Barriers to better pain control in hospitalized patients

Not Just a Pain: A Medical Simulation Case About Biased Communication and Osteomyelitis in Pediatric Sickle Cell Anemia

Introduction

Biases in communication can be harmful to patient perceptions of care and the medical team's decision-making. Optimal communication must be taught and practiced similarly to the optimal management of the complex medical conditions associated with sickle cell disease (SCD). This simulation is designed to teach about biases, optimizing communication to and about a patient with SCD, and appropriately diagnosing and managing pediatric osteomyelitis as a complication of SCD.

Methods

We designed and implemented a simulation case targeting emergency medicine residents and fellows to raise awareness about biases associated with SCD care and the complication of osteomyelitis in children with SCD. The case was delivered as a scheduled educational activity. Guided debriefing about optimizing care and communication for this patient population followed the simulation. We measured outcomes based on facilitator field notes and participant evaluations (Likert-scale and open-response questions).

Results

Forty learners of varying medical practice proficiencies, societal experiences, and demographics participated, with 30 completing the postsimulation feedback survey. A majority (97%) of participants indicated that the experience was useful and would improve their clinical performance. Participants learned from each other's language and communication styles and reflected on their own communication.

Discussion

Overall, participants found the simulation very useful as a review of the medical diagnosis and management of osteomyelitis in pediatric SCD. Moreover, they were very engaged and interested in the opportunity to learn about communication biases, particularly as these relate to SCD, to optimize their patient care.

Using four different clinical tools as predictors for pain after total hip arthroplasty: a prospective cohort study

Background

Treatment of postoperative pain remains a significant clinical problem, and prediction of patients with a risk of higher postoperative pain levels is an important focus. We aimed to identify patients undergoing total hip arthroplasty (THA) with risk of higher pain levels at 24 h postoperatively by using four simple and easily available clinical tools.

Methods

This prospective observational cohort study included 102 patients having THA at Zealand University Hospital in Denmark. The following predictive tools were investigated for identifying patients with higher postoperative pain levels at 24 h postoperatively, both at rest and during mobilization: preoperative pain by peripheral venous cannulation (PVC) (dichotomized according to numerical rating scale pain ≤ 2/> 2 (PVC-Low/PVC-High) (primary outcome); the post anesthesia care unit (PACU) nurses’ expectations of patients pain levels; patients early pain levels at the PACU; and patients own forecast of postoperative pain levels. The Mann-Whitney U test was used to analyze comparisons between prediction groups. For the primary outcome we considered a p-value < 0.01 as statistically significant and for other outcomes a p-value of 0.05.

Results

We found no significant differences between the PVC groups for pain during mobilization at 24-h postoperatively: PVC-Low: 6 (4–8) (median, (IQR)) versus PVC-High: 7 (5–8) (median, (IQR)), p = 0.10; and for pain at rest: PVC-Low 2 (0–3) (median, (IQR)) versus PVC-High 3 (2–5) (median, (IQR)), p = 0.12. Other comparisons performed between predictive groups did not differ significantly.

Conclusions

In this prospective cohort study of 102 THA patients, we did not find that preoperative pain by PVC, when using a cut-off point of NRS ≤ 2, were able to predict postoperative pain at 24 h postoperatively. Neither did PACU nurses’ prediction of pain, patients forecast of pain, nor did maximum pain levels at the PACU.

Trial registration

Retrospectively registered 20th February 2018 at ClinicalTrials.gov (NCT03439566).

Orthopedic Professionals' Recognition and Knowledge of Pain and Perceived Barriers to Optimal Pain Management at Five Hospitals

Pain is a challenge for orthopedic healthcare professionals (OHCP). However, pain studies examined the competencies of a single OHCP category, did not consider various pain management domains or barriers to optimal pain service, and are deficient across the Arabic Eastern Mediterranean region. We surveyed OHCP's recognition and knowledge of pain and perceived barriers to optimal pain service (361 OHCP, five hospitals). Chi square compared doctors' (n = 63) vs. nurses/physiotherapists' (n = 187) views. In terms of pain recognition, more nurses had pain management training, confidently assessed pediatric/elderly pain, were aware of their departments' pain protocols, and felt that their patients receive proper pain management. More doctors comfortably prescribed opiate medications and agreed that some nationalities were more sensitive to pain. For pain knowledge, more nurses felt patients are accurate in assessing their pain, vital signs are accurate in assessing children's pain, children feel less pain because of nervous system immaturity, narcotics are not preferred due respiratory depression, and knew pre-emptive analgesia. As for barriers to optimal pain service, less nurses agreed about the lack of local policies/guidelines, knowledge, and skills; time to pre-medicate patients; knowledge about medications; complexity of the clinical environment; and physicians being not comfortable prescribing pain medication. We conclude that doctors required confidence in pain, especially pediatric and geriatric pain, using vital signs in assessing pain and narcotics use. Their most perceived barriers were lack of local policies/guidelines and skills. Nurses required more confidence in medications, caring for patients on narcotics, expressed fewer barriers than doctors, and the complexity of the clinical environment was their highest barrier. Educational programs with clinical application could improve OHCPs' pain competencies/clinical practices in pain assessment and administration of analgesics.

