Pain Management Policies Research Articles

Frequency and Predictors of Analgesic Prescribing in U.S. Nursing Home Residents with Persistent Pain.

To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment. Cross-sectional study. Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims. Individuals aged 65 and older with persistent noncancer pain were identified from a cross-section of all long-stay U.S. NH residents with an MDS assessment and Medicare Part D enrollment in 2008, excluding those who were terminally ill, those with Alzheimer's disease, and those with the most-severe cognitive impairment. Residents with moderate to severe daily pain on consecutive assessments at least 90 days apart constituted the cohort with persistent pain. Part D dispensing for an opioid or nonsteroidal anti-inflammatory drug (NSAID) within 30 days of persistent pain onset was identified. Information on resident and facility characteristics was obtained from MDS and OSCAR records. Associations between resident and facility attributes and pain treatment were estimated using multilevel mixed-effects logistic regression analyses. Of the study sample of 18,526 residents with persistent pain, 3,094 (16.7%) did not receive prescription analgesics, 12,815 (69.2%) received a prescription opioid, 485 (2.6%) received a prescription NSAID, and 2,132 (11.5%) received a prescription opioid and NSAID. After adjusting for potentially confounding covariates, residents who were older (≥95, odds ratio (OR) = 2.06, 95% confidence interval (CI) = 1.70-2.49), more cognitively impaired (moderately severe cognitive impairment, OR = 2.12, 95% CI = 1.71-2.62), or black (OR = 1.20, 95% CI = 1.03-1.39) or Asian (OR = 1.97, 95% CI = 1.22-3.20) were less likely to receive a prescription analgesic. Through 2008, pain remained undertreated in NHs, especially in certain subpopulations, including cognitively impaired and older residents. Changes in pain management practice and policies may be necessary to target these vulnerable residents.

Physicians' Attitudes to Clinical Pain Management and Education: Survey from a Middle Eastern Country.

Despite promising initiatives to advance the practice of pain management in Middle Eastern countries, their pain care lags behind developed countries. The objectives of this study are to evaluate physicians' assessment of their own competency in pain management, to assess physicians' practice related to pain management, and to identify physician-related barriers to effective pain control. A cross-sectional survey was conducted in 3 teaching medical centers in Lebanon targeting the above-mentioned outcomes and assessing the impact of physicians' years in practice on the studied end-points. A total of 69 physicians were surveyed. Fifty-seven percent reported “very good to excellent” pain management skills; only 25% of them described the need for continuing professional development. When treating patients with pain, 52% of physicians refer to updated international guidelines, whereas 43% rely on their own judgment. Physicians were more likely to consult with another physician (65%) rather than a pharmacist (12%) when treating patients with pain. Fear of adverse effects of analgesics was the most commonly reported barrier (45%) to pain control among physicians from different career stages. Based on these survey findings, national pain management and practice policies are needed to optimize this area of deficiency in patient care.

Pain, Palliative Care, and Compassion in India

ABSTRACTAn estimated 1 million new cases of cancer occur each year in India, with over 80% presenting at the point at which the disease is incurable. Around 60% of the patients will already be in significant pain, and just under half will be experiencing excruciating, unbearable pain. With only a handful of outpatient palliative care clinics in Kolkata, few patients are able to access essential pain medication and palliative care services. This narrative includes five case studies exploring differing aspects of palliative care: pain management, the difficulties faced in accessing morphine, the importance of compassion in end-of-life care, and the psychological effects on families. They illustrate the degree of suffering some patients and families face, and the relatively simple measures that can be taken to alleviate this. For the current situation in India to improve, there needs to be better access to essential pain medications such as morphine, education of health care professionals and the public, as well as the implementation of government pain management and palliative care policies.

