Improving Reassessment and Documentation of Pain Management

Study on the Effect of PDCA Circulation Method on Nursing Quality Management in the Day Operating Room

Objective

The main objective is to investigate the effect of PDCA circulation management on nursing quality in the day operation room.

Methods

A retrospective study was performed in 300 patients in the day surgery room. For the control group, 150 patients received routine nursing. For the observation group, 150 patients underwent PDCA circulation nursing management. The scores for nursing quality management, the hospital infection, the detection rate of pathogenic bacteria, the incidence rate of adverse events, the negative emotion of patients, and the satisfaction rate for the day surgery department were recorded and analyzed between two groups.

Results

Compared with the control group, the scores for nursing quality management and the satisfaction rate for the day surgery department were significantly increased (all P < 0.05), while the hospital infection, the detection rate of pathogenic bacteria, HAMA scores, HAMD scores, and the incidence rate of adverse events were obviously decreased (all P < 0.05). Significantly statistical differences were observed between the two groups.

Conclusion

PDCA circulation nursing management in the day operating room could optimize the nursing quality management, improve the satisfaction rate of the operating room, reduce the negative emotions of patients, and prevent adverse events in time, with lower hospital infections.

Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Introduction

This systematic review attempts to answer the following question - which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting?

Methods

A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020.Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles.The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance.

Results

Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020.Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%.

Conclusion

Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.

Designing paper-based records to improve the quality of nursing documentation in hospitals: A scoping review

BACKGROUND

Inpatient nursing documentation facilitates multi-disciplinary team care and tracking of patient progress. In both high- and low- and middle-income settings, it is largely paper-based and may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed.

OBJECTIVE

To synthesise evidence on how paper-based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care.

DESIGN

A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA-ScR guidelines.

ELIGIBILITY CRITERIA

We included studies that described the process of designing paper-based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019.

SOURCES OF EVIDENCE

PubMed, CINAHL, Web of Science and Cochrane supplemented by free-text searches on Google Scholar and snowballing the reference sections of included papers.

RESULTS

12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges.

CONCLUSIONS

The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human-centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Paper-based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation.

Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment

INTRODUCTION

In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration.

OBJECTIVE

To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%).

METHODS

Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders.

RESULTS

Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750-239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855-80 928 per year).

CONCLUSION

Adopting John Kotter's model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact.

Observation of Emergency Room Nurses Managing Pediatric Pain: Care to Be Given… Care Given…

BACKGROUND

Although pain undeniably has negative consequences, pain management often remains suboptimal, particularly in the pediatric population in the emergency room (ER).

AIM

In this observational study using qualitative and quantitative methods, we investigated everyday adherence to current nursing best-practice pediatric guidelines in the ER paying particular attention to the interaction between children, parents, and nurses.

METHODS

An adapted version of the nursing observation tool for pain management was used to describe pediatric pain management provided by nurses caring for children (0-14 years old) admitted to the ER. We also assessed child-parent-nurse interactions. (The aim of the study was presented to the nurses as part of the survey on interactions without specifying the focus on pain management.) RESULTS: Forty-seven children were included (91 painful episodes) during the observation period (112 hours). There was a screening for pain in 55% of cases, and pain scales were used in 10% of cases. Analgesic treatments were administered in 75% of cases (procedural or disease-related pain). Follow-up evaluations were performed in 19% of cases. Nonpharmacologic approaches were scarcely used. The use of both helpful and nonhelpful languages were noted during interactions with children and parents. Parents' collaboration was rarely requested to help relieve their child's pain.

CONCLUSIONS

Our results show that pediatric pain management in the ER could be optimized. Parents are still not considerably involved in their child's pain management. Parents' involvement could contribute to improving pediatric pain management.

The association of patients' daily summarized self-rated "real-time" pain scores with physical recovery after major surgery - A repeated measurement design

Aim

To determine the associations of patients' documented self-rated pain with self-rated early postoperative physical recovery.

Design

Observational with repeated measures.

Methods

General and orthopaedic inpatients (N = 479) were during the period 2012-2015 screened for pain. Individual daily median pain scores at rest and during activity were based on 4-9 self-ratings on postoperative days 1 and 2, using the Numeric Rating Scale. Nine items reflecting physical recovery from the "Postoperative Recovery Profile" were used in a questionnaire.