The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient

Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.

Pain Knowledge and Attitude Survey among Health-care Professionals at a University Hospital in Saudi Arabia

Background:

There is growing awareness in the hospital setting toward pain management to decrease patients' suffering, improve postsurgical outcomes and to decrease cost.

Objective:

The aim of this study was to get an overview of the knowledge and attitude among health-care professionals toward pain management in the King Fahd Hospital of the University, and the need for an educational plan to improve pain service in hospitals.

Materials and Methods:

We conducted a survey over a 3-month period based on a 30-question questionnaire to test pain knowledge and attitude among nurses and physicians of different specialties, the level of education and years of experience.

Results:

The results of the data showed that knowledge and attitude of pain were deficient and unsatisfactory.

Conclusion:

We concluded that efforts to spread knowledge and education of proper pain management among health-care professionals are required. Further surveys involving more hospitals are warranted.

Painful Discrimination in the Emergency Department: Risk Factors for Underassessment of Patients' Pain by Nurses

INTRODUCTION

Unrelieved acute musculoskeletal pain continues to be a reality of major clinical importance, despite advancements in pain management. Accurate pain assessment by nurses is crucial for effective pain management. Yet inaccurate pain assessment is a consistent finding worldwide in various clinical settings, including the emergency department. In this study, pain assessments between nurses and patients with acute musculoskeletal pain after extremity injury will be compared to assess discrepancies. A second aim is to identify patients at high risk for underassessment by emergency nurses.

METHODS

The prospective PROTACT study included 539 adult patients who were admitted to the emergency department with musculoskeletal pain. Data on pain assessment and characteristics of patients including demographics, pain, and injury, psychosocial, and clinical factors were collected using questionnaires and hospital registry.

RESULTS

Nurses significantly underestimated patients' pain with a mean difference of 2.4 and a 95% confidence interval of 2.2-2.6 on an 11-points numerical rating scale. Agreement between nurses' documented and patients' self-reported pain was only 27%, and 63% of the pain was underassessed. Pain was particularly underassessed in women, in persons with a lower educational level, in patients who used prehospital analgesics, in smokers, in patients with injury to the lower extremities, in anxious patients, and in patients with a lower urgency level.

DISCUSSION

Underassessment of pain by emergency nurses is still a major problem and might result in undertreatment of pain if the emergency nurses rely on their assessment to provide further pain treatment. Strategies that focus on awareness among nurses of which patients are at high risk of underassessment of pain are needed.

iACT-CEL: A Feasibility Trial of a Face-to-Face and Internet-Based Acceptance and Commitment Therapy Intervention for Chronic Pain in Singapore

Psychological interventions are increasingly utilising online or mobile phone based platforms to deliver treatment, including that for people with chronic pain. The aims of this study were to develop an adapted form of Acceptance and Commitment Therapy (ACT) for chronic pain in Singapore and to test the feasibility of elements of this treatment delivered via the internet and email. Methods. Thirty-three participants recruited from a tertiary pain management clinic and via the clinic website participated in this program over a period of five weeks with a 3-month follow-up. Treatment outcomes were assessed at three assessment time points. Results. 90.9% of participants completed the program, with 81.8% reporting high treatment satisfaction. Significant changes in depression, t = 3.08, p = 0.002 (baseline to posttreatment), t = 3.28, p = 0.001 (baseline to follow-up), and pain intensity, t = 2.15, p = 0.03 (baseline to follow-up) were found. Mainly small effect sizes (d = 0.09-0.39) with a moderate effect size (d = 0.51) for depression were found at posttreatment. Clinically meaningful improvement in at least one outcome was demonstrated in 75.8% of participants. Conclusions. An adaptation of ACT for people with chronic pain in Singapore appears promising. Optimal treatment design and more effective ways to target outcomes and processes measured here are required.

Perception of barriers to postoperative pain management in elderly patients in Polish hospitals with and without a "Hospital Without Pain" Certificate - a multi-center study

INTRODUCTION

In 2005-2050, the global population of elderly people will increase by 12%. This will lead to increased demand for such healthcare services as hospital care or surgical interventions. Pain in elderly patients is a substantial problem. Insufficiently controlled postoperative pain continues to be a widespread phenomenon. Pain management in Poland is usually based on nursing care supervised by an anesthesiologist or surgeon. The aim of the study was to identify barriers to effective nurse-controlled analgesia in postoperative pain management in elderly patients in hospitals with and without a Hospital Without Pain certificate.

