Pain Management Algorithm Research Articles

Development of a pain management algorithm for intensive care units

ObjectivesTo develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm. BackgroundMany ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist. MethodsLiterature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest. ResultsAn algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63). ConclusionsThe content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.

Elbow pain: a guide to assessment and management in primary care.

Elbow pain is a common presenting symptom in primary care. Pathology can arise from any component of the joint including tendons, bursae, bones, or nerves. It is a commonly dislocated joint, especially in children (‘pulled elbow’). Tendinopathies (lateral and medial epicondylitis) can result from a number of popular sports and activities of daily living. Rheumatoid (inflammatory), post-traumatic, and primary osteoarthritis are three primary patterns of arthritis affecting the elbow. Elbow pain can present in any age group with varying symptom complex (Figure 1). Figure 1. Elbow pain management algorithm. DMARDs = disease-modifying anti-rheumatic drugs. MRI = magnetic resonance imaging. NSAIDs = non-steroidal anti-inflammatory drugs. PRP = platelet-rich plasma. ROM = range of movement. Rx = medication prescribed. USS = ultrasound scanning. ### Red flags Exclude red flags such as swelling and dislocation following trauma, a tender, swollen joint, or rapidly increasing mass. These require urgent referral to secondary care (Figure 1). ### Assessment of pain A systematic approach towards assessment of nature, onset, and duration of pain and associated symptoms is key to diagnosis. Also ask about exacerbating activities and mechanism of injury.

Implementation of a pain management algorithm in intensive care units and evaluation of nurses' level of adherence with the algorithm

ObjectivesTo implement a pain management algorithm in intensive care units (ICU) and to evaluate nurses' level of adherence with the algorithm. BackgroundMany ICU patients experience pain. Therefore, an evidence-based algorithm for pain management was developed. MethodsA pain management algorithm was implemented in three units over three weeks. Nurses' level of adherence with the algorithm and associations between level of adherence and patient and unit characteristics over 22 weeks were evaluated using multivariate regression analysis. ResultsNurses' level of adherence was 74.6%. Adherence rates were lower on the evening and night shifts compared to the day shift. Males were assessed significantly less frequently than females. Patients with “injury, poisoning, or certain other consequences of external causes” were assessed significantly less frequently than patients with “diseases of the respiratory system.” ConclusionsICU nurses can use a pain management algorithm consistently. Findings from this study suggest that a pain management algorithm is a useful tool to increase ICU nurses' adherence with pain assessment.

(254) A fast-track emergency department acute sickle cell pain management algorithm results in fewer hospital admissions, decreased length of stay and increased hospital revenue

(254) A fast-track emergency department acute sickle cell pain management algorithm results in fewer hospital admissions, decreased length of stay and increased hospital revenue

A Smartphone-Based Pain Management App for Adolescents With Cancer: Establishing System Requirements and a Pain Care Algorithm Based on Literature Review, Interviews, and Consensus

BackgroundPain that occurs both within and outside of the hospital setting is a common and distressing problem for adolescents with cancer. The use of smartphone technology may facilitate rapid, in-the-moment pain support for this population. To ensure the best possible pain management advice is given, evidence-based and expert-vetted care algorithms and system design features, which are designed using user-centered methods, are required.ObjectiveTo develop the decision algorithm and system requirements that will inform the pain management advice provided by a real-time smartphone-based pain management app for adolescents with cancer.MethodsA systematic approach to algorithm development and system design was utilized. Initially, a comprehensive literature review was undertaken to understand the current body of knowledge pertaining to pediatric cancer pain management. A user-centered approach to development was used as the results of the review were disseminated to 15 international experts (clinicians, scientists, and a consumer) in pediatric pain, pediatric oncology and mHealth design, who participated in a 2-day consensus conference. This conference used nominal group technique to develop consensus on important pain inputs, pain management advice, and system design requirements. Using data generated at the conference, a prototype algorithm was developed. Iterative qualitative testing was conducted with adolescents with cancer, as well as pediatric oncology and pain health care providers to vet and refine the developed algorithm and system requirements for the real-time smartphone app.ResultsThe systematic literature review established the current state of research related to nonpharmacological pediatric cancer pain management. The 2-day consensus conference established which clinically important pain inputs by adolescents would require action (pain management advice) from the app, the appropriate advice the app should provide to adolescents in pain, and the functional requirements of the app. These results were used to build a detailed prototype algorithm capable of providing adolescents with pain management support based on their individual pain. Analysis of qualitative interviews with 9 multidisciplinary health care professionals and 10 adolescents resulted in 4 themes that helped to adapt the algorithm and requirements to the needs of adolescents. Specifically, themes were overall endorsement of the system, the need for a clinical expert, the need to individualize the system, and changes to the algorithm to improve potential clinical effectiveness.ConclusionsThis study used a phased and user-centered approach to develop a pain management algorithm for adolescents with cancer and the system requirements of an associated app. The smartphone software is currently being created and subsequent work will focus on the usability, feasibility, and effectiveness testing of the app for adolescents with cancer pain.

