Adherence to Guidelines of Pain Assessment and Intervention in Internal Medicine Wards

Original Article Adherence to Guidelines of Pain Assessment and Intervention in Internal Medicine Wards Yehudit Kerner, RN, MHA,* Ygal Plakht, RN, PhD,* ,† Arthur Shiyovich, MD,† and Pnina Schlaeffer, RN, MHA*

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From the *Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel; †Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Address correspondence to Ygal Plakht, RN, PhD, Nursing Leadership, Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O.B. 151, Beer-Sheva 84101, Israel. E-mail: [email protected] Received April 6, 2011; Revised May 29, 2011; Accepted June 14, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.06.005

ABSTRACT:

Proper management of pain reduces morbidity, assists in recovery, and increases patient satisfaction. The role of a nurse in an accurate pain evaluation is pivotal. It seems that pain evaluation guidelines are not fully adhered to by nurses. The aim of this study was to assess the performance of pain evaluation and management by nurses in patients admitted in internal medicine wards and to identify groups of patients in which pain evaluation was insufficient. In this crosssectional study medical records of 59 randomly chosen patients were reviewed: age 64.5 ± 18.5 years, 55% women, and hopitalization length 3.9 ± 1.6 days. Data relating to pain evaluation and management were obtained for every patient–hospitalization day (total 213 patient-days) and compared with the guidelines. Pain was evaluated in 176 out of 213 encounters (66.2%): 84.3% upon admission and 72.7% daily routine evaluation in accordance with guidelines. In 23.7% of evaluations, pain level warranted alleviating treatment (visual analog scale $3). However, such treatment was administered in only 29.3% of these cases. Reevaluation after treatment and additional evaluations thereafter were performed in 33.3% and 22% of encounters, respectively. The independent factors associated with the reduced performance of pain evaluation were: widower (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.78-0.98; p ¼ .024), reduced level of consicousnness (OR 0.77, 95% CI 0.63-0.95; p ¼ .013), mental disorders as a cause of hospitalization (OR 0.81, 95% CI 0.71-0.94; p ¼ .004), and isolation (OR 0.87, 95% CI 0.76-0.99; p ¼ .03). Pain assessment and management in internal medicine wards is insufficient, especially in the above subgroups. Specific education programs targeted to the latter subgroups and to the unique pain assessment tools are warranted. Ó 2013 by the American Society for Pain Management Nursing Proper evaluation and management of pain may reduce morbidity, assist in recovery, and increase patient satisfaction and quality of life (Ballantyne, Carr, Chalmers, Dear, Angelillo, & Mosteller, 1993, Hurley, Coben, & Wu, 2009, The Joint Commission [TJC], 2001). Therefore, the issues of pain evaluation and management, especially in the setting of hospitalization, are an increasing interest of Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 302-309

Following Guidelines in Internal Medicine Wards

caregivers. Furthermore, TJC and the American Pain Society have suggested considering pain as ‘‘the fifth vital sign,’’ indicating that pain intensity should be measured with temperature, heart rate, blood pressure, and respiration in all patients (McCarberg & Stanos, 2008, TJC, 2001). The Israel Ministry of Health has instructed that pain evaluation is a vital measurement that must be obtained and recorded in every hospitalized patient within 12 hours of admission and at least once per hospitalization day (Ministry of Health, Israel, 2011). Despite the importance of pain management it seems that pain evaluation guidelines are not fully adhered to by caregivers (Clarke, French, Bilodeau, Capasso, Edwards, & Empoliti, 1996, Herr & Titler, 2009). Proper pain management depends on accurate pain evaluation, for which the nurse role is pivotal (Miaskowski, Nichols, Brody, & Synold, 1994). Earlier studies found that the main reason for nonadherence to pain evaluation guidelines by nurses is insufficient knowledge and practice (Bergh & Sj€ ostr€ om, 1999, Mackrodt & White, 2001). Studies that evaluated the influence of education on various behavioral changes found that nurses who were taught and educated on pain management evaluated pain more frequently and more efficiently (Hansson, Fridlund, & Hallstr€ om, 2006, Michaels, Hubbartt, Carroll, & Hudson-Barr, 2007). It was supported by Sloman, Rosen, Rom, and Shir (2005), who stated that an educational program to teach nurses the various techniques and importance of pain evaluation was warranted. Nevertheless, it was mentioned that experienced nurses are more aware of the importance of pain management than younger, often more educated, nurses (ten Cate, Snell, Mann, & Vermunt & Carlson, 2010). Five years before the present study, several programs to educate nurses in proper pain evaluation were launched in our medical center. These programs included specific courses, meetings, trainings, inspections, and introduction of pain evaluation rulers for various populations. The aims of this study were to assess the performance of pain evaluation and management in patients admitted in internal medicine wards and to identify groups of patients in which pain evaluation was insufficient.

