasis on prescribed analgesic medications.

The addition of intrathecal morphine to a transversus abdominis plane block with liposome bupivacaine provides more effective analgesia than transversus abdominis plane block with liposome bupivacaine alone: a retrospective study

Objective

The purpose of this study was to determine if the standardization of using liposomal bupivacaine in transversus abdominis plane (LB TAP) blocks eliminated the benefit of intrathecal morphine (ITM) in patients after undergoing a cesarean section.

Methods

This was a retrospective review of 358 patients who underwent cesarean section over an 11-month period. Patients were divided into two groups: those who received only an LB TAP (67 patients) vs those who received an LB TAP and ITM (291 patients). All blocks were placed bilaterally under ultrasound guidance after closure of the surgical incision, and morphine was added to the spinal used for the case.

Results

The group that received ITM in addition to the LB TAP received less opioids in the first 24 hours (median 5 range 0–150 mg morphine equivalents [ME] vs 15 range 0–76 mg ME; P<0.001) and less opioids overall (35 mg range 0–450 mg ME vs 47.5 mg range 0–189 mg ME; P=0.041) when compared to the LB TAP block only group. There was no difference between the two groups in opioid use from 24 to 48 hours or 48 to 72 hours.

Conclusion

Patients who received ITM in addition to an LB TAP block received less opioids in the first 24 hours and overall when compared to those who received an LB TAP alone. This suggests that ITM still plays a role in providing analgesia to patients who have also received an LB TAP block as a part of their multimodal pain regimen for cesarean sections.

Postoperative Pain Management: A Bedside Perspective

PURPOSE

Postoperative pain management is an ongoing challenge in surgical care, during which inadequate relief can contribute to postoperative complications, and nurses are key figures in this process. The aim of the present study was to gain knowledge of how nurses provide postoperative pain management for women undergoing major surgery for endometriosis.

DESIGN

An ethnographic field study, consisting of semi-structured interviews and participant observations, was conducted in a setting of 2 gynecological units within a large Scandinavian university hospital.

METHOD

The participants were mainly nurses and patients. The overall focus for the field observations and interviews was on how the participants interacted and made care decisions concerning pain. The analysis focused on nurse-patient interaction in postoperative bedside care. A principal theme, pain-related nursing practice emerged, together with the sub-themes nurse-patient interaction, interpretation and assessment of pain and pain management, which represented a circular process, identified in bedside practice.

CONCLUSIONS

To some extend the postoperative pain management was influenced by unexpressed health beliefs and routine actions, and patient involvement was not prominent. Furthermore, the existing guidelines for pain management did not seem useful to the nurses.

CLINICAL IMPLICATIONS

There is a need to develop a new and more practice-oriented postoperative pain management, in ways that also integrate the patient experience.