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«October 2000 Revised Edition Geriatrics and Extended Care Strategic Healthcare Group National Pain Management Coordinating Committee Veterans Health ...»

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Pain as the 5Th Vital Sign Toolkit

October 2000

Revised Edition

Geriatrics and Extended Care Strategic Healthcare Group

National Pain Management Coordinating Committee

Veterans Health Administration

810 Vermont Avenue NW

Washington, DC 20420

PREFACE

This toolkit has been prepared as a resource manual for use by Veterans Health Administration

(VHA) managers and staff in implementing the VHA National Pain Management Strategy.

More specifically, the toolkit has been designed to promote Pain as the 5th Vital Sign and to offer guidelines for the completion of comprehensive pain assessments. These are the initial steps in promoting and improving pain management for veterans receiving care within the VHA system.

This information is intended for reference only and is provided for use in the development of local pain assessment procedures.

Copyright permission has been granted by the American Pain Society to use the phrase: "Pain:

the 5th Vital Sign" as a portion of the VA take 5 logo as displayed on the front cover.

______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 1

CONTENTS

Preface 1 Contents 2 Acknowledgements 4 Toolkit Task Force 4 Content Reviewers 4 Section 1: Introduction 5 Veterans Health Administration (VHA) National Pain Management Strategy 5 Why Pain as the 5th Vital Sign 5 Overview of the Toolkit 6 Section 2: An Overview of the VHA National Pain Management Strategy 7 Implementing the Pain as the 5th Vital Sign Mandate 7 Section 3: Barriers to Pain Screening and Assessment 11 Healthcare Professionals 11 Patients 11 Healthcare System 12 Section 4: The Pain Screening Process 13 Keys to Successful Pain Screening 13

–  –  –

Toolkit Task Force Pain as the 5th Vital Sign Toolkit is the result of substantial effort by members of the Toolkit Task Force who are listed below. We are particularly indebted to Loretta Wasse and Bonnie Ryan for creating the initial draft of the toolkit and to Robert D. Kerns for subsequent revisions.

John Booss, MD Director, Neurology Service (200) Field Based VA Connecticut Healthcare System West Haven, CT 06516 Audrey Drake, RN, MSN, CNAA Program Director (118) Nursing Strategic Healthcare Group VA Headquarters 810 Vermont Avenue, NW Washington, DC 20420 Robert D. Kerns, PhD Chief, Psychology Service VA Connecticut Healthcare System West Haven, CT 06516 Bonnie Ryan, RN (Co-Chair) Chief, VA Home and Community-Based Care (114) VA Headquarters 810 Vermont Avenue, NW Washington, DC 20420 Loretta Wasse, CRNA, MEd (Co-Chair) Deputy Director, Headquarters Anesthesia Service (111L) Puget Sound Health Care System, Seattle Division 1660 South Columbian Way Seattle, WA 98108 Content Reviewers Numerous individuals both within and beyond the VHA healthcare system contributed time and talent as reviewers of the original draft of this Pain as the 5th Vital Sign Toolkit. We gratefully acknowledge their contributions, specifically recognizing the members of the VHA National Pain Management Strategy Coordinating Committee, members of the VISN 1 Pain Management Subcommittee, and staff of the Comprehensive Pain Management Center at the VA Connecticut Healthcare System.

–  –  –

Veterans Health Administration (VHA) National Pain Management Strategy VHA has initiated a comprehensive national strategy for pain management. The overall goal of the new VHA National Pain Management Strategy is to prevent pain and suffering in persons

receiving care in the veterans healthcare system. The specific objectives of this strategy are to:

• Provide a system-wide VHA standard of care for pain management that will reduce suffering from preventable pain.

• Assure that pain assessment is performed in a consistent manner.

• Assure that pain treatment is prompt and appropriate.

• Include patients and families as active participants in pain management.

• Provide for continual monitoring and improvement in outcomes of pain treatment.

• Provide for an interdisciplinary, multi-modal approach to pain management.

• Assure that clinicians practicing in the VHA healthcare system are adequately prepared to assess and manage pain effectively.

Why Pain as the 5th Vital Sign The phrase “pain as the 5th vital sign” was initially promoted by the American Pain Society to elevate awareness of pain treatment among healthcare professionals.

–  –  –

VHA recognizes the importance of making pain “visible” in an organization. Screening, assessing, and documenting pain routinely is an important first step in assuring that unrelieved pain is identified and treated promptly.

It is important to emphasize that Pain as the 5th Vital Sign is a screening mechanism for identifying unrelieved pain. Screening for pain can be administered quickly for most patients on a routine basis. As with any other vital sign, a positive pain score should trigger further assessment of the pain, prompt intervention, and follow-up evaluation of the pain and the effectiveness of treatment.





______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 5 Overview of the Toolkit This Pain as the 5th Vital Sign Toolkit has been prepared as a resource toolkit for use by

healthcare professionals. It is organized into the following sections:

Section 1: Introduction. This section presents the objectives of the VHA National Pain Management Strategy and a synopsis of the major sections of this toolkit.

