Guidelines For Acute Pain Management Research Articles

Original Research: Combating the Opioid Epidemic Through Nurse Use of Multimodal Analgesia: An Integrative Literature Review.

Opioid misuse and addiction have become a national crisis. New pain management guidelines call for the use of multimodal analgesia to manage acute pain. In hospital settings, a clinical decision aid that emphasizes multimodal analgesia may improve nurses' use of this opioid-sparing strategy. This integrative review was conducted to provide nurses with evidence-based information on the opioid-sparing benefits of multimodal analgesia. A literature search was conducted using several electronic databases and Google Scholar. These initial searches yielded 136 articles of interest. Twenty-eight were selected for retrieval and in-depth appraisal; of these, 13 met all inclusion criteria. Of the 13 reviewed studies, six were randomized controlled trials, six were retrospective cohort or population-based studies, and one was a qualitative study. Overall, the findings provided strong evidence that multimodal analgesia is effective in managing acute pain in surgical patients while reducing opioid requirements. Several studies also found that multimodal analgesia was associated with shorter hospital lengths of stay. With the appropriate tools and education, nurses can make the transition from traditional opioids to multimodal analgesia strategies. In so doing, they can have a significant positive impact on the opioid epidemic. Hospital leaders must address nursing practice regarding the use of opioids alone versus multimodal analgesia for the management of acute pain. Clinical decision tools such as the Michigan Opioid Safety Score may help nurses adopt new acute pain management guidelines. Further research regarding nursing practice and the opioid epidemic is needed.

Pain management in adults during long-bone fracture reduction in the Gaza Strip: a clinical audit

BackgroundOngoing protests in Gaza have led to numerous injuries, including long-bone fractures. We investigated assessment of pain severity and strategies for pain management in the emergency department. As no local guidelines exist, delivered care was compared with the guidance of the UK National Institute for Health and Care Excellence (NICE). MethodsA clinical audit was conducted at the emergency department in Dar Al Shifa Medical Complex, Gaza, among patients who attended the emergency department with acute long-bone fractures between April 15 and July 15, 2018. Data were collected on pain assessment methods and strategies for pain management and analgesia administration. Ethics approval was obtained from the Palestinian Ministry of Health. The purpose of the audit was explained to patients and their written consent was obtained before inclusion. FindingsOf 79 patients invited to participate, 50 gave consent. 25 patients (50%) were aged 16–24 years, 20 (40%) 25–64 years, and five (10%) 65 years and older. Structured pain assessments were performed in only three patients (6%). No analgesia was administered to patients in the emergency department, except for two patients (4%) received infiltration of lidocaine as analgesia for haematoma. InterpretationNo local guidelines for acute pain management in emergency departments exist in the Gaza Strip. Clinical practice showed no adherence to international standards, such as the NICE guidelines for pain management. Factors contributing to such poor management might be large numbers of patients presenting at the time during conflict and protests and that only one room was available in the Shifa’ Medical Complex emergency department for examining, assessment, prescribing, and cast application. A limitation of the study is the small sample size is relatively small, but strengths were the 3-month period and prospective enrolment in the emergency department. FundingNone.

Pain Management in Trauma: Maximizing Multimodals to Minimize Opioids

The US has been challenged with an opioid crisis, as these medications account for a substantial number of fatal and nonfatal overdoses. Surgeons are on the front lines of this epidemic, balancing the treatment of pain, while confronting the risks of opioids, such as gastrointestinal effects, respiratory distress, delirium, increased hospital length of stay, and potential misuse or diversion. 1 Yorkgitis B.K. Brat G.A. Postoperative opioid prescribing: Getting it RIGHTT. Am J Surg. 2018; 215: 707-711 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar ,2 American College of Surgeons Quality ProgramsBest practices guidelines for acute pain management in trauma patients. Nov 2020. https://www.facs.org/-/media/files/quality-programs/trauma/tqip/acute_pain_guidelines.ashxDate accessed: December 22, 2020 Google Scholar Recently, progress has been made in this battle, as opioid-related deaths fell in 2018 for the first time in decades. 3 Centers for Disease Control and PreventionDrug overdose deaths in the United States, 1999-2018. https://www.cdc.gov/nchs/products/databriefs/db356.htmDate accessed: December 21, 2020 Google Scholar The decrease in opioid-related deaths mirrors opioid prescribing rates, as they have been declining over the recent years. 4 Centers for Disease Control and PreventionPrescribing practices. https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.htmlDate accessed: December 21, 2020 Google Scholar Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical TrialJournal of the American College of SurgeonsVol. 232Issue 3PreviewAn effective strategy to manage acute pain and minimize opioid exposure is needed for injured patients. In this trial, we aimed to compare 2 multimodal pain regimens (MMPRs) for minimizing opioid exposure and relieving acute pain in a busy, urban trauma center. Full-Text PDF