Timely Analgesia, Reduced Hospitalization Rate, and Improved Economic Efficiency Following Implementation of a New Emergency Department Sickle Cell Pain Management Algorithm

Context: Adults with sickle cell disease (SCD) presenting to emergency departments (EDs) with severe pain often experience treatment delays and long, costly hospitalizations. Objectives: A fast-track ED SCD pain management algorithm was developed and then evaluated for its clinical and economic impact. Methods: We conducted a retrospective chart review to compare outcomes of ED visits for SCD-related pain two years before and after algorithm implementation. Patient demographics, ED utilization, and treatment outcome measures including time from registration to first opioid treatment, ED length of stay, hospitalization rate, hospitalization length of stay, and both hospital and ED revenue production were compared. Results: There was a total of 699 consecutive ED visits for SCD-related pain (131 pre- and 568 postalgorithm). Median time to first opioid dose decreased from 53 to 32 minutes (p <0.001). Disposition was determined more efficiently (210 vs. 168 minutes, p <0.001) leading to reduction in ED length of stay (345 vs. 271 minutes, p<0.001). Although ED utilization increased, this was due to a few high utilizers whose patterns of use skewed the mean. Hospitalization rate per ED visit significantly decreased (54% vs. 38%, p=0.001). Average length of stay per hospitalization decreased from 12 to 8 days (p<0.03) which was economically beneficial to the hospital in that revenue production per inpatient day increased by 28%. Conclusions: Our findings suggest algorithmic ED SCD pain management significantly improves quality and economic outcomes.

Rib Fracture Stabilization Reduces Chest Wall Pain following Blunt Thoracic Trauma

Blunt Thoracic Trauma (BTT) encompasses a wide spectrum of varying pathologic conditions of the skeletal chest wall, pulmonary parenchyma and mediastinum [1-5]. Rib fractures are one of the most common injuries sustained following BTT and result in significant disability, largely due to pain [1]. Among chest trauma patients, up to 10% of all admissions have evidence of rib fracture, with mortality rates that can exceed 20% in some series [1-4]. Older patients and those with associated pulmonary injury experience the highest rates of death [1,3-5]. A consensus management strategy of patients sustaining skeletal chest wall injury remains undefined, largely due to the lack of randomized comparative data [3-5]. Rib fractures are often one component of a larger spectrum of thoracic trauma where the focus of care is toward organ function. To date, most of the available literature focuses upon those patients with severe chest wall injury where the treatment strategy is sustaining organ function and is directed by trauma society guidelines [4]. Patients with lesser degrees of injury to the thorax are treated with optimization of chest wall mechanics through chest physiotherapy and effective analgesia. Contemporary recommendations for pain management validate intravenous and epidural analgesia as the optimal modalities for control of thoracic pain [3,4]. The use of open reduction and internal fixation of broken ribs is debatable as these techniques are morbid and traditionally reserved to severely injured patients where the goal is to improve respiratory dynamics [4,5]. However, among BTT patients with isolated rib fracture and lesser concomitant injury, the treatment goal is alleviation of pain as noted previously [3]. A cohort of such patients, particularly those with displaced rib fractures, will continue to suffer severe pain, despite maximal medical therapy. In such patients, there may be a benefit to the application of rib fracture plating as a complimentary strategy for better pain control and decreased narcotic requirement [68]. The objective of this paper is to determine if rib fracture plating can be beneficial in the pain management algorithm of patients sustaining BTT who have predominantly displaced rib fracture injury.

Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial.

Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making. The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents. The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility. The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. LIMITATIONS/LESSONS: The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing study Methodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.

138 Non-anginal chest pain: not as benign as we would like to believe!

BackgroundIn the Quick Reference Guide of the clinical guidance 95 (CG95) NICE recommends that chest pain (CP) diagnosed as non-anginal (NA) should not be investigated for stable angina routinely. In...