METHODS Study Population In this observational retrospective study, medical records of randomly chosen patients who were admitted in one of the six internal medicine wards of the Soroka University Medical Center, Tertiary medical center, Southern Israel, in February-December 2009

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were reviewed. Exclusion criteria were: 1) patients discharged or deceased #24 hours after admission; and 2) patients who were transfered between various wards. The local Ethics Committee approved the study, which was performed in accordance with the Helsinki declaration. Data Sources and Classifications Data relating to pain evaluation and management were obtained per hospitalization day from every patient. The data included the time, pain level according to the visual analog scale (VAS), and whether treatment was administered for pain relief after the evaluation. The obtained data were compared with the guidelines of the medical center, based on the guidelines of the Israel Ministry of Health, which include the following recommendations (Ministry of Health, Israel, 2011):  Pain evaluation should be performed in every patient on admission and at least once a day afterwards.  Whenever the VAS is $3, a pain relief treatment (e.g., nonsteroidal antiinflammatory drugs, opioids, etc.) should be administered and pain level reevaluated.  Furthermore, in patients with VAS $3, pain evaluation should be performed more frequently, at least once more during that day (preferably once every shift).  This process should be repeatedly followed until the patient is pain free (VAS ¼ 0) or suffers only mild pain (VAS 1-2), considering the safety of pain relief administration.

The following additional data were obtained from the hospital records and patient files: demographics (age, gender, mother tongue, primary caregiver, etc.), clinical characteristics of the admission (type of admission [urgent or elective], reason for admission, medical history, etc.), and administrative characteristics of the hospitalization (date, hour, ward, length of stay, etc.). Performance of pain evaluation according to the above guidelines was a primary endpoint. Additional outcomes were the VAS values and pain management (administration of treatment). Statistics The statistical analyses were performed using Predictive Analytics Software (PASW) Statistics 18. The analyses were performed on a per patient-day basis. We used OpenEpi Software (http://www.openepi.com) to calculate the sample size. It was based on preliminary results in ten subjects, in whom pain was evaluated in 63% in accordance with the guidelines. We assumed the annual hospital population of 88,000 patient-days (245 internal medicine patients daily). Additional assumptions were the possible percentage of pain assessments up to 70% (e.g., 7%), the mean length of

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hospital stay of 4 days, and a 95% confidence interval (CI) for the estimate. This resulted in a minimal sample size of 183 patient-days (46 patients). The rates of performed pain evaluations out of the expected pain evaluations according to the guidelines were calculated for each variable. Univariate analysis comparing pain evaluation rate according to the investigated variables adjusted for the patient characteristics was performed using generalized estimating equations (GEEs), with a logistic regression as a link function. In this analysis, the relative chance of performing pain evaluation was presented separately for each variable as odds ratio (ORs) with 95% CI. Multivariate analysis testing the independent influence of the predictors on the chance of performing pain evaluation was also done using GEE. Variables with clinical and statistical significance were included into the multivariate analysis. p values of <.05 were considered to be statistically significant.

RESULTS A total of 59 patients were included in the study. Baseline characteristics of the participants are presented in Table 1. The mean length of stay was 3.9  1.6 days. One-half of the patients were hospitalized for $4 days. In total, 213 patient-days were studied. Overall pain evaluation was performed in 66.2% of the instances recommended by the guidelines (176 out of 266 recommended assessments). There were 18 pain evaluations that were not mandatory according to the guidelines. Pain evaluation was performed in 84.3% and 72.7% of recommended encounters on admission and as part of the daily routine (at least once daily), respectively. Pain evaluation results are presented in Table 2. In 21.1% of evaluations (41 cases), VAS was $3, requiring additional pain evaluation and pain alleviation treatment throughout the same hospitalization day. However, of these encounters, subsequent pain evaluation was performed in 22% (9 evaluations). Pain relief treatment was given in 29.3% of the warranting cases (12 of 41 encounters). Evaluation after the analgesic treatment was performed in 4 out of these 12 encounters. The number of pain evaluations and their levels according to the timing of performance are presented in Table 2. There was no statistical difference in rate of VAS $3 between the different types of the encounters leading to the pain evaluation (upon admission, daily routine, additional, after treatment, and beyond guidelines; p ¼ 0.11; Table 2). Analyzing the adherence to pain evaluation guidelines, age was not a significant predictor of the pain evaluation performance (OR per year 0.997, 95% CI