Response to Dr Mion: ketamine for acute pain management

We appreciate the thoughtful comments by Dr Mion[1][1] regarding the ketamine consensus guidelines for acute pain management,[2][2] and will respond to the three main points brought to our attention. First,...

The Opioid Crisis and Surgeons: National Survey of Prescribing Patterns and the Influence of Motivators, Experience, and Gender

BackgroundSurgeons are the fifth largest prescribers of opioids in the US. Few studies exist to describe surgeon prescribing practices. MethodsA survey was conducted of surgical providers at all ACGME-accredited surgical residency programs. Statistical comparisons between groups were made. ResultsA total of 114 providers from 21 states responded; 58% male, 57% residents. Only 8% reported being told they were over-prescribing opioids.Oxycodone ± acetaminophen was most commonly prescribed (49%). Median opioids prescribed exceeded guidelines for acute pain management for every procedure except laparoscopic appendectomy/cholecystectomy, lumpectomy and laparoscopic inguinal hernia repair. Attending surgeons more often gave no opioids after laparoscopic appendectomy/cholecystectomy (9% vs 0%; p=0.012), more likely reported patient attempts to return opioids to them (33% vs 16%; p=0.04), and less likely considered patients giving their opioids to someone else (39% vs. 74%; p<0.001). PGY 1-2 residents prescribe fewer opioids than advanced residents for simple mastectomy (p=0.04), exploratory laparotomy (p=0.05), and thoracotomy (p=0.03). ConclusionsSurgeons vary significantly in their opioid prescriptions, even for the same operation. There are few differences by gender but some important differences by experience.

Administration of intravenous morphine for acute pain in the emergency department inflicts an economic burden in Europe.

BackgroundAcute pain is among the leading causes of referral to the emergency department (ED) in industrialized countries. Its management mainly depends on intensity. Moderate-to-severe pain is treated with intravenous (IV) administered opioids, of which morphine is the most commonly used in the ED. We have estimated the burden of IV administration of morphine in the five key European countries (EU5) using a micro-costing approach.ScopeA structured literature review was conducted to identify clinical guidelines for acute pain management in EU5 and clinical studies conducted in the ED setting. The data identified in this literature review constituted the source for all model input parameters, which were clustered as analgesic (morphine), material used for IV morphine administration, nurse workforce time and management of morphine-related adverse events and IV-related complications.FindingsThe cost per patient of IV morphine administration in the ED ranges between €18.31 in Spain and €28.38 in Germany. If costs associated with the management of morphine-related adverse events and IV-related complications are also considered, the total costs amount to €121.13–€132.43. The main driver of those total costs is the management of IV-related complications (phlebitis, extravasation and IV prescription errors; 73% of all costs) followed by workforce time (14%).ConclusionsIV morphine provides effective pain relief in the ED, but the costs associated with the IV administration inflict an economic burden on the respective national health services in EU5. An equally rapid-onset and efficacious analgesic that does not require IV administration could reduce this burden.

Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines.