Section 2: An Overview of the VHA National Pain Management Strategy. This section highlights the key components of the strategy and provides recommendations for implementation at individual VHA facilities (or in individual healthcare facilities if it is being used by non-VHA systems).

Section 3: Barriers to Pain Screening and Assessment. This section reviews many of the common barriers to reliable pain screening and assessment, including barriers attributable to healthcare professionals, patients, and the healthcare system. Appreciation of the factors is critical to the development of an effective program for pain management.

Section 4: The Pain Screening Process. This section includes information about the Numeric Rating Scale (NRS) for pain screening, a description of the tool, tips for using it reliably;

guidelines for frequency of screening across diverse clinical settings; and suggestions for using the tool within the context of patient/family education on pain and pain management. This section also contains information on methods for documenting pain scores in the patient record.

Section 5: Conducting a Comprehensive Pain Assessment. This section emphasizes the role of pain screening as an initial step in the comprehensive assessment of pain. The section discusses pain as a complex, perceptual phenomenon and provides a rationale for more comprehensive assessment. Key components and commonly employed methods of pain assessment are also described, followed by a description of common barriers to reliable pain assessment.

Section 6: Educational and Resource Information. This section provides information to assist individuals and facilities in the successful implementation of the Pain as the 5th Vital Sign initiative.

______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 6

SECTION 2: AN OVERVIEW OF

THE VHA NATIONAL PAIN MANAGEMENT STRATEGY

Pain as the 5th Vital Sign is just one element of the VHA National Pain Management Strategy. It is the first step toward assuring that all persons cared for in the VHA healthcare system can reliably count on prompt and appropriate treatment of pain.

The VHA Pain as the 5th Vital Sign initiative establishes the routine screening and assessment of pain and the documentation of a plan for pain reduction as national policy throughout the VHA healthcare system.

The essential components of this initiative are:

• Routine pain screening for the presence and intensity of pain for all patients using a 0-toNumeric Rating Scale (NRS).

• Documentation of present pain intensity (i.e., “pain score”) for all patients as part of the vital sign record.

• Completion of a comprehensive pain assessment, as clinically indicated, for patients reporting a significant level of pain.

• Documentation of the comprehensive pain assessment, the plan for improved pain management, and a timeframe for reassessment.

Implementing the Pain as the 5th Vital Sign Mandate Implementing Pain as the 5th Vital Sign will require every VHA medical facility to do the

following:

• Develop a comprehensive implementation plan for the facility.

• Plan and implement methods for pain screening and assessment.

• Provide for routine documentation of pain scores and assessment.

• Provide education for healthcare providers, e.g., physicians, nurses. Education should include instruction on how to use the NRS, documentation procedures, and interpretation of the results; how to conduct a comprehensive pain assessment and documentation requirements; and how to develop a plan for effective pain management and how to document it.

• Educate patients and families about pain screening, assessment, patient rights and responsibilities related to pain management, and available pain management/treatment options.

______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 7 Develop an implementation plan for your facility.

• Designate a person or team who will be responsible for implementing Pain as the 5th Vital Sign.

• Establish an action plan with timelines and assigned responsibilities. Implementing Pain as the 5th Vital Sign in all sites of care should be approached as the first step in a comprehensive plan to continuously improve pain management. It will be necessary to develop further guidelines and procedures for more comprehensive pain assessment and follow-up for patients for whom pain is identified as a problem.

• Share the plan with your VISN Pain Management Point of Contact (POC). See pages 29in Section 6 of this toolkit for a list of VISN POCs.

Plan methods for pain screening and assessment at all sites of care.

• Review the VHA National Pain Management Policy and the JCAHO Standards Related to the Assessment and Treatment of Pain, both in Section 6 of this toolkit.

• Identify procedures and guidelines for pain screening and assessment that are currently being used in your facility and/or VISN. Keep in mind that the NRS is simply an initial screening tool and is only the first step toward achieving consistent pain assessment for all patients. You may already have more comprehensive pain assessment procedures in place in some sites of care.

• Identify local pain management experts to assist in developing and reviewing policies and procedures.

• Review pain screening and assessment resources (see Section 6).

• Establish policies and procedures for your facility.

• Incorporate pain screening and assessment procedures into appropriate facility manuals, handbooks, publications, and other facility reference materials as is needed.

• Develop an implementation plan for documenting pain scores in the medical record (see Section 4).

• Develop an implementation plan for documentation of comprehensive pain assessments and care plans.

Educate healthcare providers on pain assessment.

• The Employee Education System (EES) can provide valuable assistance in developing educational materials and coordinating educational programs. Include your VISN Education Service Representative (ESR) as well as your facility and VISN education committee in planning for educational activities. See page 32 in Section 6 of this toolkit for an ESR contact list and the Web address for updates.



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