Pain management experience at a central Taiwan medical center

Pain management is typically more developed in western countries compared to Asia. From the accreditation standard of the Joint Commission International (JCI), there is a broad scope for pain management. In 2008, our medical center established the pain management policy, and the goal is to be a pain-free medical facility. The Framework of Pain Management Policy including: 1. the rights of patients and family members 2. Employee education 3. Assessment of pain (screening, evaluating, monitoring) 4. Patient care of pain.After implementation of pain management program, the compliance of pain assessment, the analysis of pain score before and after pain management and the analysis of Pain Management Index (PMI), all showed improvement in pain management program. The consumption of opioids usage steadily increased from 2010 to 2014. The success of our pain management program implementation could be attributed to the clear pain management policy, the firm support of higher leadership, the cooperation of IT department, and the quality control.

Evidence-based practice beliefs and behaviors of nurses providing cancer pain management: a mixed-methods approach.

To describe evidence-based practice (EBP) beliefs and behaviors of nurses who provide cancer pain management. Descriptive, cross-sectional with a mixed-methods approach. Two inpatient oncology units in the Pacific Northwest. 40 RNs. Data collected by interviews and web-based surveys. EBP beliefs, EBP implementation, evidence-based pain management. Nurses agreed with the positive aspects of EBP and their implementation ability, although implementation level was low. They were satisfied with their pain management practices. Oncology nursing certification was associated with innovativeness, and innovativeness was associated with EBP beliefs. Themes identified were (a) limited definition of EBP, (b) varied evidence-based pain management decision making, (c) limited identification of evidence-based pain management practices, and (d) integration of nonpharmacologic interventions into patient care. Nurses' low level of EBP implementation in the context of pain management was explained by their trust that standards of care and medical orders were evidence-based. Nurses' EBP beliefs and behaviors should be considered when developing strategies for sustaining evidence-based pain management practices. Implementation of the EBP process by nurses may not be realistic in the inpatient setting; therefore, hospital pain management policies need to be evidence-based and reinforced with nurses.

Timely Pain Management in the Emergency Department

BackgroundDelivering timely pain relief remains a challenge for most emergency departments. ObjectiveTo evaluate the effectiveness of a policy aimed at delivering analgesics within 30 min to patients presenting to an emergency department with severe pain. MethodsSubjects were aged ≥19 years, had a principal diagnosis of renal colic, hip fracture, or sickle cell disease, reported a pain score ≥8 on a scale of 0 to 10 at triage, and continued to report a score in this range until receiving analgesia. The study compared proportions of patients receiving analgesics within the 30-min target, median time to analgesic administration, and median time to relief of severe pain (decline in pain level to score <8) during 6 months before vs. 6 months after implementation of the new pain management policy. ResultsParadoxically, the median total waiting time to analgesic administration increased from 64 min (n = 75) to 80 min (n = 70) after policy implementation (p = 0.01), and the proportion of patients receiving analgesics within 30 min declined from 17% (13/75) to 7% (5/70) (p = 0.08). Median time to relief of severe pain did not differ significantly between periods (130.5 vs. 153 min; p = 0.31). ConclusionsAfter implementation of the new pain management policy, the proportion of patients with severe pain receiving analgesics within 30 min actually declined. Although a 30-min target may be unrealistic, it seems reasonable to conclude that something is wrong when patients with notoriously painful conditions must typically wait 1–2 h to obtain relief. Given the millions of individuals who receive care in emergency departments nationwide each year, the suffering caused by delays occurs on a large scale, so creative approaches are clearly needed to overcome the obstacles.

Paediatric pain management practice and policies across Alberta emergency departments.

Many children requiring acute care receive suboptimal analgesia. To describe paediatric pain management practices and policies in emergency departments (EDs) in Alberta. A descriptive survey was distributed to each of the EDs in Alberta. A response rate of 67% (72 of 108) was obtained. Seventy-one percent (42 of 59) of EDs reported the use of a pain tool, 29.3% (17 of 58) reported mandatory pain documentation and 16.7% (10 of 60) had nurse-initiated pain protocols. Topical anesthetics were reported to be used for intravenous line insertion by 70.4% of respondents (38 of 54) and for lumbar puncture (LP) by 30.8% (12 of 39). According to respondents, infiltrated anesthetic was used for LP by 69.2% (27 of 39) of respondents, and oral sucrose was used infrequently for urinary catheterization (one of 46 [2.2%]), intravenous line insertion (zero of 54 [0%]) and LP (one of 39 [2.6%]). Few Alberta EDs use policies and protocols to manage paediatric pain. Noninvasive methods to limit procedural pain are underutilized. Canadian paediatricians must advocate for improved analgesia to narrow this knowledge-to-practice gap.