Pain is common among hospitalized patients. Inpatient prescribing of opioids is not without risk. Acute pain management guidelines could inform safe prescribing of opioids in the hospital and limit associated unintended consequences. To evaluate the quality and content of existing guidelines for acute, noncancer pain management. The National Guideline Clearinghouse, MEDLINE via PubMed, websites of relevant specialty societies and other organizations, and selected international search engines. Guidelines published between January 2010 and August 2017 addressing acute, noncancer pain management among adults were considered. Guidelines that focused on chronic pain, specific diseases, and the nonhospital setting were excluded. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Four guidelines met the selection criteria. Most recommendations were based on expert consensus. The guidelines recommended restricting opioids to severe pain or pain that has not responded to nonopioid therapy, using the lowest effective dose of short-acting opioids for the shortest duration possible, and co-prescribing opioids with nonopioid analgesics. The guidelines generally recommended checking the prescription drug monitoring program when prescribing opioids, developing goals for patient recovery, and educating patients regarding the risks and side effects of opioid therapy. Additional recommendations included using an opioid dose conversion guide, avoidance of co-administration of parenteral and oral opioids, and using caution when co-prescribing opioids with other central nervous system depressants. Guidelines, based largely on expert opinion, recommend judicious prescribing of opioids for severe, acute pain. Future work should assess the implications of these recommendations on hospital-based pain management.

The Impact of Scripted Pain Education on Patient Satisfaction in Outpatient Abdominal Surgery Patients

Practice guidelines for acute pain management in perioperative patients recommend providing consistent perioperative pain education that includes medication and behavioral techniques to control pain. However, literature indicates that most nurses deliver patient education based on personal preferences, time limitations, and availability of teaching aids. The purpose of this study was to evaluate patient satisfaction with scripted preoperative pain management education for patients undergoing outpatient abdominal surgery. A pretest and posttest design compared patient perceptions of and satisfaction with pain management education before and after the introduction of scripted education. An independent t test was applied to measure differences between groups. The postscripting group responses indicated that pain education was helpful in managing postoperative pain at a significant (P = 0.03) level. Use of scripted dialog, along with specific written patient education, has a positive impact on postoperative patient satisfaction with pain management.

Opioid-Induced Pruritus

Opioid-Induced Pruritus

Updated Pain Guidelines

Rigshospitalet Copenhagen University, Copenhagen, Denmark. henrik.kehlet@rh.regionh.dkRecently, the American Society of Anesthesiologists Task Force on Acute Pain Management published an “updated report and practice guidelines for acute pain management in the perioperative setting.”1Although this is a laudable effort and the Task Force committee includes anesthesiologists with established expertise in the topic, I must admit as a surgeon with an interest in analgesia and postoperative recovery that I have several concerns on the overall message of the practice guidelines. First, it is claimed that the present guidelines differ from existing guidelines by providing “new evidence in an updated evaluation of scientific literature,” but a closer look at the reference material including almost 250 references shows less than 10 references from 2009 and upward. Many publications on single analgesic interventions as well as multimodal techniques have been published in the last 3 yr, which may change their conclusions if updated. For instance, by several meta-analyses or reviews on interventions like preventive analgesia, paravertebral blocks in pulmonary surgery, epidural analgesia in laparoscopic colonic surgery, local infiltration analgesia versus spinal analgesia in hernia surgery, and high-volume infiltration analgesia in major lower-limb arthroplasty versus peripheral blockades as well as the many efforts to provide improved analgesia and/or opioid-sparing by a combination of nonopioid analgesics. Importantly, many publications from the PROSPECT Collaboration Group have provided procedure-specific recommendations for perioperative acute pain management—which was not discussed in the present guidelines. This may be clinically important, because it has become evident that choice of analgesia is highly dependent on the specific surgical procedure regarding analgesic efficacy, potential side effects, and effects on recovery.Neither was there a comment on the extensive Australian and New Zealand guidelines for perioperative pain management.*†In summary, updated practice guidelines for acute pain management therefore must be based upon the available procedure-specific, multimodal opioid-sparing techniques and within a context to provide a rational basis for enhanced postoperative recovery and reduction of morbidity.2Rigshospitalet Copenhagen University, Copenhagen, Denmark. henrik.kehlet@rh.regionh.dk

Practice Guidelines for Acute Pain Management in the Perioperative Setting

Practice Guidelines for Acute Pain Management in the Perioperative Setting

Pain management in the intensive care unit: do we need special protocols?

