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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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• Clinician Competence and Expertise in Pain Management. All VHA medical facilities will assure that appropriate clinical staff (e.g., physicians, nurses, and therapists) have appropriate orientation and employee education related to pain assessment and pain management. VHA standards for pain management will be communicated to all medical students, allied health professional students, residents, and interns providing patient care in VHA medical facilities. VHA education programs will be developed that include principles of pain assessment and management.

• Research. VHA will expand its basic and applied research on management of acute and chronic pain, emphasizing conditions that are most prevalent among veterans. Research funded by the Health Services Research and Development Service (HSR&D) will encourage a systematic approach to identifying research priorities and providing scientific evidence on which to base pain management protocols throughout VHA and for evaluating and monitoring the quality of care.

• Coordination of National VHA National Pain Management Strategy. The consistent and effective management of pain for all veterans cared for by VHA requires a coordinated national approach. An interdisciplinary committee will be established to oversee the development and implementation of the VHA National Pain Management

Strategy. The Committee will be charged with the following responsibilities:

1. Coordinate the system-wide implementation of Pain as the 5th Vital Sign.

2. Coordinate the development and dissemination of state-of-the-art treatment protocols for pain management.


Pain as the 5th Vital Sign Toolkit Page 24

3. Identify VHA pain management expertise and resources, and facilitate a national referral system to assure that veterans in every network have access to pain management services.

4. Coordinate a national employee education initiative to assure that VHA clinicians have the expertise to provide high-quality pain assessment and treatment.

5. Identify research opportunities and priorities in pain management, and facilitate collaborative research efforts.

6. Integrate VHA pain management standards into the curricula and clinical learning experiences of medical students, allied health professional students, interns, and resident trainees.

7. Establish target goals, mechanisms for accountability and a timeline for implementing the comprehensive, integrated VHA National Pain Management Strategy.

8. Establish a communication plan for both the internal and external communication of the VHA National Pain Management Strategy.

References Principles of analgesic use in the treatment of acute pain and cancer pain. (3rd ed.). (1992). p.2.

American Pain Society.

New guidelines on managing chronic pain in older persons. JAMA, 280(4).

American Pain Society Bulletin, (6)1, 17. Jan/Feb., 1996.

Quality improvement guidelines for the treatment of acute pain and cancer pain, JAMA, Vol.274( 23), 1874-1880.

VHA pain management survey. Headquarters Anesthesia Service, July 1997.

VHA National Pain Management Strategy Coordinating Committee A multidisciplinary national committee was appointed by the Under Secretary for Health to coordinate the VHA National Pain Management Strategy. This committee includes representatives from acute care, geriatrics and extended care, nursing, pharmacy, psychology, health services research and development, employee education, and information services. The role of the committee is to coordinate the implementation of the VHA National Pain Management Strategy in a way that effectively uses VHA resources and expertise to achieve the national goals. This is a long-term initiative and it is expected that a variety of subcommittees and workgroups will be identified to focus on specific aspects of the national strategy.


Pain as the 5th Vital Sign Toolkit Page 25 Chair, VHA National Pain Management Strategy Coordinating Committee Judith A. Salerno, MD, MS Chief Consultant (114) Geriatrics & Extended Care Strategic Healthcare Group VA Headquarters 810 Vermont Avenue, NW Washington, DC 20420 202-273-8540 fax: 202-273-9131 e-mail: judith.salerno@mail.va.gov Coordinator, VHA National Pain Management Strategy Coordinating Committee Jane H. Tollett, PhD National Coordinator, Pain Management VA Headquarters 810 Vermont Avenue, NW Washington, DC 20420 202-273-8537 fax: 202-273-9131 e-mail: jane.tollett@mail.va.gov Members, VHA National Pain Management Strategy Coordinating Committee John Booss, MD Director of Neurology, Field Based Department of Veterans Affairs (200) VA Connecticut Health Care System West Haven, CT 06516 203-932-5711 x 3544 fax: 203-937-4755 e-mail: booss.john@west-haven.va.gov Michael E. Clark, PhD Clinical Director, Chronic Pain Rehabilitation Unit (116B) Tampa, FL 813-972-2000, x 7484, x 7112, x 7114 fax: 813-903-4847 e-mail: michael.clark2@med.va.gov Web site: www.vachronicpain.org ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 26 Tana Defa Program Manager, Clinician Desktop Salt Lake City Office of Information Field Office 295 Chipeta Way Salt Lake City, UT 84108 801-588-5053 fax: 801-588-5004 e-mail: tana.defa@med.va.gov Audrey Drake, RN, MSN, CNAA Program Director (118) Nursing Strategic Healthcare Group VA Headquarters 810 Vermont Avenue, NW Washington, DC 20420 202-273-8424 fax: 202-273-9066 e-mail: audrey.drake@mail.va.gov Robert Kerns, PhD Chief, Psychology Service VA Connecticut Healthcare System West Haven, CT 06516 203-937-3841 fax: 203-937-4951 email: robert.kerns@med.va.gov Claire Maklan, PhD, MPH Chief of Scientific Development (124I) Health Services R&D VA Headquarters 810 Vermont Avenue, NW Washington, DC 20420 202-273-8244 fax: 202-273-9007 e-mail: maklan.claire@mail.va.gov Ruth Markham Systems Analyst, Clinician Desktop Salt Lake City Office of Information Field Office 295 Chipeta Way Salt Lake City, UT 84108 801-588-5042 fax: 801-588-5004 e-mail: ruth.markham@med.va.gov ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 27 Richard W. Rosenquist, MD Director, Pain Management Center Department of Anesthesia University of Iowa Hospitals & Clinics 6413 JCP Iowa City, Iowa 52242 319-356-2320 fax: 319-356-3431 e-mail: richard-rosenquist@uiowa.edu Paul Rousseau, MD ACOS for Geriatrics & Extended Care VA Medical Center 650 E. Indian School Road Phoenix, AZ 85012 602-277-5551 fax: 602-222-6514 e-mail: ArizonaMD@aol.com Charles D. Sintek, MS, RPh, BCPS Clinical Pharmacy Manager (119B) Clinical Pharmacy Service VA Medical Center 1055 Clermont Street Denver, CO 80220 303-393-2806 fax: 303-393-4624 e-mail: charles.sintek@med.va.gov Anne Marie Stechmann, MA Program Development Manager Department of Veterans Affairs VA Employee Education System 5445 Minnehaha Avenue South Minneapolis, MN 55417 612-725-2000 x 4546 fax: 612-725-2053 e-mail: stechmannann@lrn.va.gov Loretta Wasse, CRNA, Med Deputy Director, Headquarters Anesthesia Service Department Of Veterans Affairs Puget Sound Healthcare System, Seattle Division 1660 South Columbian Way Seattle, WA 98108 206-764-2584 fax: 206-764-2914 e-mail: loretta.wasse@med.va.gov ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 28 VISN Pain Management Points of Contact (POCs) Every VISN has identified a point of contact (POC) for the VHA National Pain Management Strategy (see Section 6). The function of the POC is to facilitate communication and the flow of information between the Coordinating Committee and field staff in each VISN.