Assessment and management of pediatric pain based on the opinions of health professionals.

Abstract The present study characterized the opinions of health professionals about strategies for assessing and managing pediatric pain in a public teaching hospital. The sample consisted of 92 health professionals who worked in pediatric wards, pediatric intensive care, and neonatal intensive care. The sample included 45 doctors, 18 nurses, 16 psychologists, eight physiotherapists, and five occupational therapists. Data were collected through a self-administered questionnaire that included 22 open questions on the following topics: pain assessment, pharmacological management, and non-pharmacological interventions. Each area was analyzed with regard to actions, resources, gaps, and needs. The questionnaire was developed based on the principles of Strategic Planning. Two trained researchers analyzed the thematic content of all of the responses. With regard to actions and resources, 33% of the respondents mentioned the use of instruments for pain assessment, 73% reported that they prescribed pharmacological treatments for symptoms of pain, and 26% reported the use of non-pharmacological interventions for the relief of pain. The professionals predominantly reported a lack of training for pain assessment and management, standardized protocols, and human and material resources. Consequently, 96% of the professionals reported the necessity for educational training and standardized implementation guidelines for pain assessment services. These findings provide a baseline of the health professional’s opinions of pain issues, which are essential for implementing and increasing pain assessment and management policies institutionally.

Pain management policies and practices in pediatric emergency care: a nationwide survey of Italian hospitals

BackgroundPain experienced by children in emergency departments (EDs) is often poorly assessed and treated. Although local protocols and strategies are important to ensure appropriate staff behaviours, few studies have focussed on pain management policies at hospital or department level. This study aimed at describing the policies and reported practices of pain assessment and treatment in a national sample of Italian pediatric EDs, and identifying the assocoated structural and organisational factors.MethodsA structured questionnaire was mailed to all the 14 Italian pediatric and maternal and child hospitals and to 5 general hospitals with separate pediatric emergency room. There were no refusals. Information collected included the frequency and mode of pain assessment, presence of written pain management protocols, use of local anaesthetic (EMLA cream) before venipuncture, and role of parents. General data on the hospital and ED were also recorded. Multiple Correspondence Analysis was used to explore the multivariable associations between the characteristics of hospitals and EDs and their pain management policies and practices.ResultsRoutine pain assessment both at triage and in the emergency room was carried out only by 26% of surveyed EDs. About one third did not use algometric scales, and almost half (47.4%) did not have local protocols for pain treatment. Only 3 routinely reassessed pain after treatment, and only 2 used EMLA. All EDs allowed parents’ presence and most (17, 89.9%) allowed them to stay when painful procedures were carried out. Eleven hospitals (57.9%) allowed parents to hold their child during blood sampling. Pediatric and maternal and child hospitals, those located in the North of Italy, equipped with medico-surgical-traumatological ED and short stay observation, and providing full assessment triage over 24 hours were more likely to report appropriate policies for pain management both at triage and in ER. A nurses to admissions ratio ≥ median was associated with better pain management at triage.ConclusionsDespite availability of national and international guidelines, pediatric pain management is still sub-optimal in Italian emergency departments. Multifaceted strategies including development of local policies, staff educational programs, and parental involvement in pain assessment should be carried out and periodically reinforced.