TABLE 1. Patients’ Baseline Characteristics Parameter

Patients, % (n ¼ 59)

Gender: male 47.5 Age (y), mean  SD 62.78  20.39 Mother tongue Hebrew 62.7 Arabic 15.3 Russian 18.6 Other 3.4 Family status Single 6.8 Married 59.3 Divorced 8.5 Widow 25.4 Primary caregiver Spouse 40.7 Parent/s 5.1 Child/ren 32.2 Other 6.8 None 15.2 Admission shift Morning 32.2 Evening 57.6 Night 10.2 Admitting ward (code) 1 11.9 2 22 3 22 4 32.2 5 11.9 Type of admission: urgent 96.6 Level of consciousness: reduced/confused 5.1 Functional needs Brief focus intervention 67.8 Assistance at home 16.9 Nursing facility 15.3 Need of isolation 15.3 Main reason for admission Cardiovascular problems 37.3 Acute infection 15.3 Neurologic problems 13.6 Respiratory problems 10.2 Gastrointestinal problems 11.9 Mental illnesses 3.4 Other 8.3 Medical history Hypertension 49.2 Dislipidemia 39 Diabetes mellitus 39 Coronary artery disease 25.4 Arrhythmia 16.9 Infection diseases 13.6 Chronic renal failure 11.9 Chronic lung disease 10.2 Obesity 6.8 Anemia 10.2 Congestive heart failure 10.2 Mental disturbances 10.2 Malignancies 6.8 Stroke 6.8

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Following Guidelines in Internal Medicine Wards

TABLE 2. Pain Evaluation and Levels According to Time of Performance VAS Values Time of Performance On admission Routine Daily Additional After treatment Beyond guidelines

No. of Evaluations

Maximal

Mean (SD)

%¼0

%$3

51 112 9 4 18

7 8 6 4 8

1.33 (2.02) 1.01 (1.95) 2.67 (2.29) 1.5 (1.91) 1.22 (2.51)

62.7 73.2 33.3 50 72.2

23.5 17.9 55.6 25 16.7

0.99-1.001; p ¼ .155). However, a longer length of hospital stay tended to be negatively related to the probability of pain evaluation (OR per day 0.96, 95% CI 0.93-1.002; p ¼ .06). Table 3 presents the rates of performance of pain evaluation compared with the guidelines’ recommended instances stratified by the different patient and ward characteristics. Lower odds of the appropriate pain evaluations were found in widows, patients with reduced level of consciousness or who were confused, patients with greater functional needs, and those admitted with a mental illness as the main reason for admission. Moreover, statistically significant differences in adherence to the pain evaluation guidelines were found between the different wards. Multivariate analysis demonstrated that after adjustment for the differences between the wards, the following patient characteristics were significantly related to reduced rate of adherence: being widowers, reduced consciousness level or confusion, isolation during the hospitalization, and mental illness as the primary diagnosis at admission (Table 4).

DISCUSSION In the present study, the performance of pain evaluation and treatment in patients admitted in internal medicine wards of a tertiary medical center were assessed. Main findings were that pain was evaluated at least once a day in most patients. However, treatment and follow-up evaluations were not performed sufficiently. These findings are in accordance with those of Clarke et al. (1996), who reported that 73% of patient files have no information on pain and 90% have no record of pain alleviation treatment. Strohbuecker, Mayer, Evers, and Sabatowski (2005) studied pain evaluation in postsurgery patients and found that only 40% of the patients suffering significant pain received alleviating treatment. Similarly, the present study found that fewer than one-third of the patients reporting significant pain received treatment and only in about 20% was pain evaluation repeated. Herr and Titler (2009)