MATERIAL AND METHODS

The study was conducted after the approval of the study protocol by the Independent Bioethics Committee for Scientific Research of the Medical University of Gdansk. The study project was multicenter and was conducted from July 2012 to December 2013. The research was questionnaire-based and used the Polish version of the Nurses' Perceived Obstacles to Pain Assessment and Management Practices questionnaire. The project included 676 nurses from hospitals awarded the Hospital Without Pain Certificate and 926 respondents from hospitals without the certificate.

RESULTS

After calculating the overall average result in particular groups, healthcare system-related problems were first among the barriers hindering pain management in elderly patients M = (C = 3.81, N/C = 3.87). Patient-related barriers were second (M = 3.77). Physician- and nurse-related barriers took the subsequent positions, with very similar scores M = (C = 3.47, N/C = 3.44) and M = (C = 3.46, N/C = 3.44), respectively.

CONCLUSIONS

The greatest barriers to pain management in elderly patients are related to the healthcare system. Nurses from Hospital Without Pain certified hospitals devoted significantly more time to relieving pain through non-pharmacological methods.

Assessment of pain in a Norwegian Emergency Department

Background

Although pain management is a fundamental aspect of care in emergency departments (EDs), inadequate treatment of pain is unfortunately common. There are multiple local protocols for pain assessment in the ED. This study evaluated whether the initial assessment and treatment of pain in the ED are in accordance with the in-hospital protocol of the ED at a Norwegian University Hospital.

Materials and methods

Prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation. The patients’ perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10.

Results

Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58 %), only 14 % received pain relief.

Discussion

Assessment and treatment of pain in the ED are inadequate and not in line with the local protocols. A focus on strategies to improve pain treatment in the ED is a necessary aspect of developing optimal acute patient care in Norway in the future.

Healthcare providers' accuracy in assessing patients' pain: A systematic review

OBJECTIVE

Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy.

METHODS

A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain.

RESULTS

60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity.

CONCLUSION

Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (>10 years) and those providing care for vulnerable patient populations.

PRACTICE IMPLICATIONS

More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients.

Nurses' competence in pain management in patients with opioid addiction: A cross-sectional survey study

BACKGROUND

There may be up to 21 million opioid abusers in the world. Drug abuse and associated health-related problems are increasing. Opioid addiction can cause serious bacterial infection, injury and trauma, conditions that can trigger pain. Opioid abusers experience pain differently from non-addicts. There is limited research on nurses' competence to provide pain treatment to patients with opioid addiction.

OBJECTIVE

To report on a Norwegian pilot study examining nurses' knowledge about pain and competence in treating pain in patients who abuse opioids.

DESIGN

A descriptive cross-sectional survey design was employed.

PARTICIPANTS

Nurses at medical (n=64) and orthopaedic (n=34) units at two urban, public Norwegian hospitals.

METHODS

Data were collected in January 2010 using a self-administered questionnaire. Sample selection was determined by purposive sampling. The response rate was 54%.

RESULTS

Eighty-eight percent of nurses did not have sufficient knowledge about pain treatment in patients with opioid addiction. Eight-eight percent and seventy-seven percent regarded work-place experience and colleagues as the primary contributors to their knowledge about pain treatment, respectively. Work-place experience contributed most to nurses' competence. Ninety percent, 70% and 84% of nurses responded that education, literature and information technology, respectively, played a minor role in obtaining knowledge about pain management. Sixty-five percent of the respondents had basic skills for evaluating pain, although 54% could not evaluate the degree of pain. Almost 62% of nurses did not trust the pain experience self-reported by patients who were opioid abusers.

CONCLUSION

Our study shows shortcomings in the nurses' competence to evaluate and treat pain, suggesting that patients with opioid addiction may not receive adequate pain management. Nurses' competence to offer pain treatment to opioid abusers could be characterized as experience-based rather than evidence-based.

Concordance and discordance in patient and provider perceptions of dizziness

PURPOSE

The purpose of the present investigation was to determine whether there are significant differences in patient/healthcare provider perceptions of patient's dizziness severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation.

MATERIALS AND METHODS

This was a prospective investigation of 30 patient-provider dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were instructed to complete the same measures following the patient's clinic visit from what they estimated was the patient's point of view. The two measures were analyzed for concordance and discordance.

RESULTS

Patient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation.

CONCLUSIONS

The results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are rooted in clinically significant anxiety either related to, or unrelated to, a history of vestibular system impairment.

Substance misuse teaching in undergraduate medical education

BACKGROUND

Over 12,000 hospital admissions in the UK result from substance misuse, therefore issues surrounding this need to be addressed early on in a doctor's training to facilitate their interaction with this client group. Currently, undergraduate medical education includes teaching substance misuse issues, yet how this is formally integrated into the curriculum remains unclear.

METHODS

Semi-structured interviews with 17 key members of staff responsible for the whole or part of the undergraduate medical curriculum were conducted to identify the methods used to teach substance misuse. Using a previously devised toolkit, 19 curriculum co-ordinators then mapped the actual teaching sessions that addressed substance misuse learning objectives.