Pain is a major public health issue throughout the world and represents a major clinical, social, and economic problem (1). The inability of intensive-care unit (ICU) patients to report pain because of mechanical ventilation, concomitant use of sedatives, or as a consequence of loss of consciousness should not preclude pain control. Acute pain has emerged as a leading stressor for ICU patients. Moderate to severe pain intensity has been observed in nearly 50% of ICU patients (2). Various pharmacologic factors may increase the probability of excessive/prolonged effects in ICU patients including altered pharmacokinetic and pharmacodynamic characteristics with prolonged administration, altered protein binding, altered volume status, and end-organ dysfunction (3). Special complications of inappropriate pain management in ICU are as follows: under-treatment leading to prolonged mechanical ventilation, increased ICU stay, hypoxemia, thromboembolic and pulmonary complications, self-removal of tubes and catheters, violence toward caregivers, patient-ventilator asynchrony, pain-related immune suppression, and readmission for further pain management, agitation, myocardial ischemia, delirium, and chronic pain. The complications of over-treatment for pain include prolonged mechanical ventilation and associated problems such as ventilator-associated pneumonia, post-traumatic stress disorder, prolonged cognitive impairment, unnecessary testing for altered mental status, prolonged ICU stay, skin breakdown, nerve compression, delirium, respiratory depression, brain or other neurologic injury, sedation, circulatory depression, urinary retention, impairment of bowel function, and sleep disruption (4-8). It is strongly recommended that in patients with impaired cognition or concurrent diseases and in critically ill patients, additional interventions are needed for optimal pain management. A therapeutic trial of an analgesic should be considered in patients with increased blood pressure and heart rate or agitated behavior (4). The inclusion of pain management in the ICU checklist, as a part of daily rounds, can be a valuable tool for reducing the patient’s discomfort (9). Anesthesia-based pain services can improve the outcome and reduce the burden for ICU physicians and nurses (10). Thus, the optimal care of mechanically ventilated patients includes the use and integration of pain and sedation assessment tools to optimize the dosing of analgesic and sedative drugs. Do patients undergoing different type of surgery have different need for analgesia? A systematic pain assessment method for mechanically ventilated ICU patients could function as a criterion for good practice in the ICU (11). The efficacy and outcomes of analgesic protocols for acute pain management have been studied extensively and are widely adopted. The latest practice guidelines were updated as the “Practice Guidelines for Acute Pain Management in the Perioperative Setting” in February 2012 and have been adopted by the ASA (4). These guidelines are published to facilitate the safety and effectiveness of acute pain management in the perioperative setting; decrease the risk of adverse outcomes; maintain functional abilities as well as physical and psychological well-being; and improve the quality of life (4). For acceptable guideline implementation, ongoing education and training are essential to preserve one’s skills, particularly when therapeutic approaches are modified (4). Techniques for pain management include the following modalities: Intermittent or continuous systemic opioids; Multimodal techniques (administration of 2 or more drugs that act by different mechanisms to provide analgesia); Central regional (i.e., neuroaxial) opioid analgesia; and Peripheral regional analgesic techniques, including intercostal blocks, plexus blocks, and local anesthetic infiltration (4). Techniques that reduce drug dosage (opioid-sparing effect) may be suitable for ICU patients. Behavioral modalities and techniques such as PCA that depend upon self-administration of analgesics are generally less suitable for the cognitively impaired. Most patients on mechanical ventilation receive sedatives and analgesics without further evaluation (12). A prospective, multicenter, observational survey found that only 42% of patients underwent pain assessment on day 2 in the ICU, although 90% of patients were concomitantly given opioids. The survey concluded that pain assessment in patients on mechanical ventilation is independently associated with a decrease in hypnotic drug dosing, duration of mechanical ventilation, and duration of ICU stay (5, 11). Thus, pain assessment may be related to higher concomitant rates of sedation assessment and restricted use of hypnotic drugs. Several scales and tools such as the visual analog scale, behavioral pain scale, and critical care pain observations are used for the assessment of analgesia and sedation in ICU. These scales and checklists for pain emphasize the complex nature of the problem. The structured approaches and use of protocols to prevent the accumulation of drugs and metabolites that could lead to a slower recovery are supported by rapidly expanding evidence (7). Awissi and coworkers concluded that establishing protocols for the management of sedation, analgesia, and delirium is a cost-effective practice and allows savings of nearly $1000 per hospitalization (13). Thus, we strongly recommend that strategies such as administering the right drugs in the right dose to the right patient at the right time for the right reasons should be defined to establish a practice protocol.