examined the acute pain assessment and management in the emergency department that occurred over a period of time after the release of the new pain assessment and management compliance standards by TJC (2001). The authors found improvements in pain assessment practices, with 99% of patients having some documentation of pain by the end of the study’s final data collection in 2002. However, 34% of patients had no objective assessment of pain documented, reported pain intensity remained high (6.8-7.2 out of 10), and only 60% of patients had any analgesic ordered. Pain evaluation significantly depends on the interaction between the patient and the staff and often requires great attention, patience, and the ability to identify nonverbal signs using appropriate measuring tools (Miaskowski et al., 1994). Schafheutle, Cantrill, and Noyce (2001) claimed that the shortage in nursing manpower and the great work load could be responsible for reducing the interaction time between nurses and patients. Moreover, although pain evaluation is usually performed by nurses, the decision for appropriate treatment often involves physicians; therefore, insufficient collaboration between physicians and nurses could also be responsible for administration of reduced pain alleviation treatment. In the present study, subgroups of patients in which pain evaluations are significantly reduced were identified: widowers, patients with reduced level of consciousness/confused, isolation, and admitted for a mental illness. Patients in these subgroups often require use of unique pain measurement tools that comprise behavioral assessment tools, surrogate reporting (family members, caregivers) researching for potential causes of pain, an analgesic trial (Herr, Coyne, Key, Manworren, McCaffery, Merkel, Pelosi-Kelly, Wild, & American Society for Pain Management Nursing, 2006). These measurement tools require a higher level of education and experience and are usually much more time consuming than the standard VAS measurement (Baldridge & Andrasik, 2010, Cunningham, 2006, Schreier, 2010). Physiologic indicators (e.g.,

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TABLE 3. Pain Evaluation Rates and Relative Risk (Odds Ratio [OR]*) for Pain Evaluation Performed According to Patient Characteristics

Parameter Gender Male Female Mother tongue Hebrew Arabic Russian Other Family status Single Married Divorced Widow Primary caregiver Spouse Parent/s Child/ren Other None Admission shift Morning Evening Night Admitting ward (code) 1 2 3 4 5 Type of admission Urgent Elective Level of consciousness Oriented Reduced/confused Functional needs Brief focus intervention Assistance at home Nursing facility Need of isolation No Yes Main reason for admission Cardiovascular problems Acute infection Neurologic problems Respiratory problems Gastrointestinal problems Mental illnesses Other Medical history Hypertension Dislipidemia

No Yes No

Pain Evaluation Rate (% of Recommended Assessments) (n ¼ 266)

OR*

95% CI

70.4 62.9

1 0.92

0.81-1.05

.231

66.3 73.7 58.5 83.3

1 1.07 0.92 1.16

0.9-1.27 0.77-1.09 0.83-1.63

.446 .35 .379

87.5 67.3 78.6 55.2

1 0.82 0.91 0.72

0.64-1.05 0.68-1.21 0.55-0.95

.113 .5 .018

66.9 85.7 60.5 60 77.1

1 1.12 0.9 0.93 1.06

0.89-1.57 0.78-1.04 0.72-1.22 0.9-1.26

.24 .164 .608 .475

63.5 68 60

1 1.06 0.98

0.91-1.23 0.75-1.28

.44 .881

89.5 48.5 70.6 63.2 73.2

1 0.67 0.84 0.78 0.85

0.58-0.78 0.72-0.97 0.67-0.9 0.72-1

<.001 .021 .001 .052

65.8 83.3

1 1.18

0.85-1.64

.312

68.3 35.3

1 0.69

0.53-0.9

.005

70.5 63.2 54.5

1 0.93 0.84

0.78-1.12 0.71-0.99

.44 .046

69.1 53.1

1 0.86

0.72-1.01

.075

72.1 58.1 71.4 70 65.9 33.3 61.5

1 0.87 1 0.96 0.92 0.68 0.89

0.73-1.05 0.84-1.19 0.78-1.18 0.76-1.11 0.49-0.94 0.66-1.19

.144 .98 .687 .363 .019 .412

66.7 65.6 62.8

1 1.00 1

0.88-1.14

.993

p Value

(Continued )

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Following Guidelines in Internal Medicine Wards

TABLE 3. Continued

Parameter Diabetes mellitus Coronary artery disease Arrhythmia Infection diseases Chronic renal failure Chronic lung disease Obesity Anemia Congestive heart failure Mental disturbances Malignancies Stroke

Pain Evaluation Rate (% of Recommended Assessments) (n ¼ 266)

OR*

95% CI

71.6 68.1 63.2 64.9 69.4 65.5 69.6 67 62.2 65.5 70.6 65.1 73.5 65.7 70.4 65.4 73.1 66.1 66.7 68.1 51.6 67.1 52.9 65.2 84.6