Results

Associations between median pain scores on postoperative day 1 and physical recovery (fatigue, sleeping difficulties, bladder function, mobilization, muscle weakness and personal hygiene) the same day were found. Additionally, associations were found between median pain scores on day 1 and physical recovery (fatigue, sleeping difficulties, mobilization and muscle weakness) on day 2.

Interventions in pain management for persons with an intellectual disability

Pain is a multidimensional and subjective experience, and an ideal pain management regime needs to be comprehensive, integrative and involve all relevant persons. Multimodal interventions may include pharmacological, physical, social, psychological and spiritual approaches in order to address pain management at a molecular, functional, behavioural, cognitive and affective levels. Pain management interventions will vary according to pain aetiology, patient characteristics and preferences. In keeping with best practice guidelines for effective pain management, a structured approach incorporating an effective assessment of pain by the healthcare professional, identification of the source and type of pain and accurate documentation is essential. This article focuses on pharmacological and non-pharmacological pain management for individuals with intellectual disability.

Behavioral Pain Indicators in Patients with Traumatic Brain Injury Admitted to an Intensive Care Unit

Introduction: A consistent approach to pain assessment for patients admitted to intensive care unit (ICU) is a major difficulty for health practitioners due to some patients' inability, to express their pain verbally. This study aimed to assess pain behaviors (PBs) in traumatic brain injury (TBI) patients at different levels of consciousness. Methods: This study used a repeated-measure, within-subject design with 35 patients admitted to an ICU. The data were collected through observations of nociceptive and non-nociceptive procedures, which were recorded through a 47-item behavior-rating checklist. The analyses were performed by SPSS ver.13 software. Results: The most frequently observed PBs during nociceptive procedures were facial expression levator contractions (65.7%), sudden eye openings (34.3%), frowning (31.4%), lip changes (31.4%), clear movement of extremities (57.1%), neck stiffness (42.9%), sighing (31.4%), and moaning (31.4%). The number of PBs exhibited by participants during nociceptive procedures was significantly higher than those observed before and 15 minutes after the procedures. Also, the number of exhibited PBs in patients during nociceptive procedures was significantly greater than that of exhibited PBs during the non-nociceptive procedure. The results showed a significant difference between different levels of consciousness and also between the numbers of exhibited PBs in participants with different levels of traumatic brain injury severity. Conclusion: The present study showed that most of the behaviors that have been observed during painful stimulation in patients with traumatic brain injury included facial expressions, sudden eye opening, frowning, lip changes, clear movements of extremities, neck stiffness, and sighing or moaning.

Linking Pediatrics Patients and Nurses With the Pharmacy and Electronic Health Record System Through the Inpatient Television: A Novel Interactive Pain-Management Tool

OBJECTIVES

Implement a novel pain-management interface that is used to bring real-time, patient-reported pain assessments to the inpatient television and evaluate the impact of implementation on the pain-management clinical workflow, patient engagement, and nursing pain reassessments.

METHODS

We developed a pain-management tool interfacing 4 stand-alone technologies: a television-based, interactive patient care system; electronic health record system; nursing call system; and pharmacy inventory-management system. The workflow is triggered when pain medications are dispensed by sending an automatic pain assessment rating question via the patient's television at a predefined time. To measure the effects of implementation, we calculated patient and/or parent use rates and pain reassessment timely documentation rates. Data were extracted from the electronic health record for a period of 22 months and covered pre- and postimplementation.

RESULTS

A total of 56 931 patient records were identified during the study period, representing 2447 unique patients. In total, 608 parents and/or patients reported their pain through the tool. Use rates were 6.5% for responding to the pain rating prompt and 13.3% for the follow-up prompt, in which additional nonpharmacologic strategies to eliminate pain were offered. A modest increase was found in the mean timely documentation rates on the basis of nursing documentation standards (26.1% vs 32.8%, a percentage increase of 25.7%; P < .001) along with decreased median time to pain reassessment documentation (29 minutes versus 25 minutes, a percentage decrease of 13.8%; P < .001).

CONCLUSIONS

With this novel tool, we offer a potentially scalable approach in supporting the pain-management clinical workflow, integration of technologies, and promoting of patient and/or parent engagement in the inpatient setting.

Using education and support strategies to improve the way nurses assess regular and transient pain – A quality improvement study of three hospitals

Background and aims

Systematic and regular pain assessment has been shown to improve pain management. Well-functioning pain assessments require using strategies informed by well-established theory. This study evaluates documented pain assessments reported in medical records and by patients, including reassessment using a Numeric Rating Scale (NRS) after patients receive rescue medication.

