Inadequate Pain Management Research Articles

Ultrasound-guided infraclavicular brachial plexus block using bupivacaine alone or combined with dexmedetomidine for hand and forearm surgeries

Background Pain was identified by the International Association for the Study of Pain as an unpleasant sensory or emotional experience associated with actual or potential tissue damage. The incidence of inadequate pain management seems to be high, even in the developed countries. Traumatic upper limbs injuries are accountable for a considerable number of patients, who require care by medical facilities (5–10% of emergency department visits). Regional anesthesia [e.g. brachial plexus block (BPB)] is increasingly taking place in patients with upper limb injuries as it is a logical choice avoiding the side effects of muscle relaxants, narcotics, and potent volatile anesthetics used in general anesthesia. Different additives have been used as an adjuvant with local anaesthetics to achieve dense and prolonged block and adequate postoperative analgesia. Objective To evaluate the effects of adding dexmedetomidine to bupivacaine versus bupivacaine alone in infraclavicular BPB with ultrasound guidance for plastic and reconstructive surgeries of the hand and forearm as regards the duration of postoperative analgesia, onset, and the duration of sensory and motor block and postoperative analgesic requirements. Patients and methods This randomized double-blind study carried out in Alexandria Main University Hospital on 70 adult patients of both sexes aged from 20 to 40 years, who were evaluated as American Society of Anesthesiologists I or II physical status and were scheduled for plastic and reconstructive surgeries of the hand and forearm. Results The results of our study show that the duration of analgesia ranged from 450 to 690 min with a mean value of 588.90±73.15 min in group C ‘control,’ while the duration of analgesia ranged from 990 to 1440 min with a mean value of 1295.10±121.60 min in group D ‘dexmedetomidine.’ Comparing the two groups, there was significant statistical difference in the duration of analgesia between the two groups, showing prolonged duration of analgesia in group D more than in group C. Conclusion Administration of bupivacaine with dexmedetomidine in infraclavicular BPB provides prolonged postoperative analgesia without causing a significant hemodynamic instability. Also, coadministration of dexmedetomidine leads to significantly decreased total analgesic doses required postoperatively with minimal side effects.

Unmet Birth Expectations and Birth Trauma among Adolescents.

To assess and compare birth expectations of younger and older age adolescents and explore if unmet expectations predict psychological birth trauma (PBT). This secondary analysis expands findings of a previous study (N = 303) which classified adolescents' perceptions of birth into four main themes. The previous study used a mixed-methods approach providing data related to birth expectations. For the current study, expectations were determined by themes as met or unmet by three reviewers. Of 116 useable written narrations, responses of younger (ages 13-17) versus older (ages 18-19) adolescents were compared and explored for impact on PBT. Birth expectations for both age groups were more often unmet than met. Despite a smaller cohort, younger adolescents provided more remarks than older adolescents. There were no differences between groups on unmet birth expectations (p = .16). Unmet expectations most often related to pain with older adolescents more inclined to state poor pain management. Younger adolescents more often feared dying. Unmet expectations did not predict PBT. Comprehensive prenatal care can allow for early, open conversations to assess labor knowledge and misconceptions, fear of birth, existing supports, and overall birth expectations, with a premier focus on expected labor pain and pain management. Multiparous adolescents should receive prenatal assessments of posttraumatic stress (PTS) symptoms (a recognized predictor of posttraumatic stress syndrome) potentially originating from a previous traumatic birth. Following birth, symptoms of acute stress and PTS should be assessed of all adolescents, especially if experienced numerous unmet labor expectations.

The Role of Pain in the Lives of Patients with Psoriasis: A Qualitative Study on an Inadequately Addressed Symptom.

Background: Patients with psoriasis commonly report experiencing severe sensory symptoms, and the burden of these symptoms can extend beyond unpleasant experiences to impair patients' health-related quality of life (HRQL). However, the symptom of pain and its consequences are still poorly understood in psoriasis patients. Objective: To understand the quality and intensity of pain associated with psoriasis as well as its interference with daily function in patients with psoriasis. Methods: Three focus groups and four interviews with psoriasis patients were conducted (n = 25). A trained facilitator used a semi-structured interview guide based on a literature review and a theory-driven approach. Two researchers independently coded the narratives and reached a consensus on the major themes using NVivo 12 software. Results: Our analysis produced five main themes regarding pain. (1) Perception of pain was illustrated through intense descriptors. (2) Patients identified pain triggers, including self-inflicted triggers. (3) Patients found coping strategies to deal with pain, including suppression of sensory experience. (4) Emotional suffering was linked primarily to the compulsion to continue scratching despite repeated efforts to stop and the failure of physicians to acknowledge the burden of the pain, which led to inadequate pain management. (5) Pain led to an overt impact on HRQL in these patients through interference with daily activity, intimate relationships, and sleep. Conclusions: Pain can be a significant hardship for patients with psoriasis. We encourage clinicians to inquire about pain separate from pruritus and to consider HRQL impacts of their patients' pain when determining treatments.

Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study

BackgroundPatients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered.MethodsWe employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes.ResultsSixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge.ConclusionsThese findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

A Systematic Review of Pain Assessment in Mechanically Ventilated Patients

Introduction: Pain self-report is the gold standard of pain assessment. Mechanically ventilated patients cannot self-report the pain due to the presence of a tracheal tube and changes in the level of consciousness caused by sedation, exposing them to the risk of inadequate pain management that leads to psychological and physiological consequences. This study aimed to present a review of the published evidence and studies concerning the scales used in pain assessment in mechanically ventilated patients according to their psychometric characteristics and application in the nursing practice. Methods: We conducted a systematic review following PRISMA guidelines. National and international journals in such databases as Science Direct, PubMed, EMBASE, Pro Quest Central, Web of Science, SID, and Magiran were searched using Persian and English keywords, and retrieved articles were included in this review based on the inclusion and exclusion criteria. Results: 22 articles were included in this review based on the inclusion and exclusion criteria. According to the research objectives, findings were extracted from selected articles and reviewed in two sections: 1] validity and reliability, and 2] clinical application. Conclusion: Scales of CPOT and BPS are superior to NVPS, and a combination of BPS and CPOT improves the pain detection accuracy, and vital symptoms should be used cautiously for pain assessment along with objective measures due to poor evidence. Moreover, rapid and effective pain relief plays an important role in the improvement of psychological and physiological consequences.

A qualitative understanding of nurses’ challenges with pain management

BackgroundStudies have shown that providers deliver inadequate pain management, which is important since ineffective pain management can lead to patient safety concerns and negative health outcomes. There is a gap in the literature understanding the specific details of nurses’ struggles treating patients who need help with pain management. MethodsThis qualitative descriptive study assessed nurses’ challenges with pain management to provide a comprehensive, low-inference summary of the data. Participants were interviewed about their biggest challenges. FindingsThree main themes emerged from the data: prescribing patterns, education on zero pain, and system problems. Major challenges identified in this study were understanding nurses’ perceptions of pain management care delivery and the need for quality pain management education. DiscussionThe health community needs to raise awareness and provide more comprehensive education regarding the nurse’ role in pain management.

How opioid prescribing policies influence primary care clinicians' treatment decisions and conversations with patients with chronic pain.

The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain. We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies. Opioid prescribing policies influenced clinicians' treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3). Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.

ASSESSMENT OF POSTOPERATIVE PAIN AND ANALGESIC USE IN PATIENTS UNDERGOING ORTHOPEDIC SURGERY

Background: Pain is an unpleasant sensation and occurs frequently in the post-operative period. Pain impairs treatment and recovery of patients and thus should be adequately managed. This study aimed to assess the intensity of pain in the post-operative patients undergoing orthopedic surgery and to evaluate the adequacy of the analgesics used. Methods: This was a prospective observational study conducted at Chitwan Medical College, Department of Orthopedics from May to August 2019. Ninety-six patients who underwent orthopedic surgery were evaluated upto 72 hours after surgery and assessed for pain using interview, Visual Analogue Scale and medical record analysis. Type of analgesic used and its adequacy, using Pain Management Index, were also studied. Results: There were 58 male and 38 female patients with age 18-79 years (mean 38.16 ± 16.34 years). 97.9% patients complained of pain in immediate, 91.7% in 1st and 82.3% in 2nd post-operative period with mean Visual Analogue Scale scores of 6.68, 3.74 and 2.68 respectively. Non-steroidal anti-inflammatory drug was the most frequently prescribed analgesic followed by its combination with opioid. Pain management was inadequate in immediate post-operative (61.5%), but there was significant improvement in 1st and 2nd post-operative period (inadequate Pain Management Index in 28.1% and 12.5% respectively). Conclusions: Most patients experienced pain in the post-operative period, but the intensity decreased as the post-operative hours passed by. Pain management in the immediate post-operative period was inadequate in our study and therefore proper attention should be given to manage pain in the post-operative period.