RESULTS

Substance misuse teaching was delivered primarily in psychiatry modules but learning objectives were also found in other areas such as primary care placements and problem-based learning. On average, 53 teaching sessions per medical school focused on bio-psycho-social models of addiction whereas only 23 sessions per medical school focused on professionalism, fitness to practice and students' own health in relation to substance misuse. Many sessions addressed specific learning objectives relating to the clinical features of substance dependence whereas few focused on iatrogenic addiction.

CONCLUSIONS

Substance misuse teaching is now inter-disciplinary and the frequent focus on clinical, psychological and social effects of substance misuse emphasises the bio-psycho-social approach underlying clinical practice. Some areas however are not frequently taught in the formal curriculum and these need to be addressed in future changes to medical education.

Quality pain management in the hospital setting from the patient's perspective

BACKGROUND

Pain management is a crucial issue for patients, and patients' perception of care is an important quality outcome criterion for health care institutions. Pain remains a common problem in hospitals, with subsequent deleterious effects on well-being.

OBJECTIVES

To assess the epidemiology of pain (frequency, severity, and interference), patient participation in pain treatment decisions, and patient satisfaction with care in a hospital setting.

METHODS

A point-prevalence study was conducted. Data were collected with the American Pain Society Patient Outcome Questionnaire (Icelandic version). Participants (n = 308) were ≥ 18 years old, alert, and hospitalized for ≥ 24 hours.

RESULTS

The response rate was 73%. The mean age of participants was 67.5 (SD = 17.4; range 18 to 100) years, and 49% were men. Pain prevalence in the past 24 hours was 83%, mean worst pain severity was 4.6 (SD = 3.1), and 35% experienced severe pain (≥ 7 on 0 to 10 scale). Moderate to severe interference with activities and sleep was experienced by 36% and 29% of patients respectively. Patient participation in decision making was weakly associated with spending less time in severe pain and better pain relief. Patient satisfaction was related to spending less time in severe pain, better pain relief, and lower pain severity (P < 0.05).

CONCLUSIONS

Pain was both prevalent and severe in the hospital, but patient participation in decision making was related to better outcomes. Optimal pain management, with emphasis on patient participation in decision making, should be encouraged in an effort to improve the quality of care in hospitals.

Sickle cell disease: management options and challenges in developing countries

Sickle Cell Disease (SCD) is the most common genetic disorder of haemoglobin in sub-Saharan Africa. This commentary focuses on the management options available and the challenges that health care professionals in developing countries face in caring for patients with SCD. In a developing countries like Ghana, new-born screening is now about to be implemented on a national scale. Common and important morbidities associated with SCD are vaso-occlusive episodes, infections, Acute Chest Syndrome (ACS), Stroke and hip necrosis. Approaches to the management of these morbidities are far advanced in the developed countries. The differences in setting and resource limitations in developing countries bring challenges that have a major influence in management options in developing countries. Obviously clinicians in developing countries face challenges in managing SCD patients. However understanding the disease, its progression, and instituting the appropriate preventive methods are paramount in its management. Emphasis should be placed on early counselling, new-born screening, anti-microbial prophylaxis, vaccination against infections, and training of healthcare workers, patients and caregivers. These interventions are affordable in developing countries.

Semiological evaluation of pain according to its origin: a prospective, observational, and national study of current French medical practice

OBJECTIVE

To determine how the origin of acute pain influences its semiological characteristics, and to evaluate the efficacy and safety of two Level 2 analgesic combinations in general practice.

RESEARCH DESIGN AND METHODS

This prospective, observational, multicenter study enrolled patients who consulted general practitioners across France for intense pain that lasted ≥7 days and for which the physician prescribed paracetamol-codeine or paracetamol-tramadol. Completed physician (Day 0) and patient (Days 0-3 and Days 4-7) questionnaires provided data on the origin, characteristics, impact, and treatment of the pain, during the 7 days after the initial consultation.

MAIN OUTCOME MEASURES

Pain intensity (0-10 unidimensional numerical scale), type (SF-MPQ) and impact on quality of life (QoL; SF-12).

RESULTS

Overall, 1003 patient questionnaires were completed for Days 0-3 and 941 for Days 4-7. The origin of pain was most commonly disease or trauma. Mean baseline pain intensity was 7 (SD 1.3; 0-10 numerical rating scale), and was similar regardless of the origin. The time-course of pain differed according to its origin: more than two-thirds of patients with trauma/work accident related pain described it as being constant, whereas 43% of those with disease-related pain described it as recurrent/intermittent. The origin of pain also influenced its QoL impact: trauma/work accident related pain led to functional and/or professional temporary incapacity in 77% and 83% of patients (vs 63% for disease-related pain), while disease-related pain led to a change in mood and/or feeling of anxiety in 79% of patients (vs 47% [trauma] and 58% [work accident related]). Both paracetamol-codeine and paracetamol-tramadol reduced pain intensity by approximately 75% and were well tolerated. Key limitations relate to the observational study design, countered by advantages gained from the 'real life' evaluation of acute pain and its treatment in a general medical practice setting.