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Pain as the 5th Vital Sign Toolkit Page 31 Education Service Representatives (ESRs) The ESR assigned to your VISN can provide you with details on the earning activities, products, and services available to VA employees through the Employee Education System. You may send e-mail to an individual or get the latest information from the Web site http://vaww.ees.lrn.va.gov/.

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Pain as the 5th Vital Sign Toolkit Page 32 Electronic Documentation of Pain Scores Entering the Pain Score in the Vitals/Measurement Menu (also accessible from the Nursing package)

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Vitals by (A)ll patients on a unit, (S)elected Rooms on unit, or (P)atient? p Select PATIENT NAME: squirrEL, GREY 10-25-71 123994567


Enrollment Priority: GROUP 1 Category: IN PROCESS End Date:

Select Hospital Location: 13A PSYCH// Temp-Pulse-Resp-Pain: 98.7-67-15-0

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Is this correct? YES// If the answer is Yes, the pain score is stored. If the answer is No, a prompt gives the user the opportunity to re-enter a correct pain score. If the user enters Yes, and the stored pain score is incorrect, the Edit a Vital/Measurement Entered in Error option must be used to mark the record in error.


Pain as the 5th Vital Sign Toolkit Page 33 Vitals Reports in the Vitals/Measurement Menu Vitals/Measurements Results Reporting Menu

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NW Enter New Allergy/ADR CV (Change View...) SP Select New Patient AD Add New Orders CC Chart Contents... Q Close Patient Chart Select: Next Screen// Select Item(s): Next Screen// ______________________________________________________________________________________________

Pain as the 5th Vital Sign Toolkit Page 35 Viewing Vitals from CPRS GUI

Vitals displayed from the CPRS GUI Cover Sheet:


Pain as the 5th Vital Sign Toolkit Page 36

Vitals detail display from the CPRS GUI Cover Sheet:


Pain as the 5th Vital Sign Toolkit Page 37

Vitals data entry from the CPRS GUI Cover Sheet:

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140 103/39.4 130 102/38.9 ' 120 101/38.3 110 100/37.8 100 99/37.2 98.6 90 98/36.7 80 97/36.1 70 96/35.6

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Pain as the 5th Vital Sign Toolkit Page 40 Examples of Local Facility Pain Assessment Tools and Templates Source: VA Medical Center, New York, NY - Pain Management Team

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Patient's stated level of acceptable pain intensity (0-10 scale) Acceptable pain intensity __________ DATE _________ Acceptable pain intensity ___________ DATE ___________ Acceptable pain intensity __________ DATE _________ Acceptable pain intensity ___________ DATE ___________

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Does the pain travel to another part of your body? Where?________________

Are there any particular times of the day when it is worse?________ Can you describe your pain's quality? Aching ( ) burning ( ) shooting ( ) stabbing ( ), other ___________

Does your pain interfere with your daily activities? Check all that are applicable:

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What makes your pain worse? ___________What relieves your pain?________ List all the medicines are you currently taking for your pain.


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Are you having any side effects from these medicines? If so what are they?

Constipation ( ) Dizziness ( ) Other ( ) ________________

What medicine(s) have you used in the past for your pain and why did you stop taking them?


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