The Effectiveness of Intraoperative Ketamine and Fentanyl as Preemptive Analgesia Assessed with qNOX Score

Background: Inadequate management of intraoperative pain poses a risk of postoperative chronic pain complications. The use of preemptive analgesia before the onset of surgical incision stimulation was considered to prevent central sensitization. Clinical research around the terms of preemptive analgesia needs to be proven by nociception-based intraoperative monitoring. An objective modality with EEG guidance can provide information on noxious stimuli.Objective: To determine the effectiveness of ketamine and fentanyl administration as preemptive analgesia measured by qNOX scores through the CONOX tool.Methods: This study is a single-blinded randomized experiment with the division of two groups: control and treatment. The control group received preemptive fentanyl, and the treatment group received preemptive ketamine and fentanyl. Then the qNOX score was assessed during operation.Result: The qNOX score of the treatment group in minute-15 and 30 was lower than the control group (p = 0.007; p = 0.025), while in the minute-90 it was higher than the control group (p = 0.001). The mean first 1-hour qNOX score was lower in the treatment group (p <0.001), while in the second 1-hour was higher in the treatment group (p = 0.003). The mean total dose of fentanyl supplementation in the treatment group was lower than in the control group (71.3 ± 25.1 grams vs. 92.0 ± 28.3 grams; p = 0.044).Conclusion: The administration of combined ketamine and fentanyl as preemptive analgesia is more effective in the first hour of surgery compared to single preemptive fentanyl measured by qNOX score. Preemptive ketamine and fentanyl decrease the total dose of intraoperative fentanyl supplementation compared with single-dose preemptive fentanyl administration.

Efficacy of a combination of regional methods of anesthesia with general anesthesia in corneal transplantation

Background. Despite the significant development of modern anesthesiology, the pain relief of surgical patients is still unsatisfactory. Inadequate pain management causes psychological discomfort and complications. The combination of general anesthesia with various options for local anesthesia allows one to get closer to solving the problem of pain. The aim of the study was to compare the effect of multicomponent balanced anesthesia (intravenous + inhalation) and multicomponent balanced anesthesia, supplemented by pterygopalatine fossa blockade on the safety and efficacy of anesthesia for corneal transplantation. Materials and methods. The study included 73 patients, divided into two groups. Group С received multicomponent balanced anesthesia, group B — pterygopalatine fossa blockade additionally. The main criteria for evaluating the results of the study were: stability of hemodynamics and gas exchange during surgery, the severity of intraoperative pain syndrome by recording the analgesia nociception index, the severity of postoperative pain syndrome and the incidence of postoperative nausea and vomiting. Results. Both schemes of anesthetic management made it possible to avoid pronounced fluctuations in hemodynamic and gas exchange parameters at all stages of the study. Analyzing the severity of intraoperative pain, we found that in group С, pain relief could be considered insufficient during the first 7 minutes of the most traumatic stage of the operation, while in group B the analgesia nociception index did not decrease below 50. Statistically significant differences were obtained during 8 out of 10 minutes of the stage. Analysis of the pain relief quality in the postoperative period has shown that the level of pain according to the visual analogue scale upon awakening was equal to 0 in both groups, at the next three stages of the study (two and six hours after surgery and on the morning of the next day) the level pain in group C was significantly higher than in group B. Conclusions. The addition of regional blockade to multicomponent general anesthesia allows for adequate control of postoperative pain without compromising the safety profile.

