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Making Pain Visible: An Audit and Review of Documentation to Improve the Use of Pain Assessment by Implementing Pain as the Fifth Vital Sign
Original Article Making Pain Visible: An Audit and Review of Documentation to Improve the Use of Pain Assessment by Implementing Pain as the Fifth Vital Sign ---
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From the *Central Manchester University Hospitals Foundation Trust; †High Wycombe Hospital; ‡ University of Manchester, Manchester, United Kingdom. Address correspondence to Cliff Richardson, PhD, RN, University of Manchester, School of Nursing, Midwifery and Social Work, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. E-mail: clifford. [email protected] Received January 4, 2012; Revised July 30, 2012; Accepted July 30, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.07.007
Liz Purser, PGCert, RN,* Kelly Warfield, MSc, RN,† and Cliff Richardson, PhD, RN‡
ABSTRACT:
Pain has been promoted as the fifth vital sign for a decade, but there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain. This was a three-stage audit of pain assessment in one large teaching hospital in the Northwest of England. Stage one measured the baseline pain assessment activity on surgical and medical wards and identified that the pain assessment tool was not visible to nurses. Stage two redesigned the patient observation charts held at the end of the bed and piloted two versions for clinical utility. Version 2 which had pain assessment alongside the early warning score was adopted and introduced throughout the hospital. Stage three audited pain assessment and management 8 months after the introduction of the new charts. Pain was assessed more regularly at the stage three audit than at the baseline audit. On average, pain was assessed alongside other routine observations 70% of the time across surgical and medical wards. Medical wards appeared to improve their pain assessment using the philosophy of pain being the fifth vital sign better than surgical wards, because they assessed pain alongside routine observations in >90% of cases. Stage three identified that where a high pain score was recorded, analgesia was delivered in the majority of cases (88%). Introducing the philosophy of pain as the fifth vital sign and making pain assessment more visible on the patient observation chart improved the uptake of pain assessment. Pain management strategies were stimulated when high pain scores were identified. Ó 2014 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 137-142
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Purser, Warfield, and Richardson
Several studies have shown that hospitalized patients experience inadequate pain relief and report moderate to high pain scores (Cousins, Power, & Smith, 1996; Powell, Davies, Bannister, & Macrae, 2004; Shi, Langer, Cohen, & Cleeland, 2007; Sommer et al., 2008). This poor pain management incurs costs for the individual and to society. The individual costs include psychologic distress, reduced function, development of chronic pain, and reduced quality of life (Liu & Wu, 2007; Peters, Sommer, van Kleef, & Marcus, 2010). Societal effects include inability to work and increased health care costs (Peters et al., 2010; VanDenKerkhof et al., 2006). Pain assessment is a key component of successful pain management (Breivik et al., 2008). According to Breivik et al. (2008) pain at rest and movement can be reliably assessed using tools such as the numeric rating scale or visual analog scale, especially when looking for changes in pain intensity (Breivik, Bjornsson, & Skovlund, 2000). One way that has been proposed to improve pain assessment is to regard pain as the fifth vital sign (Joint Commission on Acreditation of Healthcare Organizations, 2001; Lanser & Gesell, 2001; Lynch, 2001a; Rousseau, 2008). The premise being that if pain was assessed with the same priority as the other vital signs, which are often carried out as part of the early warning score (EWS), unnecessary suffering and pain-related complications could be avoided and patient outcomes improved (Lynch, 2001b; Merboth & Barnason, 2000). Improving pain assessment and documentation has been shown to improve pain management (Morrison et al., 2006; Ravaud, Keita, Porcher, Durand-Stocco, Desmonts, & Mantz, 2004). Providing adequate pain management is a quality issue, but studies designed to audit and research the effects of using the principle of pain as the fifth vital sign have shown mixed results. A retrospective study using electronic medical records found no improvement in pain assessment (Mularski, White-Chu, Overbay, Miller, Asch, & Ganzini, 2006). However, because the electronic device was not always available during assessments, staff were not always prompted to record pain along with other vital signs, so those results should be viewed with caution. Ravaud et al. (2004) found greater numbers of patients having pain assessed after the introduction an education program that promoted pain as the fifth vital sign. It was, however, unclear as to whether there was improved pain management alongside the increased pain assessment. Emphasis on the importance of measuring the impact of interventions on the quality of patient outcomes is urgently required to evaluate the effects of strategies such as making pain the fifth vital sign and
whether implementing it makes a difference. The present audit was proposed initially to identify if promoting pain assessment as the fifth vital sign affected nurses’ pain management behavior; however, while undertaking a preaudit review, we saw that this could not be introduced in isolation from making some other structural and contextual changes. A more complex change model was needed alongside the audit of the effects of the new philosophy for pain assessment.