CONCLUSIONS

Acute pain should not be understood as a single entity but as multiple entities with specific characteristics related to its underlying origin. Furthermore, our data suggest that, as already demonstrated in clinical trials, Level 2 analgesia provides effective relief of acute pain in 'real life' conditions.

Pain in children: knowledge and perceptions of the nursing staff at a rural tertiary care teaching hospital in India

OBJECTIVES

To assess the knowledge and perception regarding pain amongst nursing staff and to determine whether varying clinical exposure to painful procedures in children had any association with their perception of pain.

METHODS

A consensually validated questionnaire containing combination of questions from basic (must know) and advanced (nice to know) areas of knowledge about nursing pediatric patients and questions related to nurses' perception about pain in pediatric patients was administered to the eligible nursing staff at a Rural Tertiary Care Hospital in Western India. The responses to the questionnaire were analyzed using descriptive statistics and the comparisons were made by applying chi-square test.

RESULTS

Three Hundred and Fifty one usable questionnaires (83.37 %) out of 421 were returned. The knowledge of the nurses in general regarding pain was observed to be poor. Only 60 % of all the nurses had complete knowledge of all the basic questions asked. Only 3.1 % had answered all of the five advanced questions correctly, while 96.9 % of the nurses had answered one or more questions incorrectly.

CONCLUSIONS

The deficit in knowledge and shortcomings in perception of nursing staff needs to be addressed and steps need to be taken to improve the nurse's knowledge and modify beliefs and attitude of the nursing staff towards the pain of the pediatric patients.

A silent epidemic: community nursing and effective pain management

Effective pain management presents challenges to health care practitioners, particularly in the community setting. This is evident from the complexities associated with the phenomenon of pain and the circumstances for those patients suffering from pain. An overwhelming amount of literature and research surrounding pain exists in an effort to improve our understanding of pain, assessment and management strategies. But patients in pain are not managed well in the community or acute setting. Health care professionals continue to underestimate and under treat pain, failing to meet the patient's individual needs. Pain management it is not about cure, nor is it as simple as reporting zero on a pain score- it is about knowledge, expertise and understanding. Pain is a subjective and very personal experience, wherein health care professionals must listen to the patients' story. Myths and fears surrounding pain remains a barrier to effective management and care. This article aims to dispel the myths and improve clinical practice, particularly in effective pain assessment so patients in the community presenting with pain can be managed individually and effectively. Nurses need to be proactive in their approach, through effective communication and decision making, trusting in our patients' and their pain experience. This is key to a successful approach to managing patients' pain effectively.

Pain and anxiety during bone marrow aspiration/biopsy: Comparison of ratings among patients versus health-care professionals

PURPOSE

To assess pain and anxiety during bone marrow aspiration/biopsy (BMA) among patients versus health-care professionals (HCPs).

METHOD

235 adult hematologic patients undergoing BMA were included. BMA was performed by 16 physicians aided by nine registered nurses (RNs). Questionnaires were used to obtain patients and HCPs ratings of patients' pain and anxiety during BMA. Patterns of ratings for pain and anxiety among patients HCPs were estimated with proportions of agreement P(A), Cohen's kappa coefficient (κ), and single-measure intra-class correlation (ICC). We also explored if associations of ratings were influenced by age, sex, type and duration of BMA.

RESULTS

The P(A) for occurrence of rated pain during BMA was 73% between patients and RNs, and 70% between patients and physicians, the corresponding κ was graded as fair (0.37 and 0.33). Agreement between patients and HCPs regarding intensity of pain was moderate (ICC=0.44 and 0.42). Severe pain (VAS>54) was identified by RNs and physicians in 34% and 35% of cases, respectively. Anxiety about BMA outcome and needle insertion was underestimated by HCPs. P(A) between patients and RNs and patients and physicians regarding anxiety ranged from 53% to 59%. The corresponding κ was slight to fair (0.10-0.21). ICC showed poor agreement between patients and HCPs regarding intensity of anxiety (0.13-0.36).

CONCLUSIONS

We found a better congruence between patients and HCPs in pain ratings than in anxiety ratings, where the agreement was low. RNs and physicians underestimated severe pain as well as anxiety about BMA outcome and needle insertion.

Prevalence and treatment of pain in adults admitted to Italian hospitals

BACKGROUND

Very few studies have been conducted on the presence and control of pain in Italian hospitals.

AIMS

The present study estimates pain prevalence and therapy in Italian hospitalised patients.

METHODS

In the autumn of 2000, a survey was taken on 4523 inpatients throughout Italy. All eligible patients were given a questionnaire with two Numerical Rating Scales (NRS) concerning their pain intensity at interview and over the previous 24 h. Nurses were given a second questionnaire asking for information on analgesic treatment and another NRS about the pain they supposed the patient felt.