Methods

Documentation surveys (DS) and patient surveys (PS) were performed at baseline (BL), after six months, and after 12 months in 44 in-patient wards at the three hospitals in Östergötland County, Sweden. Nurses and nurse assistants received training on pain assessment and support. The Knowledge to Action Framework guided the implementation of new routines.

Results

According to DS pain assessment using NRS, pain assessment increased significantly: from 7% at baseline to 36% at 12 months (p < 0.001). For PS, corresponding numbers were 33% and 50% (p < 0.001). According to the PS, the proportion of patients who received rescue medication and who had been reassessed increased from 73% to 86% (p = 0.003). The use of NRS to document pain assessment after patients received rescue medication increased significantly (4% vs. 17%; p < 0.001).

Conclusions

After implementing education and support strategies, systematic pain assessment increased, an encouraging finding considering the complex contexts of in-patient facilities. However, the achieved assessment levels and especially reassessments related to rescue medication were clinically unsatisfactory. Future studies should include nursing staff and physicians and increase interactivity such as providing online education support. A discrepancy between documented and reported reassessment in association with given rescue medication might indicate that nurses need better ways to provide pain relief.

Implications

The fairly low level of patient-reported pain via NRS and documented use of NRS before and 12 months after the educational programme stresses the need for education on pain management in nursing education. Implementations differing from traditional educational attempts such as interactive implementations might complement educational programmes given at the work place. Standardized routines for pain management that include the possibility for nurses to deliver pain medication within well-defined margins might improve pain management and increase the use of pain assessments. Further research is needed that examines the large discrepancy between patient-reported pain management and documentation in the medical recording system of transient pain.

Hydromorphone vs fentanyl for epidural analgesia and anesthesia

BACKGROUND

Epidural analgesia/anesthesia is used during surgery because it dramatically relieves pain and attenuates the stress response. Because limited data exist regarding the relative merits of hydromorphone (HM) and fentanyl (FENT), the objective was to determine which was more safe and effective.

METHODS

Prospective case-matched, observational study evaluated elective surgery patients: 30 HM and 60 FENT. Variables were measured perioperatively.

RESULTS

Of the 90 patients, mean age was 52 years; simplified acute physiology score was 26 ± 10; and American Society of Anesthesiologists score was 2.4 HM vs 2.7 FENT, P = .03. HM patients were more apt to be excessively sedated (16% HM vs 1% FENT, P = .007) and have poor mental unresponsiveness (6% HM vs 0% FENT, P = .04). The incidence of hypotension was not different, 76% HM vs 80% FENT, not significant.

CONCLUSIONS

In a closely case-matched population, FENT caused less excessive sedation and unresponsiveness. FENT patients had better intraoperative urine output and tended to have less repeated episodes of hypotension.

Pain management at the end of life: A comparative study of cancer, dementia, and chronic obstructive pulmonary disease patients

BACKGROUND

Limited data exist concerning the unique pain characteristics of patients with non-cancer terminal diseases referred for inpatient hospice care.

AIMS

To define the unique pain characteristics of patients admitted to an acute inpatient hospice setting with end-stage dementia or chronic obstructive lung disease (or chronic obstructive pulmonary disease) and to compare them to patients with end-stage cancer.

DESIGN

Retrospective patient chart review. Demographic, physiological, pain parameters, and medication utilization data were extracted. Associations between pain characteristics, medication utilization, and admission diagnoses were assessed. Analyses included descriptive statistics.

SETTING/PARTICIPANTS

In total, 146 patients admitted to an acute inpatient hospice between 1 April 2011 and 31 March 2012 with an underlying primary diagnosis of chronic obstructive pulmonary disease (n = 51), dementia (n = 48), or cancer (n = 47).

RESULTS

Pain was highly prevalent in all diagnostic groups, with cancer patients experiencing more severe pain on admission. Cancer patients received a significantly higher cumulative opioid dose compared with dementia and chronic obstructive pulmonary disease patients. Pain control within 24 h of pain onset was achieved in less than half of all patient groups with chronic obstructive pulmonary disease patients the least likely to achieve pain control.

CONCLUSIONS

Despite the fact that pain is the most common complaint at the end of life, pain management may be suboptimal for some primary diagnoses. Admission diagnosis is the strongest predictor of pain control. Patient with cancer achieve the best pain control, and chronic obstructive pulmonary disease patients are the least likely to have their pain adequately treated.