Pain management strategies used during early childhood immunisation in Victoria

The study aims to identify pain management practices used during scheduled childhood immunisation. A survey of members of the Australian Nurses Federation (Victorian Branch) Immunisation Nurses Special Interest Group. Questions included frequency of use of pain reduction strategies during immunisations for infants, toddlers and children, injection techniques and existence of an articulated pain management policy. The survey was emailed to 274 Immunisation Nurses Special Interest Group members with registered email addresses, and 125 (46%) completed the survey. Nineteen respondents (15.2%) stated their main place of employment had a pain management policy during immunisations and 20 (16.0%) respondents were not sure. Distraction strategies were frequently used during immunisation for all age groups, with 95 (76.0%) replying that distraction was used often or always. Breastfeeding during immunisation for infants younger than 6 months was used occasionally (n = 54, 44.6%), often (n = 11, 9.1%) or never (n = 55, 45.5%) and was used even less frequently for infants aged 6-12 months. Sucrose or other sweet solutions were almost never used for infants prior to, or during, immunisation. As a reward, lollies were frequently given to children after immunisations. Topical anaesthetics were almost never used in any age groups. Over half the respondents used a rapid injection technique; 55 (44.7%) used a slow technique and four respondents aspirated the needle before injections. Many distraction strategies were used during and following immunisation but sweet solutions, breastfeeding or topical anaesthetics were rarely used. Use of these strategies where feasible, should be facilitated in diverse settings where immunisations take place.

Military medical revolution

Abstract : The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.

Pain and Pain Management in a Hong Kong Emergency Department

Background The prevalence of pain is high in emergency departments (ED), according to previous studies. There is little information on the epidemiology of pain in Hong Kong EDs. This study aimed to explore the epidemiology of pain in a single academic ED in Hong Kong, and to evaluate the pain management policy in the ED. Methods Retrospective case review study with explicit record review of ED clinical records; records obtained by means of systematic sampling of a seven-consecutive-day period attendance. Data on the prevalence and location of pain, waiting time for drugs for pain relief, and pain drug prescription rates were obtained. Descriptive data analysis was performed. Results A total of 494 ED clinical records were reviewed. The prevalence of pain was 60.7% (300/494) during the study period. 72.3% (217/300) of patient attendances with pain had duration of pain not exceeding three days; 79.0% (237/300) of them were classified as ‘semi-urgent’ or ‘non-urgent’. 41.7% (125/300) of patients suffering from pain were given drugs for pain relief. The median time for patients to receive analgesic drugs was 56.0 (IQR 25.0-104.5) minutes after registration. Pain assessment using a numerical rating scale was positively associated with drug prescriptions for pain relief. Conclusion The prevalence of pain in ED patients was high, and comparable with the figures from studies in other EDs. Patients attending with pain had to wait more than 60 minutes for drugs for pain relief on average. (Hong Kong j.emerg.med. 2011;18:406-411)

134 Management of Acute Pain in Paediatric Emergency Departments: A Survey of Policies in Italy

Aims: To explore the policies of Italian paediatric emergency departments (ED) towards management of acute pain in children. Methods: Eleven paediatric and two general hospitals with separate paediatric triage were recruited. Policies regarding pain management at time of triage and in the emergency clinical area were surveyed through a structured questionnaire. Information regarding the hospital and the ED were also collected. Multiple correspondence analysis (MCA) was carried out to explore relationships between variables related to pain management and hospital characteristics. The study was supported by Angelini ACRAF. Results: Six hospitals routinely carried out pain assessment at triage, and 7 in the emergency clinical area. Nine hospitals (69%) used validated tools such as FLACC (7 hospitals), Wong-Baker (7) visual analogic or visual numeric scales (8). EMLA cream for anticipated venous cannulation was used “sometimes” (10 to 50% of events) by 4 hospitals, and often (51 to 90%) by 1. MCA identified two main dimensions, explaining 85.3% of variance in pain management policies: 1) routine pain assessment, joint medical nursing protocols for pain treatment, and EMLA at least sometimes; and 2) pain measurement through validated tools and recording of results. Being a paediatric hospitals, university affiliation, medico-surgical and trauma emergency functions, global triage on a 24h basis, and possibility for short-stay observation were associated with higher scores on both dimensions. Conclusions: Despite a general awareness of the relevance of acute pain in children and widespread presence of protocols, use of validated tools and prophylaxis of procedural moderate pain are still insufficiently applied.