METHOD This was a three-stage audit designed by the nursing pain team to identify current pain assessment practice and to monitor the effects of introducing the principles of pain as the fifth vital sign. As the audit stages progressed, organizational learning occurred and led to the development of new observation charts and a short education program that assisted in implementing the new pain assessment philosophy. This learning led to adaptations of the final stage data collection owing to gaps identified in the first stage by the data collectors. Each stage reviewed documentary evidence of pain assessment in one 24-hour period. The third stage reviewed analgesic administration alongside pain assessment to try to establish a link between assessment and management. Stage one was an evaluation of current pain assessment practice. It was practice in our hospital to use the 0-10 numeric rating score to assess pain, and the audit was used to judge how widely the 0-10 score was being used. All of the patients on eight surgical and five medical wards in the hospital were selected. All of the charts held at the end of the bed were reviewed by a member of the pain team to identify baseline levels of pain assessment. The review categorized the patients and analyzed how many had their pain assessed. If pain was assessed, a count of the number of times it was assessed was taken. No judgment was made as to the necessity or accuracy of the assessment. During this process, however, it was noted that the pain assessment chart was printed on the back of the observation chart held at the end of the patient’s bed. This was identified at this stage to be a potential inhibitor to the introduction of pain as the fifth vital sign, which led to the development of stage two. Stage two took account of the results from stage one. It was a pilot of two new forms of observation chart. Both had pain assessment integrated alongside the other important patient observations rather than on the back of the chart. Version one (V1) required pain scores on movement to be plotted graphically along with temperature recordings. Version two (V2) had boxes for recording pain at rest and on movement
Making Pain Assessment Visible
which were placed alongside the EWS. Qualitative feedback from the nurses who used the new observation charts was collected to find out their views about the chart usability and clinical utility. Stage three occurred after the results of stage two were known. One of the new observation charts was preferred by the nurses who piloted it and was chosen to be introduced across the hospital. An education program written and delivered by the specialist pain nurses and targeted for all nurses was rolled out across the whole hospital. This included familiarization with the new observation chart, which was only implemented once all education had been completed. Eight months after the introduction of the new chart into clinical practice, a review similar to that performed at stage 1 was completed on the same wards. To judge the full extent of the change in practice, additional factors were audited at stage 3. These included scrutiny of the new charts to establish whether pain was being assessed as the fifth vital sign. This was determined by identifying if pain was recorded at the same times as other observations. The second addition was designed to enable a measurement of the effectiveness of the pain assessment rather than just the fact that assessment was performed. Cross-reference was made between the pain assessment and the delivery of analgesia by setting an arbitrary pain score of $5/10 to represent this link. When a pain score of $5 was found, the audit identified whether analgesia was given and then whether the pain score decreased to <5 within an hour of the first recording.
RESULTS Stage One All of the selected thirteen ward areas participated; however, the number of forms returned by each ward varied from 4 to 24. A total of 212 forms were returned, but 10 were only partially completed and were discarded, leaving a total of 202 patients included in the analysis. Almost one-half of the patients were postsurgical (88; 44%) or nonsurgical (99; 49%) with a small group of presurgical patients (15; 7%). Twelve patients (6%) were identified to have a chronic pain condition either as the reason for their admission or additional to their reason for admission (i.e., admission for surgery but had an underlying chronic pain condition). The average age of the patients from each ward varied considerably, with one ward’s average age being 28 years (12 patients) and another being as high as 74 years (17 patients). The overall average age was 54 years. A large majority (171; 85%) of the patients did not have pain assessment recorded on their charts. Of the
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31 patients (15%) that had pain assessed, 20 had it assessed more than once, with the largest number of assessments in any one patient being 12. The average number of assessments performed in the patients who had pain assessed was 3.4, but the mode was 1. Stage Two Following the results of stage 1, it was considered to be important to try to find new ways to assist nurses in assessing pain. One way to do this was thought to be to move the pain assessment tool from the back of the chart to the front to make it more visible. Two pilot versions of a new patient observation chart were devised and tested. V1 was tested on 23 patients on one surgical ward. V2 was piloted on 37 patients on one surgical and one medical ward. Despite the fact that the pain score was visible on both versions of the chart, pain assessment was performed on 100% of the patients on whom V2 was used but on only 34% of patients on whom V1 was used. Qualitative data collected from the nurses using the pilot versions resoundingly supported the use of V2. Examples of the positive comments are: ‘‘chart’s excellent’’ ‘‘would like to continue using this.’’ ‘‘good that it is close to the EWS.’’
