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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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• Each facility has an Education Point of Contact Person (POC) who can be identified by reviewing the list in Outlook under “VHA Education POCs.” ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 8

• Identify the target audience for Pain as the 5th Vital Sign, e.g., physicians, nurses, nurses aides, medical technicians, pharmacists, therapists, chaplains, social workers. Consider a broad audience for initial, basic education. Remember that one objective of this initiative is to raise awareness of the importance of pain assessment and pain management throughout the organization. All members of the healthcare team should be able to understand and use the NRS. Professional staff who will have responsibility for conducting comprehensive pain assessments and for the development of plans for pain management/treatment will necessarily require additional specialized training.

• Identify educational resources (see Section 6). A wide array of published materials is available, as well as information on the Internet that can be readily adapted for use in staff education.

• Identify local pain management experts to assist in the development of employee education programs and materials.

• Develop an educational plan with a timetable and assigned responsibilities. Keep in mind that this is an ongoing project. Consider starting with the basics and building more detailed and comprehensive educational programs over time. Ask: What does staff need to know? Who needs to know? When, where, and how should training be provided?

• Incorporate pain assessment into the initial orientation and ongoing education of all appropriate staff.

• Share your education plan with your VISN Pain Management Point of Contact (POC) and your VISN Education Service Representative (ESR). See lists in Section 6 of this toolkit.

Educate patients and families.

• Identify the contact person for patient education in your facility and/or your VISN patient education committee. Enlist their assistance in coordinating your patient education activities. A listing of local “Patient Education Contacts” is available in Outlook.

• Identify patient and family education materials on pain assessment and pain management that are already in use in your facility and/or VISN.

• Identify local experts to assist with the development of patient and family education materials.

• Identify educational resources (see Section 6). There is an abundance of published materials, as well as information on the Internet designed for patient and family education related to pain assessment and treatment.

• Review the JCAHO Standards Related to the Assessment and Treatment of Pain provided in Section 6 of this toolkit, paying particular attention to the chapters on “Rights and Ethics” and “Education.”

• Develop a plan for educating patients and families on pain assessment and management.

Again, keep in mind that this is an ongoing effort. Establish priorities and a realistic ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 9 timeline based on an assessment of needs and resources available. Consider starting with a simple instruction tool for use of the NRS for rating pain intensity.

• Share your plan for patient and family education with your VISN Pain Management Point of Contact (POC), listed in Section 6 of this toolkit.

Use the Numeric Rating Scale (NRS) to teach patients and families.

• Define the word “pain.” For example, you might describe “pain” as a physical discomfort that may have various characteristics such as aching, pulling, tightness, burning, or pricking, and you might explain that pain may be mild to severe.

• To verify that the patient understands how the word “pain” (or other word preferred by the patient) is used, ask the patient to give examples of pain he or she has experienced. If the patient is already in pain, use the present situation as the example.

• Emphasize to the patient and family that the patient's self-report of pain is the single most reliable indicator of how much pain the patient is experiencing. Explain that the patient must volunteer information. Although caregivers will ask about pain regularly, they do not know when the patient has pain unless the patient reports it. This information helps staff establish pain relief satisfactory to the patient. Emphasize also that the patient's report about his/her pain level is always what is recorded in the patient's record.

• Show the patient and family the NRS and explain that its primary purpose is to provide quick, consistent communication between the patient and caregivers, including nurse and physician. Explain that 0 represents no pain, while 10 represents the worst possible pain.

If the patient does not understand, select another pain intensity scale.

• If the patient reports more than one site or painful condition, discuss the importance of providing a single, global measure of pain intensity. The patient should be encouraged to take into account a primary site of pain (e.g., surgical wound) but also to consider all other relevant sites of pain, as well.

• Ask the patient to practice using the NRS by rating his/her present painful experiences or those that he/she remembers.

• Ask the patient what pain rating would be acceptable or satisfactory to him/her. This helps set a realistic, initial goal. Zero pain is not always possible. Once the initial goal is achieved, the possibility of better pain relief can then be considered. Emphasize to the patient that satisfactory pain relief is a level of pain that is not distressing, and one that enables the patient to sleep, eat, and perform other required physical activities.