An Australian Audit of ED Pain Management Patterns

Timely and appropriate pain management is an important quality indicator of ED performance. Emergency health care workers are well positioned to become active leaders and innovatively responsive in reducing human suffering. A pain management audit was conducted to determine Australia practice patterns. A 12-month retrospective descriptive cohort audit was undertaken. Through the randomization process a medical record audit tool was completed for each record identified. Ethical approval for the study was obtained. Seventy-four hospitals agreed to conduct the audit, 36 (48%) provided data. The total number of patient notes reviewed was 2,066. Ninety-five percent (1,966) of patients arrived by ambulance. Of the patients (n=547; 56.4%) with a documented triage pain score the majority arrived in severe pain (n=300; 41.3%). Of the total number of patients (1,966) documented arriving in pain 1,473 (74.9%) received an analgesic. Six hundred and forty-four (32.7%) patients received an opioid. From time of emergency department arrival, the median time for analgesic administration was 70 minutes (IQR 58 minutes to 92 minutes). Twenty-five emergency departments (69.4%) had pain management policies that enabled nurses to initiate a pharmacological analgesia without medical consultation. The Australian pain management audit highlighted current practices and potential areas for further research. While the audit demonstrated that nurse initiated pain management interventions promoted better analgesic response, greater consistency of triage pain assessment, code allocation, and documentation of pain scores may go some way to improving the timeliness of analgesia.

Policy Emulation or Policy Convergence? Potential Ambiguities in the Dyadic Event History Approach to State Policy Emulation

I demonstrate a source of bias in the common implementation of the dyadic event history model as applied to policy diffusion. This bias tends to severely overstate the extent to which policy changes depend on explicit emulation of other states rather than on a state's internal characteristics. This happens because the standard implementation conflates policy emulation and policy adoption: since early adopters are policy leaders, later adopters will appear to emulate them, even if they are acting independently. I demonstrate this ambiguity analytically and through Monte Carlo simulation. I then propose a simple modification of the dyadic emulation model that conditions on the opportunity to emulate and show that it produces much more accurate findings. An examination of state pain management policy illustrates the inferential differences that arise from the appropriately modified dyadic event history model.

Fundamentals of Anesthesia Care: Competency-Based Learning Modules for the Health Professions

This book was originally developed as the curriculum for the University of Manitoba’s Anesthesia Clinical Assistant Program. Over 100 authors have contributed to the book’s 165 teaching modules, which are organized into eleven broad sections: Airway, Anesthesia Considerations, Assessment, Equipment, Cannulation and Injection Procedures, Monitors, Pharmacology and Physiology, Clinical Management, Pediatric Anesthesia, Regional Anesthesia and Pain Management Protocols, and Policies and Guidelines. In general, each teaching module is similarly organized. Each module begins with learning objectives that outline core knowledge. The objectives are followed by several pertinent references (from textbooks, journal articles, or websites), and after the reference section is a list of competencies representing the requisite clinical skills. Each module also includes a few multiple choice questions as well as a set of advanced topics for consideration. This book provides comprehensive coverage of the topics in anesthesia practice. However, there are some inconsistencies in the effectiveness of the various teaching modules. For instance, the degree of detail in the learning objectives and competencies varies from descriptions that are succinct to those that are over a page in length. Some material tends to be basic and redundant (e.g., a full page description of Korotkoff sounds, p. 216), while material in other sections is esoteric and beyond the scope of practice of an anesthesia assistant (e.g., consideration of succinylcholine for stridor, p. 315). As well, some of the authors combine teaching material with their objectives, which can distract the reader. Although the modules are designed to be independent, the order of topics can be counter-intuitive, for example, in the Airway section, advanced airway modules, such as awake fibreoptic intubation, are presented before the modules pertaining to preoxygenation and basic orotracheal intubation. Unfortunately, the book does not address the evaluation of competencies. Despite the aforementioned limitations, Fundamentals of Anesthesia Care: Competency-Based Learning Modules for the Health Professions represents a unique contribution to addressing anesthesia assistant training in Canada. Although some modules provide teaching material, this book cannot be used as a stand-alone text, as most of the teaching information is referenced to outside sources. As a teaching manual, its size and detail may make it unwieldy for general use, and teachers will have to be selective in their use of the learning material. The book’s major strength lies in its broad coverage of the scope of anesthetic practice and its delineation of the clinical competencies of an anesthesia assistant. Also, this book may be useful for advanced learners from other disciplines and beneficial as a reference guide to aid teachers in curriculum development.