In contrast, comments associated with V1 were generally negative. Examples of comments written about V1 are: ‘‘confusing and messy.’’ ‘‘would be better as numbers.’’ ‘‘would be better at the bottom as part of the EWS.’’
Because V2 was identified as having the better clinical utility, it was adopted as the new observation chart and introduced across the hospital. Stage Three The same eight surgical wards and five medical wards used in stage one took part in stage three. A total of 253 patient’s data were analyzed; however, some data sheets were not fully completed, so the denominator in the results varies. The type of patient was similar to those in stage one (Table 1), as was the average age of 58 years. Thirty-four patients (14%) were identified to have a chronic pain condition. These were found on a mixture of surgical and medical wards. Eighteen patients (7%) had patient-controlled analgesia (PCA) or epidural analgesia at the time of the audit. Pain Assessment. Ninety-six percent of patients had at least one pain score documented. This compared
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TABLE 1. Comparison of Patients Audited at Stage One and Stage Three (%) Patient Type Medical Surgical Presurgical Other
Stage 1
Stage 3
49 44 7 —
46 36 5 12
with 15% in stage one. The frequency of assessment also improved between audits, with 83% of patients having three or more pain scores documented in stage three (Fig. 1). Fifth Vital Sign. Pain was always recorded alongside the other vital signs in 70% of patients. Differentiating by ward type, it was found that medical wards linked the recording of these observations more often than the surgical wards (Fig. 2). The Effect of Pain Assessment. Sixty five patients (26%; n ¼ 253) had at least one pain score of $5/10 during the audit period and 57 (88%) of these had a pain management intervention immediately or close to the assessment time. Most of the interventions were to administer already prescribed analgesia (65%), but in a small amount of cases the analgesia was altered (17%) or an additional bolus dose of analgesic was prescribed and delivered (6%) (Table 2). Seven of the eight additional bolus doses were given on medical wards, so they were not thought to be linked to PCA, which is rarely used on medical wards in our hospital, and could not be associated with epidural infusions, because these are not used on general wards. After the intervention, a pain score was recorded within an hour in 29 patients (44%), and in the majority (56%) the reassessment score was <5/10. Of the 65
FIGURE 2. - Percentage of patients where pain was assessed alongside the recording of other observations.
patients with a score of $5/10, 15 (26%) were those identified to have chronic pain and therefore may not be expected to respond in the same way as those with acute pain.
DISCUSSION Audit and practice development can go hand in hand. A new initiative to promote pain as the fifth vital sign was considered, but to judge its effectiveness, data were required from the times before and after the introduction of the initiative. The stage 1 audit identified that pain assessment within the hospital was rarely performed, but at this time it was thought that one potential reason for this lack of assessment was the visibility of the pain assessment tool. All pain assessment information was therefore moved to the front of the patient observation chart. The pilot of two new observation charts identified that visibility in itself was not sufficient to improve nursing adherence to pain assessment. A pilot chart where the pain assessment scale was both visible and placed next to the EWS achieved higher levels of adherence compared with one where pain assessment was visible and plotted alongside the patients’ temperature. Nurses’ qualitative responses suggested that the chart with pain assessment alongside the EWS also had a high level of clinical utility. Piggybacking the recording of pain assessment to the prominent EWS magnified the effect of the improved visibility.
TABLE 2. Interventions Made for a Pain Score of $5 FIGURE 1. - Percentages of patients who had pain assessed in stage one and stage three.