RESULTS

At interview, 91.2% (95%CI: 90.3-92.1%) of the patients reported pain; 46.6% reported severe pain. The prevalence of severe pain was significantly lower in women and was double in general medicine wards compared to surgical wards. The degree of agreement between the pain reported by the patient and the pain scores given by the nurse was poor (Cohen K=0.318). Only 28.5% of the inpatients had taken analgesics in the past 24 h and the probability of receiving analgesic treatment was higher for women (adjusted OR=1.33, 95%CI: 1.14-1.54) and lower for general medicine compared to surgical wards (adjusted OR=0.55, 95%CI: 0.45-0.64), while it was unrelated both to the patient's self-reported pain and to level of pain assessed by the nurse.

CONCLUSIONS

Pain affects an impressively high percentage of inpatients and is largely untreated and unrecognised in Italian wards. Educational intervention is required to improve the knowledge and attitudes of health professionals towards the approach and handling of patients in pain.

Pain in the ICU: a psychiatric perspective

Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.

Computational opioid prescribing: a novel application of clinical pharmacokinetics

We implemented a pharmacokinetics-based mathematical modeling technique using algebra to assist pre-scribers with point-of-care opioid dosing. We call this technique computational opioid prescribing (COP). Because population pharmacokinetic parameter values are needed to estimate drug dosing regimen designs for individual patients using COP, and those values are not readily available to prescribers because they exist scattered in the vast pharmacology literature, we estimated the population pharmacokinetic parameter values for 12 commonly prescribed opioids from various sources using the bootstrap resampling technique. Our results show that opioid dosing regimen design, evaluation, and modification is feasible using COP. We conclude that COP is a new technique for the quantitative assessment of opioid dosing regimen design evaluation and adjustment, which may help prescribers to manage acute and chronic pain at the point-of-care. Potential benefits include opioid dose optimization and minimization of adverse opioid drug events, leading to potential improvement in patient treatment outcomes and safety.

The influence of anchoring on pain judgment

CONTEXT

Research on decision making suggests that a wide range of spontaneous processes may influence medical judgment.

OBJECTIVES

We considered an easily accessible strategy, anchoring and insufficient adjustment, which might contribute to health care professionals' miscalibration of patients' pain.

METHODS

A sample (n=423) of physicians, nurses, medical students, and nursing students participated in a computerized task that showed 16 vignettes featuring fictitious patients reporting headache. In the experimental condition, participants were asked to evaluate the severity of the patient's pain before and after knowing the patient's rating. In the control condition, participants were shown all information about the patient at the same time and were required to make judgments in a single stage.

RESULTS

When participants could express an initial impression before knowing the patient's rating, they fully anchored to their initial impressions in almost half of the responses. Moreover, even among those who revised their initial impression, the extent of the revision was often insufficient. Greater anchoring was associated with patients' ratings that were higher than the participants' initial impression. Finally, we provided evidence that anchoring increased pain miscalibration. We discuss our findings in terms of their contribution to the understanding of the cognitive processes involved in pain assessment.

CONCLUSION

When estimating patients' pain intensity, observers are driven by anchoring, a rule of thumb that might have pernicious consequences in terms of unwarranted overreliance on initial impressions and insufficient revision in light of relevant disconfirming evidence. Taking this heuristic into account might foster accurate pain assessment and treatment.

Patient perceptions of pain management therapy: a comparison of real-time assessment of patient education and satisfaction and registered nurse perceptions

Nurses must have an understanding of their patients' perception to assist in meeting analgesic goals. Adequate patient teaching is essential. The value of a simplified tool to assess patients' satisfaction has not been widely examined. This study examined if nurses' perceptions of their patients' satisfaction with pain management are congruent with patients' self-report, and if patients' level of satisfaction corresponds with the type of therapy used and adequacy of teaching related to their pain management plan. Data were collected though a survey in a community hospital. It was designed as an evaluative study of the variables in two nursing units and as a pilot study of the survey tool. Ratings of patient satisfaction by nurses (3.8 ± 0.88 [mean ± SD]) were similar to patients' self-ratings (4.08 ± 1.06). Higher self-report of pain (visual analog scale 4.00 ± 2.22) was associated with lower levels of satisfaction (3.80 ± 0.881). Patients reporting adequate teaching rated a higher satisfaction score (4.46) than patients reporting inadequate teaching [3.59; t (48) = -3.12; p = .003]. Patients receiving intravenous analgesia as needed had higher pain VAS scores (4.74) than patients receiving other analgesia protocols [3.37; t(48) = -2.26; p = .028]. Measuring patient satisfaction has become critical in evaluating adequacy of treatment. Factors that affect patients' satisfaction with pain management include the adequacy of teaching they receive and the type of therapy they are provided. A simple survey can be a useful tool in measuring satisfaction.