Epigallocatechin-3-Gallate Modulates Postoperative Pain by Regulating Biochemical and Molecular Pathways

Treating postoperative (PO) pain is a clinical challenge. Inadequate PO pain management can lead to worse outcomes, for example chronic post-surgical pain. Therefore, acquiring new information on the PO pain mechanism would increase the therapeutic options available. In this paper, we evaluated the role of a natural substance, epigallocatechin-3-gallate (EGCG), on pain and neuroinflammation induced by a surgical procedure in an animal model of PO pain. We performed an incision of the hind paw and EGCG was administered for five days. Mechanical allodynia, thermal hyperalgesia, and motor dysfunction were assessed 24 h, and three and five days after surgery. At the same time points, animals were sacrificed, and sera and lumbar spinal cord tissues were harvested for molecular analysis. EGCG administration significantly alleviated hyperalgesia and allodynia, and reduced motor disfunction. From the molecular point of view, EGCG reduced the activation of the WNT pathway, reducing WNT3a, cysteine-rich domain frizzled (FZ)1 and FZ8 expressions, and both cytosolic and nuclear β-catenin expression, and the noncanonical β-catenin–independent signaling pathways, reducing the activation of the NMDA receptor subtype NR2B (pNR2B), pPKC and cAMP response element-binding protein (pCREB) expressions at all time points. Additionally, EGCG reduced spinal astrocytes and microglia activation, cytokines overexpression and nuclear factor kappa-light-chain-enhancer of activated B cells (NFkB) pathway, downregulating inducible nitric oxide synthase (iNOS) activation, cyclooxygenase 2 (COX-2) expression, and prostaglandin E2 (PGE2) levels. Thus, EGCG administration managing the WNT/β-catenin signaling pathways modulates PO pain related neurochemical and inflammatory alterations.

Effectiveness of an Educational Program on Nurses’ Knowledge and Attitudes about Pain Assessment and Management in Imam Hussein Medical City in Holy Karbala

Background: Pain is a physical and emotional distressing sensation that is associated with tissue damage,both actual and potential. Inadequate pain management has been shown to affect patient outcomes byprolonging the hospitalization period and delaying the recovery process; therefore, pain management hassignificant implications. A descriptive-analytic (quasi-experimental) design was conducted to determinethe effectiveness of an educational program on nurses’ knowledge and attitudes about pain assessment andmanagement in imam Hussein medical city in holy KarbalaMethodology: A quasi-experimental design was used to guide this study, it was applied by use of the preand post-test approach for two groups of samples (study and control). It was conducted at the Imam Husseinmedical city during the period from 15th November 2020 to 9th March 2021.Results: The study findings show that participants’ age group at a level (20-29 years) were (63.3%) of thestudy group, and (53.3%) of the control group. (50.0%) of the study group were male, while (46.7%) of thecontrol groups were female.Findings showed that the total mean score was unacceptable level for both study and control groups beforegiving intervention, while a good level for the study group post-intervention, regarding the knowledge andattitude of pain assessment and management. Highly statistically significant differences in post-test for thestudy group as compared with the control groups for knowledge and attitude domains.Conclusion: The study indicates that the education program had a positive effect on nurse’s knowledge andattitude about pain assessment and management. This conclusion is based on the result of our study thatreveals significant differences between pre-intervention and post-intervention.Recommendations: The study recommended that educational and training programs be routinely providedto develop their knowledge and attitude, and keep them up to date on pain management, also, the distributionof the applied educational program of this study as a booklet or posters for the hospital staff.

PMS29 Qualitative Study to Understand the Patient Experience of Knee Osteoarthritis (OA) and Assess the Content Validity of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and HIP Disability and Osteoarthritis Outcome Score (HOOS) Measures

Osteoarthritis (OA) affects 30-million people in the USA, more commonly affecting women. Despite available treatments focusing on symptomatic relief, most patients report inadequate pain management and reduced health-related quality of life. This study aimed to understand knee OA disease burden and to confirm content validity of the Knee injury and Osteoarthritis Outcome Score (KOOS) and Hip Disability and Osteoarthritis Outcome Score (HOOS) in a population that included older patients. A draft conceptual framework was development from reviews of literature and online OA-patient forums. Existing knee OA patient-reported outcome (PRO) measures were also reviewed. Concept elicitation (CE) interviews were conducted with knee OA patients (with/without hip/hand OA), exploring patients’ symptoms, treatments, and impacts. The conceptual model was refined and used to assess coverage of the PRO measures. The KOOS and HOOS were selected for interviews to further confirm their content validity. Three clinicians and a patient advocate provided expert input throughout this study. Thirty patients participated in the CE interviews (age 40-78 years; 60% female). A multitude of symptoms characterized knee OA, markedly pain, stiffness, and swelling. Pain was considered most bothersome and important to treat, with substantial impact on functioning. Treatment symptom relief was partial and/or short-lived. Thirty patients participated in the cognitive interviews (age 40-76 years; 60% female) where 20 and 10 patients were debriefed the KOOS and HOOS, respectively. Most patients confirmed that the items were relevant, well understood and interpreted as intended, although with reports of some unfamiliar phrases such as ‘knee catch/hang up,’ ‘straightening hip fully’ and ‘twisting/pivoting on loaded leg’. Pain, stiffness and swelling are defining knee OA symptoms, which substantially impact functioning, and are only partially relieved by current treatments. The KOOS and HOOS demonstrated strong content validity but may benefit from minor modification (or patient training) to ensure that items are interpreted consistently.