Current analgesia given Analgesia altered/increased Bolus dose
65% 17% 6%
Making Pain Assessment Visible
Additionally, a short education program targeted toward the use of pain as the fifth vital sign was delivered to nurses across the hospital. This was in the form of a powerpoint presentation which was placed on the desktop of all ward computers. All nursing staff were asked to read through it and, once completed, sign a ward list of names to enable the pain team to identify the level of compliance. There were some notable results from the stage three audit. First, although more surgical than medical wards were audited, the number of patients using the more technical forms of pain relief, such as PCA and epidural infusions, was low. Patients with PCA and epidurals often have specialized observation charts including pain assessment, and compliance with these charts has been high (Rawal, 1999). The majority of patients in this sample were therefore the hard-to-reach group of patients where traditionally the recording of pain assessment has generally been low (Rawal, 1999). Improving the recording of pain assessment in this group is welcomed. Patients on medical wards had pain assessed alongside other observations in >90% of cases, which supports the philosophy of making pain the fifth vital sign. Such a good result supports the fact that making pain assessment visible, along with a short education program, can affect nursing practice. It could also be argued, however, that linking pain assessment to routine observation measurement could reduce the individualization of nursing care and potentially restrict nurses to only assessing pain at these times rather than when the patient requires it. Because pain assessment was performed regularly on the majority of patients at stage three, it was possible to explore if performing pain assessment had an effect on pain management. Pain management interventions were not measured at stage one, so it was not possible to compare between stage one and stage three; however, the vast majority of patients (88%) with high pain scores at stage three had analgesia delivered. Most were given already prescribed analgesics, but some had newly prescribed analgesics, including new bolus (one off/stat) doses, which may signify that nurses were using more complex decision-making judgments. Significantly, once delivered the analgesics reduced the pain below the threshold chosen for this audit, which was 5/10, in more than one-half (56%) of the cases. It is appreciated that the likelihood of relief in chronic pain patients using analgesia in this way is less than it is for acute pain. Removing the chronic pain patients from this analysis may well have increased the numbers that successfully decreased to <5/10, but because of the nature of the way data were collected it was impossible to identify
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the acute pain patients from the chronic pain patients. Future audits will be modified to enable capturing this important aspect of pain management. It is recognized that the cutoff point (5/10) for intervention was arbitrary; however, it was chosen to represent the effects of pain assessment on pain management and should not be evaluated as a statement that only scores $5 should receive relief. From our data, it is unclear as to what caused the effects seen. It could be that using the philosophy of pain being the fifth vital sign, the modifications made in the observations charts, or the brief pain education made the difference, but in reality it is likely that all three aspects played a role. Chronic pain patients were identified in both stage one (6%) and stage three (14%) of this audit. It is recognized that patients with acute and chronic pain have different needs and that pain intensity scores are less important for chronic pain patients; however, in an acute care setting, such as our hospital, it was considered that any pain assessment is useful as a starting point for the care planning of all patients in pain. If nothing else, the results have identified to the pain team the approximate numbers of chronic pain patients and has commenced a focus on how to integrate them into the work of the team. A new algorithm has been developed that identifies suggested analgesia and actions to be taken if the response to the analgesic is slow. We anticipate that this will enable early identification of chronic pain patients and therefore improve the care they receive over time. Future audits are planned to explore this further. One significant limitation with these results is that they arise from audit data rather than research. Close monitoring during the audit process, however, enabled nurse practitioners to enact clinical modifications that have the potential to improve the efficacy of pain assessment. Further work is ongoing to establish these changes throughout the hospital and maintain them in the areas studied so far.
CONCLUSION Introducing the philosophy of making pain the fifth vital sign can affect nursing practice. Making the change, however, may require additional structural modifications, and the key may be the change process adopted. This may be influenced by the context of the change and would vary between organizations. It appears that improving the visibility of pain assessment increased its use and promoted pain management procedures.