Patients speak out: development of an evidence-based model for managing orthopaedic postoperative pain

Perioperative pain management after total joint replacement continues to be a concern for orthopaedic nurses. In our institution, the results of routine post-hospital stay surveys had shown below average scores in the area of pain management. This began as a quality management issue, became a pain subcommittee issue, and drew in the research nurses to ask what we can learn from this process. Changing the method of handling pain management is not easy, but it makes a difference in patients' hospital experiences. We learned that cooperation and expertise from multiple departments within the institution and some organizations outside the institution is needed to bring about change. We learned that education of not just staff members but also patients on pain management affected the outcome. This article describes our journey to enhance pain management in our institution.

Validation of the MPI patient profiles by partners and healthcare providers

The Multidimensional Pain Inventory (MPI) is one of the most widely used instruments to assess patients' coping with chronic pain. It provides a psychosocial classification system that categorizes patients into three coping styles: Adaptive, Dysfunctional, and Interpersonally Distressed. To date, comprehensive information about the validity of the MPI taxonomy obtained from informants other than the patient has been unavailable. This has limited conclusions about the extent to which the MPI captures patients' adaptation to chronic pain beyond self-report. The present study is the first to examine whether the distinct multidimensional profiles underlying the patient clusters can be confirmed by proxy report. Ninety-nine chronic pain patients, their partners, and their healthcare providers participated in the study. Patients completed the MPI twice to determine stability of classification. Partners and providers rated the patient on MPI proxy versions developed for this study. Results revealed that partner- and provider-reported MPI ratings corresponded with the self-report patient profiles. The profiles of patients showing classification stability rather than switching of cluster assignment between the two MPI assessments had the highest correspondence with proxy ratings. These results extend prior validity research on the MPI and demonstrate that differential psychological adaptational styles to chronic pain can be reliably recognized by partners and healthcare providers.

Assessment of quality of care in acute postoperative pain management

BACKGROUND/AIM

Managing of acute postoperative pain should be of great interest for all hospital institutions, as one of the key components of patients satisfaction, which indicates quality, as well as the outcome of treatment. The aim of this study was to assess the quality of nursing care in managing acute postoperative pain and to establish factors which influence patients assessment of the same.

METHOD

The investigation was conducted on the sample of 135 patients hospitalized in surgical clinics of the Clinical Centre of Vojvodina in Novi Sad in the form of cross-sectional study, by interviewing patients during the second postoperative day and collecting sociodemographic variables, type of surgical procedure and applied analgesic therapy which were taken from their medical documentation. The modified questionnaire of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) was used as the instrument of the investigation. The data were processed with suitable mathematical statistics methods such as multivariate analyses of variance (MANOVA), discriminative and other parametric procedures and methods. Roy's test, Pearson's coefficient contingency (X), multiple correlation coefficient (R) were conducted amongst other univariant procedures.

RESULTS

The mean score for the individual items of SCQIPP questionnaire was between 2.0 and 4.7 (scale range 1-5) and the percentage of patients answers "strongly agree" ranged from 4.4 to 77%. The smallest number of positive answers were given by the patients for the item "In order to assess pain intensity, some of the staff asked me at least once in the morning, in the afternoon and in the evening to show the number from 0-10". Most of the patients (57%) evaluated severe pain during the previous 24 hours, as moderate pain, which represents significantly greater number of patients which complain of severe pain and mild pain (p < 0.001). The analysis of patients evaluation (MANOVA p < 0.05 and discriminative p < 0.05) indicates the existence of significant difference between the assessment of nursing care quality in managing acute postoperative pain as regards to clinics as the place for pain management, patient's sex and his expectations. Evaluation from "communication" subscale gives the greatest contribution (24.9%) to the difference between the observed clinics, and the greatest contribution (25.7%) to the difference in evaluation of nursing care quality as regards to patients' sex has the evaluations from "procedure" subscale.

CONCLUSION

The results of this study show a useful evidence and identify aspects of nursing care in postoperative management of acute pain which are still to be improved. According to the patients' answers the priority should be given to a regular assessment of the intensity of postoperative pain and evaluation of the effects of analgesic therapy.

Pain behavior in rheumatoid arthritis patients: identification of pain behavior subgroups

This study used Ward's minimum variance hierarchical cluster analysis to identify homogeneous subgroups of rheumatoid arthritis patients suffering from chronic pain who exhibited similar pain behavior patterns during a videotaped behavior sample. Ninety-two rheumatoid arthritis patients were divided into two samples. Six motor pain behaviors were examined: guarding, bracing, active rubbing, rigidity, grimacing, and sighing. The cluster analysis procedure identified four similar subgroups in Samples 1 and 2. The first subgroup exhibited low levels of all pain behaviors. The second subgroup exhibited a high level of guarding and low levels of other pain behaviors. The third subgroup exhibited high levels of guarding and rigidity and low levels of other pain behaviors. The fourth subgroup exhibited high levels of guarding and active rubbing and low levels of other pain behaviors. Sample 1 contained a fifth subgroup that exhibited a high level of active rubbing and low levels of other pain measures. The results of this study suggest that there are homogeneous subgroups within rheumatoid arthritis patient populations who differ in the motor pain behaviors they exhibit.