Interscalene Block Superior to General Anesthesia

Baystate Medical Center and the Tufts University School of Medicine, Springfield, Massachusetts. scott.reuben@bhs.orgI read with interest the article by Hadzic et al. 1about the use of interscalene block compared with general anesthesia for outpatient rotator cuff surgery. Although I agree that there are advantages to using nerve block anesthesia for outpatient shoulder surgery, I believe the comparator group receiving general anesthesia in the current Clinical Investigation1was a recipe for failure. I am not surprised by the 16% hospital admission rate for refractory pain observed in those patients receiving general anesthesia. I would hope with our current understanding of the pathophysiology of acute pain that we as anesthesiologists will offer our patients more effective perioperative analgesic techniques. I was surprised that the current clinical investigation failed to use nonopioid analgesics, including nonsteroidal antiinflammatory drugs, in a multimodal approach to perioperative pain management as outlined by the recent American Society of Anesthesiologists Practice Guidelines for acute pain management in the perioperative setting state.2A more aggressive preventive multimodal pharmacologic approach3including the use of nonsteroidal antiinflammatory drugs, acetaminophen, intraarticular local anesthetics, opioids, and α2agonists and postoperative cold therapy may have resulted in a less dramatic benefit compared with interscalene block. Failure to do so may result in inadequate analgesia for our patients, as demonstrated in the current study by Hadzic et al. 1Baystate Medical Center and the Tufts University School of Medicine, Springfield, Massachusetts. scott.reuben@bhs.org

Development of a new pain scale: Colorado Behavioral Numerical Pain Scale for sedated adult patients undergoing gastrointestinal procedures.

A limited number of studies have addressed pain assessment among sedated patients undergoing a gastrointestinal examination. The Colorado Behavioral Numerical Pain Scale is a quick, simple tool that can provide an estimation of the patient's comfort level while sedated. Multiple studies completed in intensive care unit and postanesthesia care unit settings provide ample evidence of the accuracy of behavioral pain scales ratings. In developing the Colorado Behavioral Numerical Pain Scale, experienced endoscopy nurses provided suggestions and modifications of descriptive words for behavioral assessment of pain selected from the relevant literature. Three nurses simultaneously rated pain using the scale for 30 procedures. Interrater reliability was high with 82% of observations in total agreement and 17% having one of the three persons disagreeing on the rating. Nurses from four hospitals and one ambulatory facility also evaluated the Colorado Behavioral Numerical Pain Scale tool. In this evaluation, 98% of the 52 respondents agreed that the words described what they observed during a gastrointestinal examination and 94% felt it was a better descriptor of pain than a patient self-report numerical scale. Assessment of pain for the sedated patient undergoing gastrointestinal procedures is often difficult due to the patient's inability to report pain levels. The sedated patient undergoing painful procedures depends on the nurse to interpret physical signs to quantify his or her distress. The Acute Pain Management Guidelines (AHCPR, 1992) promotes the use of both physiological and behavioral responses to pain for assessment when self-report is absent. While an individual's self-report of pain intensity and distress is the most accurate assessment measurement, the validity of a sedated patient's elicited response about pain is questionable. It is the nurse, through observation, who attempts to assess the sedated individual's pain levels.

Acute pain management after surgery or in the emergency room in Switzerland: a comparative survey of Swiss anaesthesiologists and surgeons

The treatment of acute pain remains unsatisfactory despite advances in pain research and the publication of numerous guidelines. The aim of this study was to survey postoperative and emergency room acute pain treatment in Switzerland, particularly regarding compliance with practice guidelines on therapeutic responsibility, treatment algorithms, pain documentation, quality control and education.A representative sample of anaesthesiologists and surgeons (general and orthopaedic) was selected from all Swiss hospitals with regular surgical activity and sent a 256 point questionnaire on acute pain management.Five hundred and seventy five doctors were contacted in 98 hospitals, 44% of doctors (covering 89% of hospitals) returned fully completed questionnaires. Half the respondents work in a hospital with an acute pain service. For postoperative pain management, only 10% of prescription is by algorithm, less than a third of respondents regularly determine pain scores, only 15% perform any statistical analysis of pain management, less than one third regularly meet to discuss management problems, and half claim not to have received—or be receiving—formal (i.e. structured/accredited) pain education. The situation is even less satisfactory for emergency room analgesia. Respondents accept the contribution of postoperative and emergency room analgesia to reduced costs and improved medical outcomes. Asked to highlight their major concerns in acute pain management, lack of education and inadequate organisation are listed in first and second positions.This survey suggests that compliance with published practice guidelines for acute pain management can be improved, and highlights the need for continuing organisational and educational development in acute analgesia, particularly for the emergency room. Copyright 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd. All rights reserved.