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REFERENCES Breivik, E. K., Bjornsson, G. A., & Skovlund, E. (2000). A comparison of pain rating scales by sampling from clinical trial data. Clinical Journal of Pain, 16(1), 22–28. Breivik, E. K., Borchgrevink, P. C., Allen, S. M., Rosselond, L. A., Romundslad, L., Hals, E. K. B., Kvarstein, G., & Stubhaug, A. (2008). Assessment of pain. British Journal of Anaesthesia, 101(1), 17–24. Cousins, M. J., Power, I., & Smith, G. (1996). Pain—A persistent problem. The Labat Lecture. Regional Anaesthesia & Pain Medicine, 25, 6–21. Joint Commission on Acreditation of Healthcare Organizations (2001). Pain Standards. Illinois: JCAHO. Lanser, P., & Gesell, S. (2001). Pain management: The fifth vital sign. Healthcare Benchmarks, 8, 68–70. Liu, S. S., & Wu, C. L. (2007). The effect of analgesic technique on postoperative patient-reported outcomes including analgesia: A systematic review. Anesthesia & Analgesia, 105, 789–808. Lynch, M. (2001a). Pain as the fifth vital sign. Journal of Intravenous Nursing, 24, 85–94. Lynch, M. (2001b). Pain: The fifth vital sign. Comprehensive assessment leads to proper treatment. Advance for Nurse Practitioners, 9, 28–36. Merboth, M. K., & Barnason, S. (2000). Managing pain: The fifth vital sign. Nursing Clinics of North America, 35, 375–383. Morrison, R. S., Meier, D. E., Fischberg, D., Moore, C., Degenholtz, H., Litke, A., Maroney-Galin, C., & Siu, A. L. (2006). Improving the management of pain in hospitalized adults. Archives of Internal Medicine, 166, 1033–1039. Mularski, R. A., White-Chu, F., Overbay, D., Miller, L., Asch, S. M., & Ganzini, L. (2006). Measuring pain as the
5th vital sign does not improve quality of pain management. Journal of General Internal Medicine, 21, 607–612. Peters, M. L., Sommer, M., van Kleef, M., & Marcus, M. A. E. (2010). Predictors of physical and emotional recovery 6 and 12 months after surgery. British Journal of Surgery, 97, 1518–1527. Powell, A. E., Davies, H. T. O., Bannister, J., & Macrae, W. A. (2004). Rhetoric and reality on acute pain services in the UK: A national postal questionnaire survey. British Journal of Anaesthesia, 92, 689–693. Ravaud, P., Keita, H., Porcher, R., Durand-Stocco, C., Desmonts, J. M., & Mantz, J. (2004). Randomized clinical trial to assess the effect of an educational programme designed to improve nurses’ assessment and recording of postoperative pain. British Journal of Surgery, 91, 692–698. Rawal, N. (1999). 10 years of acute pain services— Achievements and challenges. Regional Anesthesia & Pain Medicine, 24, 68–73. Rousseau, P. (2008). Pain as the fifth vital sign. Archives of Surgery, 143, 98–99. Shi, Q., Langer, G., Cohen, J., & Cleeland, C. S. (2007). People in pain: How do they seek relief? Journal of Pain, 8, 624–636. Sommer, M., de Rijke, J. M., van Kleef, M., Kessels, A. G. H., Peters, M. L., Geurts, J. W. J. M., Gramke, H. F., & Marcus, M. A. E. (2008). The prevalence of postoperative pain in a sample of 1490 surgical inpatients. European Journal of Anaesthesiology, 25, 267–274. VanDenKerkhof, E. G., Hopman, W. M., Towheed, T., Wilson, R., Murdoch, J., Rimmer, M., Stutzman, S. S., Tod, D., Dagnone, V., & Goldstein, D. H. (2006). Pain, health-related quality of life and health care utilization after inpatient surgery: A pilot study. Pain Research & Management, 11, 41–47.
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From the *Central Manchester University Hospitals Foundation Trust; †High Wycombe Hospital; ‡ University of Manchester, Manchester, United Kingdom. Address correspondence to Cliff Richardson, PhD, RN, University of Manchester, School of Nursing, Midwifery and Social Work, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL. E-mail: clifford. [email protected] Received January 4, 2012; Revised July 30, 2012; Accepted July 30, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.07.007
Liz Purser, PGCert, RN,* Kelly Warfield, MSc, RN,† and Cliff Richardson, PhD, RN‡
ABSTRACT:
Pain has been promoted as the fifth vital sign for a decade, but there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain. This was a three-stage audit of pain assessment in one large teaching hospital in the Northwest of England. Stage one measured the baseline pain assessment activity on surgical and medical wards and identified that the pain assessment tool was not visible to nurses. Stage two redesigned the patient observation charts held at the end of the bed and piloted two versions for clinical utility. Version 2 which had pain assessment alongside the early warning score was adopted and introduced throughout the hospital. Stage three audited pain assessment and management 8 months after the introduction of the new charts. Pain was assessed more regularly at the stage three audit than at the baseline audit. On average, pain was assessed alongside other routine observations 70% of the time across surgical and medical wards. Medical wards appeared to improve their pain assessment using the philosophy of pain being the fifth vital sign better than surgical wards, because they assessed pain alongside routine observations in >90% of cases. Stage three identified that where a high pain score was recorded, analgesia was delivered in the majority of cases (88%). Introducing the philosophy of pain as the fifth vital sign and making pain assessment more visible on the patient observation chart improved the uptake of pain assessment. Pain management strategies were stimulated when high pain scores were identified. Ó 2014 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 137-142
138
Purser, Warfield, and Richardson
Several studies have shown that hospitalized patients experience inadequate pain relief and report moderate to high pain scores (Cousins, Power, & Smith, 1996; Powell, Davies, Bannister, & Macrae, 2004; Shi, Langer, Cohen, & Cleeland, 2007; Sommer et al., 2008). This poor pain management incurs costs for the individual and to society. The individual costs include psychologic distress, reduced function, development of chronic pain, and reduced quality of life (Liu & Wu, 2007; Peters, Sommer, van Kleef, & Marcus, 2010). Societal effects include inability to work and increased health care costs (Peters et al., 2010; VanDenKerkhof et al., 2006). Pain assessment is a key component of successful pain management (Breivik et al., 2008). According to Breivik et al. (2008) pain at rest and movement can be reliably assessed using tools such as the numeric rating scale or visual analog scale, especially when looking for changes in pain intensity (Breivik, Bjornsson, & Skovlund, 2000). One way