Prevalence of low back pain by anatomic location and intensity in an occupational population

Background

Low Back Pain (LBP) is a common and costly problem, with variation in prevalence. Epidemiological reports of rating of pain intensity and location within the low back area are rare. The objective is to describe LBP in a large, multi-center, occupational cohort detailing both point and 1-month period prevalence of LBP by location and intensity measures at baseline.

Methods

In this cross-sectional report from a prospective cohort study, 828 participants were workers enrolled from 30 facilities performing a variety of manual material handling tasks. All participants underwent a structured interview detailing pain rating and location. Symptoms in the lower extremities, demographic and other data were collected. Body mass indices were measured. Outcomes are pain rating (0–10) in five defined lumbar back areas (i) LBP in the past month and (ii) LBP on the day of enrollment. Pain ratings were reported on a 0–10 scale and subsequently collapsed with ratings of 1–3, 4–6 and 7–10 classified as low, medium and high respectively.

Results

172 (20.8%) and 364 (44.0%) of the 828 participants reported pain on the day of enrollment or within the past month, respectively. The most common area of LBP was in the immediate paraspinal area with 130 (75.6%) participants with point prevalence LBP and 278 (77.4%) with 1-month period prevalence reported having LBP in the immediate paraspinal area. Among those 364 reporting 1-month period prevalence pain, ratings varied widely with 116 (31.9%) reporting ratings classified as low, 170 (46.7%) medium and 78 (21.4%) providing high pain ratings in any location. Among the 278 reporting 1-month period prevalence pain in the immediate paraspinal area, 89 (32.0%) reported ratings classified as low, 129 (46.4%), medium and 60 (21.6%) high pain ratings.

Conclusions

Pain ratings varied widely, however less variability was seen in pain location, with immediate paraspinal region being the most common. Variations may suggest different etiological factors related to LBP. Aggregation of different locations of pain or different intensities of pain into one binary classification of LBP may result in loss of information which may potentially be useful in prevention or treatment of LBP.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-283) contains supplementary material, which is available to authorized users.

The utility of pain scores obtained during 'regular reassessment process' in premature infants in the NICU

OBJECTIVE

To examine the association of pain assessment scores achieved through regular reassessment practice, as required by the Joint Commission (JC), with painful events and the use of analgesics in premature, ventilated infants.

STUDY DESIGN

A cross-sectional study was performed in two tertiary level neonatal intensive care units. Pain was assessed at regular intervals at each center using validated multidimensional instruments in accordance with the JC standards.

RESULT

Sample comprised 196 ventilated premature infant patient-days. Overall, 2% of scores suggested the presence of pain, and 0.1% of pain scores were associated with analgesia. Ventilated infants who were exposed to multiple pain-associated procedures in a day never demonstrated pain score elevations despite infrequent preemptive or continuous analgesic administration.

CONCLUSION

Pain assessment scores achieved using regular reassessment processes were poorly correlated with exposure to pain-associated procedures or conditions. Low pain scores achieved through regular reassessment may not correlate to low pain exposure. Resources that are expended on regular reassessment processes may need to be reconsidered in light of the low yield for clinical alterations in care in this setting.

A prospective audit project into the adequacy of pain assessment in the medical and surgical wards in a North London District General Hospital

BACKGROUND

Accurate assessment of pain is associated with improved pain management, which can lead to better patient outcomes. It has been recommended that all patients have their pain assessed and the scores documented as the 'fifth vital sign'.

METHOD

All inpatients in the medical and surgical wards in our hospital were asked directly to score their pain according to the hospital-wide scoring system. Their observation charts and drug charts were then reviewed in order to determine the accuracy of documented pain assessments and the subsequent analgesic management.

RESULTS

Of the 208 patients reviewed, 20 (15%) patients on medical wards and 26 (38%) patients on surgical wards were in moderate to severe pain. Documentation of pain scores was not universal, with 29 (14%) patients having no score documented with their last set of observations. Of those with a score recorded, it was not found to correlate with the scores reported on direct questioning in 41% of medical patients and 71% of surgical patients. Provision of analgesia was also found to differ between medical and surgical wards.

DISCUSSION

The care of pain in the wards falls below the standards set by the Royal College of Anaesthetists. It is necessary to undertake a programme of education to increase awareness of the problem and to improve assessment and management to enhance the patient experience.

Patient perspectives of patient-controlled analgesia (PCA) and methods for improving pain control and patient satisfaction

BACKGROUND AND OBJECTIVES

This study aimed to (1) identify patient-controlled analgesia (PCA) attributes that negatively impact patient satisfaction and ability to control pain while using PCA and (2) obtain data on patient perceptions of new PCA design features.