Prevalence and impact of pain in neurological inpatients of a German teaching hospital

OBJECTIVES

The authors sought to determine the prevalence of pain among neurological inpatients and the impact of pain on psychological and social variables depending on severity and chronicity of pain.

PATIENTS AND METHODS

400 consecutive newly referred inpatients to a neurological department who were 18 years and older and able to speak German were asked to complete a self-administered epidemiological questionnaire containing demographics and socioeconomics, pain variables, health care utilization, screening for depression and anxiety, habitual well-being, and health-related quality of life.

RESULTS

320 patients (80%) complained of pain in the past 3 months. 43% showed higher pain severity -- mirroring severely disabling pain with additionally moderate to high interferences with daily activities. Two-thirds of the neurological patients suffering from pain have to be considered "chronic pain patients". Pain patients had significantly higher depression scores, bodily complaints, more severe disabilities and lower well-being scores compared to patients without pain.

CONCLUSION

This study documents a high prevalence of pain with high grades of pain severity and chronicity in neurological inpatients. Pain presents a major problem as a secondary comorbid condition among neurological inpatients.

Emergency management of chronic pain and drug-seeking behavior: an alternate perspective

Pain is one of the most prevalent conditions treated by Emergency Physicians, although it remains contested how to interpret, measure, and treat this condition. In particular, there is controversy over how to identify and treat patients with chronic under-treated pain and those who are potentially malingering (drug-seeking). This article discusses currently accepted paradigms for treating potentially malingering patients, difficulties some communities may have when these paradigms are applied, and the results of implementing pain treatment guidelines that limit opioid use. Systematically limiting opioids via these guidelines was not associated with a decrease in overall patient satisfaction, patient satisfaction with pain management, overall volume, or volume of patients with potential drug-seeking diagnoses. Emergency Physicians' perception of quality of care delivered, as well as job satisfaction, increased after implementation of the guidelines.

Postoperative Pain After Cesarean Birth Affects Breastfeeding and Infant Care

OBJECTIVE

To study women's experience of postoperative pain and pain relief after cesarean birth and factors associated with pain assessment and the birth experience.

DESIGN

Descriptive patient survey. Data were collected through a questionnaire. The outcome variables were assessments of pain using a Visual Analog Scale and women's birth experience measured on a seven-point Likert scale.

SETTING

Central Swedish county hospital, maternity unit.

PATIENTS/PARTICIPANTS

The sample consisted of 60 women undergoing cesarean birth.

RESULTS

Women reported high levels of experienced pain during the first 24 hours. Seventy-eight percent of the women scored greater than or equal to 4 on the Visual Analog Scale, which can be seen as inadequately treated pain. There was no difference between elective and emergency cesarean births in the levels of pain. In spite of high levels of pain, women were pleased with the pain relief. The risk of a negative birth experience was 80% higher for women undergoing an emergency cesarean birth compared with elective cesarean birth. Postoperative pain negatively affected breastfeeding and infant care.

CONCLUSIONS

There is a need for individual and adequate pain treatment for women undergoing cesarean birth, as high levels of pain interfere with early infant care and breastfeeding.

Effectiveness of oxycodone, ibuprofen, or the combination in the initial management of orthopedic injury-related pain in children

OBJECTIVE

Orthopedic injuries comprise a majority of the indications for analgesia in the emergency department. Oxycodone and ibuprofen have demonstrated efficacy for this indication, but no studies have compared these drugs in children. Our objective was to investigate the effectiveness of oxycodone, ibuprofen, or their combination for the management of orthopedic injury-related pain in children.

METHODS

This prospective, randomized, double-blinded, clinical trial compared the effectiveness of oxycodone, ibuprofen, and the combination in children (age, 6-18 years), with pain from a suspected orthopedic injury. Subjects were block-randomized to receive 1 of the 3 treatment regimens. Pain was assessed with the Faces Pain Scale (FPS) and Visual Analog Scale at baseline, postimmobilization, 30, 60, 90, and 120 minutes postmedication. The change in the FPS score over time was compared between the 3 treatment groups using a generalized estimating equation model.

RESULTS

Although all 3 treatment groups demonstrated a decrease in the FPS score over time, there were no significant differences between the groups. Among the 66 total children enrolled in the 3 treatment groups, there were no statistically significant differences in demographics or injury characteristics. There were 28 subjects with fractures. Immobilization of the injury demonstrated a significant reduction in the FPS score. Subjects in the combination treatment group reported more adverse effects.

CONCLUSIONS

Oxycodone, ibuprofen, and the combination all provide effective analgesia for mild-to-moderate orthopedic injuries in children. Oxycodone or ibuprofen, alone, can be given, thereby avoiding the increase in adverse effects when given together.