Pain management practices in paediatric emergency departments in Australia and New Zealand: A clinical and organizational audit by National Health and Medical Research Council's National Institute of Clinical Studies and Paediatric Research in Emergency Departments International Collaborative

To audit pain management practices and organization in paediatric ED across Australia and New Zealand. Retrospective audit of pain management practices in Paediatric Research in Emergency Departments International Collaborative ED in 20 cases each of migraine, abdominal pain and femoral shaft fracture. Review of organizational status of pain management at Paediatric Research in Emergency Departments International Collaborative sites. Of 14 ED, 10 participated in the clinical audit. A total of 196 migraine, 197 abdominal pain and 177 femur fracture cases were reviewed. Less than half had degree of pain measured or had pain score documented on triage. Migraine received analgesia in 62% of cases (opioids in 11%). Abdominal pain received analgesia in 62% of cases (opioids in 14%). Fractured femurs received analgesia in 78% of cases (opioids 49%, femoral nerve blocks 40%). Median minutes to enteral medication were 100, 85 and 75, and for parenteral medication (mainly opiates) 103, 137 and 26, for migraine, abdominal pain and femur fracture, respectively. Thirteen hospitals participated in the organizational audit. Of all ED, 92% had pain management policies or guidelines, 92% taught pain management topics in education programmes and 62% used mandatory pain competencies. Only 15% had quality improvement programmes for pain reduction. We found a notable lack of pain assessment documentation and delays to analgesia. There is a need to improve pain assessment and management, although a majority of paediatric ED surveyed had important organizational and educational structures in place. Issues to explore include use of opioids in migraine and the underuse of femoral nerve blocks.

Improving compliance with institutional pain management policies: a collaboration between nursing &amp; pharmacy

Improving compliance with institutional pain management policies: a collaboration between nursing &amp; pharmacy

A New Way to Assess Pain in Laboring Women: Replacing the Rating Scale With a “Coping” Algorithm

In 2001, the Joint Commission introduced a compliance guideline designed to improve pain care for all patients. In response, most hospitals created a pain policy that was intended to be implemented for all hospital patients. This article describes how nurses in a busy labor and delivery unit created a pain management policy that met the Joint Commission's goals and also supported their desire to assist laboring women in the most appropriate way possible.

Promoting a "good death": determinants of pain-management policies in the United States.

Many Americans do not experience a good death. The inadequate treatment of pain at the end of life has been associated with a lack of supportive public policies more than a lack of evidence-based clinical practices or organizational efforts. Given a widespread lack of understanding about pain policies, we examine the critical role played by state medical boards in developing pain policies and then apply event history analysis to identify the variables most critical to the formation of these policies. We develop an integrated model and evaluate the adoption of eight different types of pain policies. The analytic models incorporate fifteen years of observational data and test the impact of contextual, political, extrinsic, and institutional variables. They reveal that the presence of legal counselors on state medical boards has consistently increased the likelihood that state boards adopt policies associated with progressive pain management. Further, policy has been negatively influenced by historical activity: boards that previously adopted one pain policy have been less likely to subsequently adopt additional pain policies. This work illuminates mechanisms behind state pain-policy adoption and provides valuable information for advocates who seek to improve pain-management policy and reduce the amount of pain at the end of life.