METHODS

We conducted a prospective survey study of postoperative pain control among patients using a PCA device. The survey was designed to evaluate patient satisfaction with pain control, understanding of PCA, difficulties using PCA, lockout-period management, and evaluation of new PCA design features.

RESULTS

A total of 350 eligible patients completed the survey (91%). Patients who had difficulties using PCA were less satisfied (P < 0.001) and were more likely to feel unable to control their pain (P < 0.001). Satisfaction and self-reported ability to control pain were not affected by patient education about the PCA. Forty-nine percent of patients reported not knowing if they would receive medicine when they pushed the PCA button, and of these, 22% believed that this uncertainty made their pain worse. The majority of patients preferred the proposed PCA design features for easier use, including a light on the button, making it easier to find (57%), and a PCA button that vibrates (55%) or lights up (70%), alerting the patient that the PCA pump is able to deliver more medicine.

CONCLUSIONS

A majority of patients, irrespective of their satisfaction with PCA, preferred a new PCA design. Certain attributes of current PCA technology may negatively impact patient experience, and modifications could potentially address these concerns and improve patient outcomes.

Quality improvement in clinical documentation: does clinical governance work?

Introduction

The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation.

Methods

A quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist.

Results

There were no differences between a nurse’s demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program.

Conclusion

Although some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.

Healthcare professionals' perceptions of the use of pain scales in postoperative pain assessments

AIM

To describe how healthcare professionals perceive the use of pain scales in postoperative care.

BACKGROUND

Pain scales are important but not an obvious choice to use in postoperative care. No study has explored how healthcare professionals experience the use of pain scales.

METHODS

An explorative design with a phenomenographic approach was used. The sample consisted of 25 healthcare professionals. Semistructured interviews were performed.

RESULTS

Four descriptive categories emerged - the use of pain scales facilitated the understanding of postoperative pain, facilitated treatment, demanded a multidimensional approach and was affected by work situations.

CONCLUSIONS

Healthcare professionals described that pain scales contribute to the understanding of patient's postoperative pain. It is important to ensure patient understanding and be aware about variations in pain ratings. Dialogue and observations are necessary to be certain what the ratings mean to the patient. The use of pain scales depends on patient's needs and organization.

[Postoperative pain assessment after middle ear surgery]

BACKGROUND

The purpose of this work was to assess postoperative pain management after middle ear surgery.

MATERIALS AND METHODS

In a prospective clinical study, 73 adults were evaluated on the first postoperative day after middle ear surgery using the questionnaire of the Germany-wide project QUIPS (quality improvement in postoperative pain management). The main outcome measures were patients' characteristics, pain parameters, outcome, and pain therapy process parameters.

RESULTS

Overall, pain on the first postoperative day was mild. Pain management consisted predominately of premedication with midazolam, remifentanil intraoperatively, metamizole in the recovery room and on the ward. Otherwise healthy patients suffered significantly more from pain than patients with reduced general condition in univariate and multivariate analyses. About half of the patients demanded pain relief on the ward. Despite immediate pain management with nonopioids and/or opioids, these patients had significantly more maximal pain and were less satisfied with overall pain therapy than patients not demanding pain therapy.

DISCUSSION

QUIPS is a simple tool to evaluate the quality of in-hospital postoperative pain management following ear surgery. Pain on the first postoperative day seems to be moderate but should be improved for patients demanding more analgetics despite baseline pain therapy on the ward.

Evaluating the effectiveness of pediatric pain management guidelines

In response to unit nursing quality and patient satisfaction concerns, the shared governance councils identified opportunities to improve overall assessment and management of pain in hospitalized pediatric patients. Together, the unit-shared governance councils evaluated current practice and reviewed the literature to develop comprehensive Pediatric Pain Assessment and Management Guidelines. The purpose of this study was to evaluate the effectiveness of implementing an evidence-based pain assessment and management guideline on nurses' knowledge, ability to assess and manage the patients' pain, and patient/family satisfaction with staff's management of pain. This intervention study with a pre-post design included three assessment intervals described as baseline and 3 and 6 months after guideline implementation. The sample included pediatric and pediatric intensive care unit (PICU) nursing staff, retrospective chart reviews of pediatric and PICU patients, and patient/parent satisfaction scores. No differences were found between nurses' knowledge and attitudes regarding pain before and after implementation of the guideline. Significant increases in pain assessment, use of correct tool, and reassessment were found following implementation. Although improving, there was no difference in patient/family satisfaction after guideline implementation.