Managing Pain with Algorithms: An Opportunity for Improvement? Or: The Development and Utilization of Algorithms to Manage Acute Pain

Pain management in a hospital setting remains a challenge today. Many health care providers remain anxious and uninformed regarding analgesic titration within a hospital setting. Overcoming the potential risks to obtain the benefits of opiate titration is a challenge within any health care setting. Virginia Commonwealth University, a tertiary medical center which houses schools of medicine, nursing, and pharmacy, evaluated the use of algorithms for managing acute pain. This article describes the Pain Committee's efforts and offers one potential intervention for safe analgesic opioid titration, an algorithm for acute pain management.

PAIN IN CHRONIC KIDNEY DISEASE: PREVALENCE, CAUSE AND MANAGEMENT

Pain is an unpleasant sensory and emotional experience and is the most common symptom experienced by renal patients. It can be caused by primary co-morbid diseases, renal replacement therapies, medication or treatment side effects, and its intensity varies from moderate to severe. Pain management in renal patients is difficult, since the distance between pain relief and toxicity is very small. This paper will provide an algorithm for pain management proposed using paracetamol, nonsteroid anti-inflamatory drugs (NSAIDs), mild and stronger opioids as well as complementary techniques. Quality of Life (QoL) and overall enhancement of the patient experience through better pain management are also discussed. To improve pain management it is essential that nurses recognise that they have direct responsibilities related to pain assessment and tailoring of opioid analgesics and better and more detailed education.

Algorithmus zur postoperativen Schmerztherapie in der Viszeral- und Thoraxchirurgie: Eine Verlaufuntersuchung

We report the results of an observational study of pain intensity before and after implementation of an algorithm for postoperative pain management. The algorithm included multiple factors for treatment. Data of 130 consecutive patients with defined surgical procedures were extracted from charts before and after implementation of the algorithm. Our patients documented pain intensity at rest and on movement on a numerival rating scale (NRS) from 0 (= no pain) to 10 (= worst pain). A successful pain management was definded as maximum pain intensity at rest ≤ 3 and on movement ≤ 5 on the NRS. For statistical analysis we used the Wilcoxon and the chi squared test. The frequency of a successful pain management increased from 49 % (individual pain management) to 85 % (algorithm) at rest 8 (p < 0.001), on movement the rates were 42 % and 86 %, respectively (p < 0.001). In the total group, we found a reduction of maximum pain intensity at rest (mean ± sd) from 4.05 ± 2.54 to 2.18 ± 1.82 (p < 0.001) and with movement from 6.04 ± 2.51 to 3.5 ± 2.08 (p < 0.001). Implementing an algorithm for postoperative pain management resulted in a clinically relevant reduction of postoperative pain. Our findings reflect the result of a complex change in pain management, and therefore cannot be attributed to any single factors involved.

Response to Dr. Schofferman

Dear Editor, We would like to respond to Dr. Schofferman's letter to the Editor regarding our Editorial on using the SAFE principles for medical algorithmic thinking. The intent of Krames et al. was not to propose a single algorithm for all chronic nonmalignant pain syndromes but instead to offer a new perspective regarding the development of chronic pain management algorithms. Medical algorithms are designed to guide clinicians and patients along certain pathways to achieve specific endpoints. As such they tend to be rigid and quickly outdated as circumstances change. The use of the SAFE principles in the design of pain management algorithms allows for greater flexibility …

Stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant.

The purpose of this cross-sectional, correlational study was to describe stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant. The hypotheses that significant, positive relationships would exist between oral pain and stomatitis, state anxiety, depression, and alteration in swallowing were tested. Stomatitis, sensory dimension of oral pain, and state anxiety were hypothesized to most accurately predict oral pain overall intensity. Thirty-two women were recruited at 2 East Coast comprehensive cancer centers. Data were collected on bone marrow transplantation day +7 +/- 24 hours using Painometer, Oral Mucositis Index-20, Oral Assessment Guide, State-Trait Anxiety Inventory, and Beck Depression Inventory. Data analysis included descriptive statistics, correlations, and stepwise multiple regression. All participants had stomatitis; 47% had oral pain, with a subset reporting continuous moderate to severe oral pain despite pain management algorithms. Significant, positive associations were seen between oral pain, stomatitis, and alteration in swallowing and between oral pain with swallowing and alteration in swallowing. Oral pain was not significantly correlated with state anxiety and depression. Oral sensory and affective pain intensity most accurately predicted oral pain overall intensity. Future research needs to explore factors that affect perception and response to stomatitis-related oropharyngeal pain and individual patient response to opioid treatment.