that has been proposed to improve pain assessment is to regard pain as the fifth vital sign (Joint Commission on Acreditation of Healthcare Organizations, 2001; Lanser & Gesell, 2001; Lynch, 2001a; Rousseau, 2008). The premise being that if pain was assessed with the same priority as the other vital signs, which are often carried out as part of the early warning score (EWS), unnecessary suffering and pain-related complications could be avoided and patient outcomes improved (Lynch, 2001b; Merboth & Barnason, 2000). Improving pain assessment and documentation has been shown to improve pain management (Morrison et al., 2006; Ravaud, Keita, Porcher, Durand-Stocco, Desmonts, & Mantz, 2004). Providing adequate pain management is a quality issue, but studies designed to audit and research the effects of using the principle of pain as the fifth vital sign have shown mixed results. A retrospective study using electronic medical records found no improvement in pain assessment (Mularski, White-Chu, Overbay, Miller, Asch, & Ganzini, 2006). However, because the electronic device was not always available during assessments, staff were not always prompted to record pain along with other vital signs, so those results should be viewed with caution. Ravaud et al. (2004) found greater numbers of patients having pain assessed after the introduction an education program that promoted pain as the fifth vital sign. It was, however, unclear as to whether there was improved pain management alongside the increased pain assessment. Emphasis on the importance of measuring the impact of interventions on the quality of patient outcomes is urgently required to evaluate the effects of strategies such as making pain the fifth vital sign and
whether implementing it makes a difference. The present audit was proposed initially to identify if promoting pain assessment as the fifth vital sign affected nurses’ pain management behavior; however, while undertaking a preaudit review, we saw that this could not be introduced in isolation from making some other structural and contextual changes. A more complex change model was needed alongside the audit of the effects of the new philosophy for pain assessment.
METHOD This was a three-stage audit designed by the nursing pain team to identify current pain assessment practice and to monitor the effects of introducing the principles of pain as the fifth vital sign. As the audit stages progressed, organizational learning occurred and led to the development of new observation charts and a short education program that assisted in implementing the new pain assessment philosophy. This learning led to adaptations of the final stage data collection owing to gaps identified in the first stage by the data collectors. Each stage reviewed documentary evidence of pain assessment in one 24-hour period. The third stage reviewed analgesic administration alongside pain assessment to try to establish a link between assessment and management. Stage one was an evaluation of current pain assessment practice. It was practice in our hospital to use the 0-10 numeric rating score to assess pain, and the audit was used to judge how widely the 0-10 score was being used. All of the patients on eight surgical and five medical wards in the hospital were selected. All of the charts held at the end of the bed were reviewed by a member of the pain team to identify baseline levels of pain assessment. The review categorized the patients and analyzed how many had their pain assessed. If pain was assessed, a count of the number of times it was assessed was taken. No judgment was made as to the necessity or accuracy of the assessment. During this process, however, it was noted that the pain assessment chart was printed on the back of the observation chart held at the end of the patient’s bed. This was identified at this stage to be a potential inhibitor to the introduction of pain as the fifth vital sign, which led to the development of stage two. Stage two took account of the results from stage one. It was a pilot of two new forms of observation chart. Both had pain assessment integrated alongside the other important patient observations rather than on the back of the chart. Version one (V1) required pain scores on movement to be plotted graphically along with temperature recordings. Version two (V2) had boxes for recording pain at rest and on movement
Making Pain Assessment Visible
which were placed alongside the EWS. Qualitative feedback from the nurses who used the new observation charts was collected to find out their views about the chart usability and clinical utility. Stage three occurred after the results of stage two were known. One of the new observation charts was preferred by the nurses who piloted it and was chosen to be introduced across the hospital. An education program written and delivered by the specialist pain nurses and targeted for all nurses was rolled out across the whole hospital. This included familiarization with the new observation chart, which was only implemented once all education had been completed. Eight months after the introduction of the new chart into clinical practice, a review similar to that performed at stage 1 was completed on the same wards. To judge the full extent of the change in practice, additional factors were audited at stage 3. These included scrutiny of the new charts to establish whether pain was being assessed as the fifth vital sign. This was determined by identifying if pain was recorded at the same times as other observations. The second addition was designed to enable a measurement of the effectiveness of the pain assessment rather than just the fact that assessment was performed. Cross-reference was made between the pain assessment and the delivery of analgesia by setting an arbitrary pain score of $5/10 to represent this link. When a pain score of $5 was found, the audit identified whether analgesia was given and then whether the pain score decreased to <5 within an hour of the first recording.