Inpatient palliative care and patient pain: pre- and post-outcomes

CONTEXT

Hospitalized patients with serious illness often receive inadequate pain and symptom management at the end of life.

OBJECTIVES

To test the effectiveness of an interdisciplinary inpatient palliative care (IPC) consultation program in the management of pain among seriously ill patients during hospitalization, and to examine IPC patient pain outcomes 10 days following hospital discharge.

METHODS

A two-year pre-post study was conducted at a nonprofit health maintenance organization medical center in Los Angeles County. Hospital patients (n = 484) aged 65 years and older with life-threatening, complex, chronic conditions received comprehensive assessment, pain and symptom relief, care planning, counseling, and other supportive services from an IPC team. Measures included self-reported pain at baseline, two and 24 hours following IPC intervention, discharge, and 10 days post-discharge.

RESULTS

Mean pain was significantly different between baseline (1.56 ± 2.79) and two hours (0.91 ± 1.59; P < 0.001), 24 hours (0.77 ± 1.58; P < 0.001), and hospital discharge (0.40 ± 1.09; P < 0.001). Mean pain 10 days after discharge (2.04 ± 2.79; P < 0.001) was significantly higher than mean pain at discharge. Number of chronic conditions, probability of mortality, and discharge to hospice care significantly predicted increased pain following discharge.

CONCLUSION

To the authors' knowledge, this is the first study to follow IPC patient pain after hospital discharge. Findings support IPC teams' effectiveness in managing pain during hospitalization but suggest a lack of continuity in pain management following discharge. Research exploring IPC patient post-discharge transition experiences will likely improve understanding of post-discharge pain outcomes.

Postoperative pain assessment after functional endoscopic sinus surgery (FESS) for chronic pansinusitis

Postoperative pain after functional endoscopic sinus surgery (FESS) and its optimal management has not been described in detail. The objective was to evaluate pain, its influencing factors and its management on the first postoperative day following FESS. In a prospective case study, 101 FESS patients were examined after removal of the nasal packing within the Quality Improvement in Postoperative Pain Management (QUIPS) project allowing a standardized assessment of patients' characteristics, pain parameters, outcome and process parameters. The influence of these parameters on the patients' postoperative pain was estimated by univariate and multivariate statistic analysis. Pain during the first postoperative day after FESS was moderate. Younger patients reported significantly more pain than did older patients. Specific counseling about the possibilities of postoperative pain management reduced pain intensity highly significantly in univariate and multivariate analysis. Patients demanding for pain relief in the recovery room and on the ward predominantly received acetaminophen as non-opioid and piritramide as opioid. This pain management was obviously insufficient as these patients still reported significantly more from pain on the first postoperative day than patients not demanding for pain relief. We conclude that QUIPS could help to optimize the quality of postoperative pain management following FESS.

Postoperative pain assessment after septorhinoplasty

Postoperative pain after septorhinoplasty and its optimal management has not been described in detail. Fifty-two adult septorhinoplasty patients were included in a prospective cohort single center study. Patients' and surgical characteristics were evaluated. Outcome and process parameters were analyzed using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Management (QUIPS) on the first postoperative day. Pain during the first operative day after septorhinoplasty was moderate. Pain management predominately consisted of remifentanil intraoperatively, metamizole in the recovery room, in combination with piritramide in one-third of the patients, and metamizole on ward. Patients younger than 31 years were less satisfied with pain management (P = 0.018). Open rhinoplasty was associated with less satisfaction with pain management (P = 0.007). Use of rib grafts led to more mobility, breathing, sleeping and mood disturbances (P = 0.003, 0.047; 0.047; 0.022, respectively). Preoperative pain counseling was followed by higher satisfaction, less breathing and mood disturbances after surgery (P = 0.021; 0.004; 0.046, respectively). Opioids in the recovery room in addition to non-opioids and treatment with non-opioids on ward led to less maximal pain (P = 0.027 and 0.040, respectively). We conclude that QUIPS is an easy tool to evaluate the quality of postoperative pain management following rhinoplasty. Preoperative pain counseling, specific care for patients with rib grafts, consequent use of opioids in the recovery room in addition to non-opioids, and use of non-opioids on ward seem to be effective to improve pain management after septorhinoplasty.

Hospital do-not-resuscitate orders: why they have failed and how to fix them

Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.