Adherence Level Of Medical Personnel In Implementing 2019 Postoperative Pain Management Guidelines

Introduction: Inadequate pain management may increase the risk of complications and postoperative chronic pain. Postoperative Pain Management Guidelines of The Anesthesiology and Reanimation Department, Faculty of Medicine Universitas Airlangga/ Dr. Soetomo Hospital Surabaya were arranged in 2019. Purposes: This study aim is to analyze the medical personnel’s adherence in implementing postoperative pain management guidelines. Methods: This is descriptive observational study with retrospective design. Total sampling was carried out on the medical records of patients who underwent elective surgery and received postoperative acute pain management during March-May 2020. Results: A total of 349 patients, most of the pain intensity was moderate (62.8%). The medical personnel adherence with postoperative pain management guidelines was 88.0%. The overall use of multimodal analgesia was 61.0%. Adherence to guidelines on pain category was mostly good adherence: 99.1% in mild pain, 82.6% in moderate pain, and 81.2% in severe pain. The use of multimodal analgesia was found in 12.3% mild pain; 83.6% moderate pain, and 100% severe pain patients. Conclusion: Most of the medical personnel have adhered to the postoperative pain management guideline, and widely-used multimodal analgesia. Systematic evaluation of guidelines implementation, patient satisfaction, and outcomes are needed.

Symposia Abstracts

Symposia Abstracts

Barriers and enablers of intensive care unit nurses' assessment and management of patients' pain.

Inadequate pain assessment and management is a problem in hospitalized patients that impairs their well-being. Intensive care unit nurses' pain practices are affected by several barriers and enablers. To explore intensive care unit nurses' pain education, perceived barriers, and enablers of pain assessment and management practices among critically ill patients. A cross-sectional descriptive design was used in the study. Convenience sampling technique was used, including 300 nurses recruited from 22 intensive care units in Jordan. The Pain Assessment and Management for Critically Ill Adults Survey was used to collect data. Descriptive statistics, spearman correlation, and chi-square tests were used to analyse the data. Only 127 (42.3%) of the nurses reported moderate to extreme satisfaction about receiving professional development education related to pain among critically ill patients. Nurse workload (65.3%), patient instability (54.4%), patient inability to communicate (53.3%), and sedation interfering with pain assessment (50%) were reported by nurses as the most frequent barriers impacting pain assessment and management. Enablers of pain assessment and management reported most frequently were "pain assessment and management is a unit priority" (63.7%), "enthusiastic and motivated staff" (61.3%), "protocols and guidelines are in use" (57.4%), and "standardized assessment tools are in use" (57%). Some barriers and enablers to pain assessment and management and pain education differed significantly according to nurses' experience and hospital type. This study identified a range of enablers and barriers to pain assessment and management practices perceived by intensive care unit nurses. Nurse workload was an important barrier while making pain assessments, and management a unit priority was an important enabler for pain assessment and management. Frequent assessment of barriers and enablers of pain assessment and management is needed in critical care units to improve nurses' practices. Pain education should be included in the hospitals' continuous educational program.

A qualitative assessment of discharge against medical advice among patients hospitalized for injection-related bacterial infections in West Virginia.