RESULTS Stage One All of the selected thirteen ward areas participated; however, the number of forms returned by each ward varied from 4 to 24. A total of 212 forms were returned, but 10 were only partially completed and were discarded, leaving a total of 202 patients included in the analysis. Almost one-half of the patients were postsurgical (88; 44%) or nonsurgical (99; 49%) with a small group of presurgical patients (15; 7%). Twelve patients (6%) were identified to have a chronic pain condition either as the reason for their admission or additional to their reason for admission (i.e., admission for surgery but had an underlying chronic pain condition). The average age of the patients from each ward varied considerably, with one ward’s average age being 28 years (12 patients) and another being as high as 74 years (17 patients). The overall average age was 54 years. A large majority (171; 85%) of the patients did not have pain assessment recorded on their charts. Of the
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31 patients (15%) that had pain assessed, 20 had it assessed more than once, with the largest number of assessments in any one patient being 12. The average number of assessments performed in the patients who had pain assessed was 3.4, but the mode was 1. Stage Two Following the results of stage 1, it was considered to be important to try to find new ways to assist nurses in assessing pain. One way to do this was thought to be to move the pain assessment tool from the back of the chart to the front to make it more visible. Two pilot versions of a new patient observation chart were devised and tested. V1 was tested on 23 patients on one surgical ward. V2 was piloted on 37 patients on one surgical and one medical ward. Despite the fact that the pain score was visible on both versions of the chart, pain assessment was performed on 100% of the patients on whom V2 was used but on only 34% of patients on whom V1 was used. Qualitative data collected from the nurses using the pilot versions resoundingly supported the use of V2. Examples of the positive comments are: ‘‘chart’s excellent’’ ‘‘would like to continue using this.’’ ‘‘good that it is close to the EWS.’’
In contrast, comments associated with V1 were generally negative. Examples of comments written about V1 are: ‘‘confusing and messy.’’ ‘‘would be better as numbers.’’ ‘‘would be better at the bottom as part of the EWS.’’
Because V2 was identified as having the better clinical utility, it was adopted as the new observation chart and introduced across the hospital. Stage Three The same eight surgical wards and five medical wards used in stage one took part in stage three. A total of 253 patient’s data were analyzed; however, some data sheets were not fully completed, so the denominator in the results varies. The type of patient was similar to those in stage one (Table 1), as was the average age of 58 years. Thirty-four patients (14%) were identified to have a chronic pain condition. These were found on a mixture of surgical and medical wards. Eighteen patients (7%) had patient-controlled analgesia (PCA) or epidural analgesia at the time of the audit. Pain Assessment. Ninety-six percent of patients had at least one pain score documented. This compared
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TABLE 1. Comparison of Patients Audited at Stage One and Stage Three (%) Patient Type Medical Surgical Presurgical Other
Stage 1
Stage 3
49 44 7 —
46 36 5 12
with 15% in stage one. The frequency of assessment also improved between audits, with 83% of patients having three or more pain scores documented in stage three (Fig. 1). Fifth Vital Sign. Pain was always recorded alongside the other vital signs in 70% of patients. Differentiating by ward type, it was found that medical wards linked the recording of these observations more often than the surgical wards (Fig. 2). The Effect of Pain Assessment. Sixty five patients (26%; n ¼ 253) had at least one pain score of $5/10 during the audit period and 57 (88%) of these had a pain management intervention immediately or close to the assessment time. Most of the interventions were to administer already prescribed analgesia (65%), but in a small amount of cases the analgesia was altered (17%) or an additional bolus dose of analgesic was prescribed and delivered (6%) (Table 2). Seven of the eight additional bolus doses were given on medical wards, so they were not thought to be linked to PCA, which is rarely used on medical wards in our hospital, and could not be associated with epidural infusions, because these are not used on general wards. After the intervention, a pain score was recorded within an hour in 29 patients (44%), and in the majority (56%) the reassessment score was <5/10. Of the 65
FIGURE 2. - Percentage of patients where pain was assessed alongside the recording of other observations.
patients with a score of $5/10, 15 (26%) were those identified to have chronic pain and therefore may not be expected to respond in the same way as those with acute pain.