1.09 1 0.98 1 1.08 1 1.03 1 0.96 1 1.07 1 1.08 1 1.06 1 1.11 1 1.01 1 0.83 1 0.85 1 1.19

0.96-1.24

.165

0.86-1.13

.817

0.94-1.24

.289

0.87-1.22

.767

0.81-1.15

.689

0.88-1.29

.515

0.89-1.3

.453

0.86-1.31

.569

0.91-1.35

.318

0.82-1.25

.911

0.67-1.04

.108

0.64-1.13

.256

0.95-1.45

.129

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes

p Value

*OR <1 denotes association with lower level of pain evaluation performance.

changes in heart rate, blood pressure, or respiratory rate) are no longer considered to be sensitive for discriminating pain from other sources of distress. Despite its frequent use, little research supports the use of vital sign changes for identifying pain. Absence of increased vital signs does not indicate absence of pain; therefore, it is recommended to minimize their use in this setting (Herr et al., 2006). Bradbeer, Helme, Yong, Kendig, and Gibson (2003) reported that widowers that often feel lonely

and bereaved have higher rates of medical conditions involving pain. This group usually requires more attention, empathy, and time from the medical staff. This could explain the insufficient pain management in this group. Significant differences in adherence to pain evaluation guidelines between the different wards were found in the present study. We think that these results indicate different policies and involvement by the nursing manager and the nurse responsible for implementation of the pain management guidelines in

TABLE 4. Multivariate Analysis: Patient Characteristics Independently Associated with Reduced Chance of Pain Evaluation Parameter

OR*

95% CI

p Value

Family status: widow vs. other Level of consciousness: Reduced/confused vs. oriented Need of isolation: yes vs. no Main reason for admission: mental illnesses vs. all others

0.88 0.77 0.87 0.81

0.78-0.98 0.63-0.95 0.76-0.99 0.71-0.94

.024 .013 .03 .004

*Adjusted for the differences in pain evaluations between the hospital wards. OR <1 denotes associations with lower level of performing pain evaluation.

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a specific ward, in addition to level of collaboration with the physicians. De Rond, de Wit, and van Dam (2001) reported that documentation of the pain evaluations improved pain management and communication with the patient. Despite the importance of pain evaluation and alleviation, there are major concerns about the expectation that patients be ‘ pain free.’ A significant increase in deaths associated with too aggressive management of pain with the use of opioids has been reported (Bohnert, Valenstein, Bair, Ganoczy, McCarthy, Ilgen, & Blow, 2011, Dunn, Saunders, Rutter, Banta-Green, Merrill, Sullivan, & von Korff, 2010). Therefore, interventions, particularly the administration of analgesics, is based on more than pain intensity, with safety of administration an uppermost concern. Caregivers should avoid promising patients a pain-free state and should very carefully evaluate the safety of the next analgesic dose. A level of pain control that will allow acceptable function and achievement of recovery goals is the current focus. Limitations First, our data were based on medical records rather than observations; therefore it is possible that in some cases pain was evaluated but not documented, as previously reported by De Marinis, Piredda, Pascarella, Vincenzi, Spiga, Tartaglini, and Matarese (2010). Second, the relatively small sample size may have limited the power of subset analyses and may have precluded the possibility of reaching statistical significance in some of the analyses. Third, we were

not able to differentiate between pain evaluations initiated by the nursing team and those stemming from patients’ complaints. Fourth, we did not evaluate various characteristics of the medical personnel to identify additional factors that affect proper pain evaluation and management.

Conclusions and recommendations Pain is the most common complaint expressed by patients. Being most available for the patients in most referral centers, nurses play a pivotal role in pain evaluation and management (Briggs, 2010). However, despite various programs of education in the pain management field, evaluation and treatment remain insufficient (Lui, So, & Fong, 2008). This is most prominent in specific populations, such as widowers, patients with reduced level of consciousness or confusion, patients requiring assistance in their daily life or residents of nursing homes, and in patients admitted for mental illnesses. We think that specific educational programs targeted to those specific populations and to the unique pain evaluation tools are warranted to improve pain evaluation and management by nurses. However, education alone in unlikely to suffice; more fundamental changes in the systems focusing on physician-nurse-patient interactions must be implemented. Moreover, increasing manpower, appointing a staff member in each department as responsible for follow-up and enforcement of pain policy, and further emphasizing this issue by managers and supervisors could also improve pain assessment and management.

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