The incidence of infective endocarditis (IE) and other systemic bacterial infections is increasing, and people who inject drugs (PWID) have higher rates of discharge against medical advice (AMA) for these infections than patients whose infections are not injection-related. In this study, we characterize factors that contribute to AMA hospital discharge among PWID. We conducted qualitative interviews with twenty PWID hospitalized with serious injection-related bacterial infections in West Virginia. Participants completed a brief survey and in-depth qualitative interview. Interviews were recorded and transcribed verbatim and analyzed using a codebook developed based on deductive and inductive thematic analysis. We also conducted medical records abstraction and used descriptive statistics to summarize medical and survey data. Average age was 34 years, 55% were female, 95% identified as white, and 75% had a primary diagnosis of IE. Drugs injected prior to hospitalization were methamphetamine (60%), prescription opioids (38%), and/or heroin/fentanyl (25%). Participants cited multiple contributors to AMA discharge including negative interactions with hospital staff that they perceived as stigmatizing, including being searched or monitored for illicit drug use; inadequate management of pain and withdrawal; boredom and confinement during lengthy hospitalizations; and isolation from family and other social supports. We identified multiple factors contributing to AMA discharge that are amenable to intervention. Given the significant morbidity, mortality, and financial costs associated with hospitalizing PWID for serious injection-related bacterial infections, hospitals should be highly motivated to develop and test interventions designed to improve outcomes among these patients.

89 Improving Pain Assessment and Management for Patients with Cognitive Impairment on the Care of the Older Person (COOP) Wards

Abstract Introduction Patients with cognitive impairment are at risk of underassessment and inadequate management of pain. Self-reporting is unlikely to be a reliable indicator of pain and numerical scales have reduced validity, hence an alternative assessment tool must be used. The Abbey Pain Scale is widely regarded to be user friendly. Regular analgesia should be used for these patients where possible instead of “as required” (PRN). Using QIP methodology, we aimed to improve the use of the Abbey Pain Scale for assessment of patients with cognitive impairment and better analgesia prescribing. Methods Audit of patient records on COOP wards (computer and physical notes, n = 48 first cycle, n = 32 second cycle) before and after staff training, assessing patients with cognitive impairment for: use of Abbey Pain Scale; use of regular paracetamol; pain assessments documented by different healthcare professionals. Results In the first cycle, 16 patients had cognitive impairment: only 1 of these patients (6%) was assessed using the Abbey Pain Scale. Group teaching for the multidisciplinary team on pain assessments was undertaken with practice development nurses. In the re-audit, 13 patients had cognitive impairment and 6 of these (46%) were assessed using the Abbey Pain Scale, showing a clear improvement following staff training. The second cycle showed a 50% increase in the prescription of regular paracetamol for patients with cognitive impairment. There was also a 2.5-fold improvement in therapy staff documenting pain assessments between the two audits. Conclusions Staff training in the use of the Abbey Pain Scale led to an almost 8-fold increase in its use for patients with cognitive impairment. Training on the use of the Abbey Pain Scale should be regularly provided to nurses, physiotherapists and doctors on the care of the older person wards.

Topical Sevoflurane: A Novel Treatment for Chronic Pain Caused by Venous Stasis Ulcers.

In the US, an estimated 1 - 2% of chronic venous insufficiency (CVI) patients (of 6 - 7 million nationwide) develop at least one venous stasis ulcer (VSU) during their illness. Of these, approximately 40% develop subsequent ulcers, making VSU prognostically poor. Current management of VSU is costly, with poor prognosis, high recurrence rate, inadequate pain management, and significantly reduced quality of life (QoL). Topical volatile anesthetic agents, such as sevoflurane, offer improved pain relief and symptom control in patients suffering from chronic VSU. The immediate impact of topical sevoflurane in reducing pain associated with ulcer bed debridement has several implications in improving the quality of life in patients with CVI induced ulcers and in the prognosis and healing of the ulcers. This review summarizes a topical formulation of a volatile anesthetic and its implications for the management of VSUs.

Pain Assessment: Benefits of Using Pain Scales for Surgical Patients in South Bohemian Hospitals.

Pain is a medical and nursing problem that is common in surgical departments. Inadequate pain management can lead to patient distress, as well as extending the period in which the patient’s quality of life is reduced. The standardized SF-MPQ-2 questionnaire provides nurses with the opportunity to assess pain within a broader context. The aim of this descriptive and exploratory study was to describe the state of pain assessment in surgical patients in the South Bohemian Region and to highlight the benefits of using a standardized tool for proper pain assessment. The research was carried out using a quantitative survey within the South Bohemian Region (Czech Republic). The participants in the study were nurses working in surgical departments in hospitals in the region as well as hospitalized patients. The results show that nurses pay slightly more attention to pain assessments than doctors. We know that, generally, pain decreases with time after surgery. Nonetheless, returning pain, as well as continuous pain, can occur, both of which have an emotional component. The results of this study are directed at nurses and include a call for more effective pain management through improved assessment.