DISCUSSION Audit and practice development can go hand in hand. A new initiative to promote pain as the fifth vital sign was considered, but to judge its effectiveness, data were required from the times before and after the introduction of the initiative. The stage 1 audit identified that pain assessment within the hospital was rarely performed, but at this time it was thought that one potential reason for this lack of assessment was the visibility of the pain assessment tool. All pain assessment information was therefore moved to the front of the patient observation chart. The pilot of two new observation charts identified that visibility in itself was not sufficient to improve nursing adherence to pain assessment. A pilot chart where the pain assessment scale was both visible and placed next to the EWS achieved higher levels of adherence compared with one where pain assessment was visible and plotted alongside the patients’ temperature. Nurses’ qualitative responses suggested that the chart with pain assessment alongside the EWS also had a high level of clinical utility. Piggybacking the recording of pain assessment to the prominent EWS magnified the effect of the improved visibility.
TABLE 2. Interventions Made for a Pain Score of $5 FIGURE 1. - Percentages of patients who had pain assessed in stage one and stage three.
Current analgesia given Analgesia altered/increased Bolus dose
65% 17% 6%
Making Pain Assessment Visible
Additionally, a short education program targeted toward the use of pain as the fifth vital sign was delivered to nurses across the hospital. This was in the form of a powerpoint presentation which was placed on the desktop of all ward computers. All nursing staff were asked to read through it and, once completed, sign a ward list of names to enable the pain team to identify the level of compliance. There were some notable results from the stage three audit. First, although more surgical than medical wards were audited, the number of patients using the more technical forms of pain relief, such as PCA and epidural infusions, was low. Patients with PCA and epidurals often have specialized observation charts including pain assessment, and compliance with these charts has been high (Rawal, 1999). The majority of patients in this sample were therefore the hard-to-reach group of patients where traditionally the recording of pain assessment has generally been low (Rawal, 1999). Improving the recording of pain assessment in this group is welcomed. Patients on medical wards had pain assessed alongside other observations in >90% of cases, which supports the philosophy of making pain the fifth vital sign. Such a good result supports the fact that making pain assessment visible, along with a short education program, can affect nursing practice. It could also be argued, however, that linking pain assessment to routine observation measurement could reduce the individualization of nursing care and potentially restrict nurses to only assessing pain at these times rather than when the patient requires it. Because pain assessment was performed regularly on the majority of patients at stage three, it was possible to explore if performing pain assessment had an effect on pain management. Pain management interventions were not measured at stage one, so it was not possible to compare between stage one and stage three; however, the vast majority of patients (88%) with high pain scores at stage three had analgesia delivered. Most were given already prescribed analgesics, but some had newly prescribed analgesics, including new bolus (one off/stat) doses, which may signify that nurses were using more complex decision-making judgments. Significantly, once delivered the analgesics reduced the pain below the threshold chosen for this audit, which was 5/10, in more than one-half (56%) of the cases. It is appreciated that the likelihood of relief in chronic pain patients using analgesia in this way is less than it is for acute pain. Removing the chronic pain patients from this analysis may well have increased the numbers that successfully decreased to <5/10, but because of the nature of the way data were collected it was impossible to identify
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the acute pain patients from the chronic pain patients. Future audits will be modified to enable capturing this important aspect of pain management. It is recognized that the cutoff point (5/10) for intervention was arbitrary; however, it was chosen to represent the effects of pain assessment on pain management and should not be evaluated as a statement that only scores $5 should receive relief. From our data, it is unclear as to what caused the effects seen. It could be that using the philosophy of pain being the fifth vital sign, the modifications made in the observations charts, or the brief pain education made the difference, but in reality it is likely that all three aspects played a role. Chronic pain patients were identified in both stage one (6%) and stage three (14%) of this audit. It is recognized that patients with acute and chronic pain have different needs and that pain intensity scores are less important for chronic pain patients; however, in an acute care setting, such as our hospital, it was considered that any pain assessment is useful as a starting point for the care planning of all patients in pain. If nothing else, the results have identified to the pain team the approximate numbers of chronic pain patients and has commenced a focus on how to integrate them into the work of the team. A new algorithm has been developed that identifies suggested analgesia and actions to be taken if the response to the analgesic is slow. We anticipate that this will enable early identification of chronic pain patients and therefore improve the care they receive over time. Future audits are planned to explore this further. One significant limitation with these results is that they arise from audit data rather than research. Close monitoring during the audit process, however, enabled nurse practitioners to enact clinical modifications that have the potential to improve the efficacy of pain assessment. Further work is ongoing to establish these changes throughout the hospital and maintain them in the areas studied so far.
CONCLUSION Introducing the philosophy of making pain the fifth vital sign can affect nursing practice. Making the change, however, may require additional structural modifications, and the key may be the change process adopted. This may be influenced by the context of the change and would vary between organizations. It appears that improving the visibility of pain assessment increased its use and promoted pain management procedures.
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