Pain as the 5th Vital Sign Toolkit Page 10


Before presenting the key parameters of the pain screening and assessment process, it is important to consider the numerous obstacles to this process.

The patient's subjective pain experience may be difficult to communicate because the patient and provider have different languages, experiences, expectations, and frames of reference. Prior to assessment, it is important that the provider be aware of and sensitive to these types of barriers.

A range of additional barriers attributable to healthcare professionals, patients, and the healthcare system have also been articulated and deserve special attention in promoting reliable pain assessment and optimal pain management.

Traditional patterns of professional practice may be among the most difficult barriers to overcome. Healthcare providers and institutions must address these barriers in their practice settings to assure that all patients receive quality pain care.1 Healthcare Professionals How we think about pain influences the way we go about evaluating a person who reports the presence of pain. Assessment of pain is also influenced by learned behavioral responses from a given culture or subculture. It is important that all practitioners be aware of how their own biases may influence pain assessment. The following may affect practitioners’ responses to

patients’ reported pain:

• Attitudes - Fear of patient addiction. Concern that attention to pain may encourage additional complaints of pain and medication seeking.

• Skills - Inadequate knowledge and experience related to pain assessment and management.

• Knowledge - Concern about the side effects of analgesics.

• Practice behavior - Failure to routinely assess and document.

Patients Patient barriers may make pain assessment more difficult, prevent successful application of a

useful treatment, or block the recovery process. Some examples of patient barriers are:

• Language or cultural barrier

• Chemical dependency

• Physical, emotional, or sexual abuse

• Litigation

• Chaotic psychosocial lifestyle ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 11

• Medical illness

• Reluctance to report pain or use the word “pain” − Fear that having pain may indicate a more serious disease than if there were no pain − Concern about not being a “good” patient − Fear of diagnostic tests, procedures, or medications

• Reluctance to take pain medications − Fear of addiction − Worries about side effects Healthcare System

Barriers within the healthcare system may be due to:

• A low priority given to pain care

• Inadequate reimbursement for costly care given to patients

• Restrictive regulation of controlled substances

• Lack of access to pain specialists ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 12


Pain as the 5th Vital Sign is a strategy for promoting increased attention to unrecognized and under-treated pain among patients receiving care in the VHA healthcare system. The strategy calls for a routine screening, where patients are asked whether they are experiencing pain and are then asked to rate the intensity of their pain using the 0-to-10 Numeric Rating Scale (NRS) on which 0 equals no pain while 10 represents the worst possible pain. The number reported by each patient is the pain score and should be documented in the medical record. The presence of pain at any level serves a cue to the provider to conduct additional assessment and to initiate interventions designed to promote pain relief, as clinically indicated.

Documentation of pain scores in a systematic and consistent manner is an important mechanism for promoting identification of unrelieved pain at the individual patient care level. It is also the first step toward implementation of a single standard of care and a system-wide approach to improving pain management throughout the VHA healthcare system. Availability of pain scores will provide important information for the VHA about the presence and intensity of pain problems among veterans receiving care in its healthcare system. Finally, the availability of pain scores will provide an important index for monitoring improvement in pain management throughout the system.

Keys to Successful Pain Screening Successful pain screening relies on practitioners’ consistent commitment to several core


• The patient's self-report of pain is the single most reliable indicator of pain.

• Observations of behavior and vital signs should not be used instead of self-report unless the patient is unable to communicate.

• Pain can occur when there is no physiological cause, and it is just as real to the patient.

The Numeric Rating Scale (NRS) There is no pain thermometer. Measurements of pain must rely on patients' self-reports or the inferences we can make based on their behaviors. Screening for pain intensity is an important aspect of patient care.

For several reasons, the VHA has chosen the NRS as the tool for pain screening:

1. A large body of research supports the reliability and validity of the NRS as a single index of pain intensity or severity, and it compares favorably to other commonly employed strategies.

2. Studies suggest that the NRS is valid for use in the assessment of acute, cancer, or chronic nonmalignant pain and in varied clinical settings.


Pain as the 5th Vital Sign Toolkit Page 13

3. The NRS is simple for practitioners to describe and easy for most patients to understand and use. There is evidence of a high degree of compliance with the task.

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