Reducing pain in patients undergoing cardiac surgery after implementation of a quality improvement postoperative pain treatment program

Purpose The aim of this study was to test the effectiveness of a quality improvement postoperative pain treatment program after cardiac surgery. Materials and Methods This was a prospective, quasiexperimental study using nonequivalent groups comprising 3 periods: baseline (group baseline), implementation of the algorithm for acute pain management, and reassessment (group reassessment). Inclusion of 133 patients after elective cardiac surgery at an 18-bed surgical intensive care unit (SICU) at a Swiss university hospital. The algorithm was implemented by training, pocket guidelines, regular audits, and feedback. The implementation period was completed when the adherence to 2 of 3 process indicators attained at least 70% over 2 months. Visual analog scales (VAS) for pain, morphine consumption, pain perception, and sleep quality were assessed during stay in SICU and after 1 month and 6 months. Results The assessment included 79 patients at baseline and 54 in the reassessment periods. Pain intensity at rest decreased from 2.7 ± 1.4 to 2.2 ± 1.4 cm (VAS; P = .008). Retrospective perception of pain intensity at rest decreased from 3.8 ± 2.2 to 2.6 ± 1.8 ( P = .004). The proportion of patients with no pain or often without pain increased from 11% to 37% ( P = .005). The number of patients with sleep disturbances decreased from 68% to 35% ( P = .012). No differences were observed at 1 and 6 months postoperatively. Conclusions After algorithm implementation in the SICU, pain intensity at rest decreased and quality of sleep improved.

Industrial Medicine and Acute Musculoskeletal Rehabilitation. 2. Medications for the Treatment of Acute Musculoskeletal Pain

Sullivan WJ, Panagos A, Foye PM, Sable AW, Irwin RW, Zuhosky JP. Industrial medicine and acute musculoskeletal rehabilitation. 2. Medications for the treatment of acute musculoskeletal pain. This self-directed learning module highlights medications used in the treatment of acute musculoskeletal pain in the context of industrial rehabilitation. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article compares various skeletal muscle relaxants, addresses issues related to nonsteroidal anti-inflammatory medications, provides an algorithm for acute pain management in an injured worker, and discusses topical medications for the treatment of pain. Overall Article Objective To summarize medication options in the treatment of acute musculoskeletal pain in the setting of injured workers.

Delayed diagnosis of endometriosis

When following current pelvic pain management algorithms, appropriate counseling may lessen emotional and social issues associated with endometriosis-associated pelvic pain.

Managing Noncardiac Pain in Heart Failure Patients

Both acute and chronic pain are common coexisting problems in patients with heart failure. Because nonsteroidal anti-inflammatory drugs and corticosteroids are contraindicated in heart failure, traditional pain management algorithms require modification. This article reviews pertinent pain management principles, including pain vocabulary, barriers to pain management, and general pain assessment and treatment measures. Issues unique to the heart failure patient are discussed and specific interventions for the heart failure patient with acute or chronic pain are then delineated.

Coxibs: Evolving role in pain management

Traditional pain management strategies have relied on the use of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, as well as other adjuvant analgesics. However, the limited activity of these drugs and the substantial adverse effects associated with their use has left many patients without dependable options for effective treatment. Recent advances in the understanding of pain and its pathophysiologic mechanisms have led to the development of novel therapeutic options. Cyclooxygenase (COX)-2–specific inhibitors (coxibs) have an established efficacy in the treatment of chronic arthritic pain comparable to that of traditional NSAIDs, without the degree of gastrointestinal (GI) complications commonly attributed to NSAID use. Recent trials also have shown the effectiveness of 1 of the coxibs for relief of chronic lower back pain. Numerous studies have shown that coxibs are efficacious for the management of acute pain in various clinical settings, including orthopedic surgery, dental surgery, and dysmenorrhea. The superior safety profile of coxibs in conjunction with a comparable efficacy to nonselective NSAIDs supports the use of coxibs in balanced analgesic regimens. Decreased GI and antiplatelet effects of coxibs compared to traditional NSAIDs provide the potential to incorporate coxibs into the pain management algorithm used to treat cancer pain. Semin Arthritis Rheum 32(Suppl 1):15-24 Copyright 2002, Elsevier Science (USA). All rights reserved.

PACU pain management algorithm

Effective and safe pain management for a patient emerging from the effects of anesthesia is a specialized skill that is often acquired only through years of experience. This article provides perianesthesia nurses with a technique to assess the cognitively impaired postanesthesia patient and to incorporate vital circumstantial criteria in determining the presence of pain. Intervention recommendations are also included. The pain management algorithm includes research-based information from the following sources: Pain: Clinical Manual (ed 2), by pain nurse experts Margo McCaffery, RN, MS, FAAN, and Chris Pasero, RN, MS; and the American Pain Society's Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (ed 4). Parameters are incorporated for clinical use. © 2002 by the American Society of PeriAnesthesia Nurses.