Factors influencing hospital implementation of acute pain management practice guidelines

Study Objective: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. Design: Two questionnaire surveys. Setting: Healthcare Association of New York State, Albany, NY. Measurement: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital’s chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs’ survey data with the clinical directors’ report of guideline usage. Main Results: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. Conclusions: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Hospital Room or Treatment Room for Pediatric Inpatient Procedures: Which Location Do Parents and Children Prefer?

OBJECTIVE: The acute pain management guidelines put forth by the Agency for Health Care Policy and Research recommend that inpatient pediatric procedures be performed in a treatment room rather than in a child′s hospital room. However, hospitals vary widely in their use of treatment rooms for pediatric procedures. Because there has been little empirical investigation of this clinical issue, the present study explores the preferences of parents and children regarding the performance site of inpatient procedures.SUBJECTS AND METHODS: One hundred and sixty parents of hospitalized children three to 14 years of age were interviewed about previous experience with medical procedures, procedure site preference (treatment room or hospital room) and reasons for room preference. Children five years of age and older were also asked for their preferences regarding the procedure site.RESULTS: The hospital room was preferred by the majority of parents and children for minor procedures (blood test, intravenous insertion, bandage change) for reasons consisting primarily of the child′s emotional or physical comfort, convenience and difficulties moving the child due to motor impairment or medical condition. The treatment room was generally selected for more invasive procedures (lumbar punctures, bone marrow aspirations, bladder catheterizations) due to concerns for the privacy of the child and roommate, and the need for special equipment or supplies.CONCLUSIONS: Results suggest that parents and children may prefer the hospital room or treatment room for a variety of different reasons. More research is needed in this area to develop better guidelines regarding the performance of inpatient pediatric procedures.

Changing Acute Pain Management to Improve Patient Outcomes: An Educational Approach

The United States Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines were written to provide a scientific basis for practice. Educational programs designed to promote use of the guidelines may change practice in community hospitals. This article describes the development and implementation of an education program for nurses, physicians, and pharmacists in six community hospitals. Program content addressing the use of continuous quality improvement (CQI) teams, detailed pain histories, application of algorithms and dose calculation is described; direct and indirect outcome measures are reviewed. Six months after the program, all three experimental sites reported use of the AHCPR Guidelines in practice. Nurses reported that assessment and documentation of patients’ duration of pain were perceived to be the most important caregiver behaviors providing benefit to patients: Across all respondents’ reports of regularly performed activities, the activity performed by the largest proportion was assessing and documenting pain using a 0–10 rating scale. J. Pain Symptom Manage 1999;17:277–287.

Burn Pain Management

The pain associated with burn injury and treatment often is managed poorly. The purpose of this article is to describe available pain-management guidelines and to explain how burn pain can be enhanced by using a guideline-based approach. Data from a retrospective audit are used to highlight several of the common causes of pain mismanagement: including inadequate pain assessment, analgesic-knowledge deficits, and incomplete documentation. Key recommendations from the Agency for Health Care Policy and Research's Acute Pain Management Guidelines are highlighted. Guideline-based suggestions from these and other guidelines are presented as a basis for burn pain management-guideline development. Guidelines for burn-pain management must be broad in scope to allow for variations in analgesic needs across all patient populations and phases of burn recovery. Guidelines are necessary because studies show that information and education alone have little effect on the quality of pain management. What is effective are guideline-based initiatives that make pain visible and care providers accountable.

A805 Impact of Clinical Practice Guidelines for Acute Pain Management in New York State

A805 Impact of Clinical Practice Guidelines for Acute Pain Management in New York State