Pain Management: It is a Focus of Care and a Focus of Auditors Part 1
Despite the fact that it is a patient’s right to have appropriate pain management, evidenced-based pain management is not always followed consistently and thus pain management has attracted audit focus. Because pain is considered the fifth vital sign, it is expected to be assessed and documented with each clinical visit.
Patients who transfer to home care frequently have long-term chronic pain that has been intermittently managed. But, are all of the clinicians comfortable in managing pain? An increasing number of home health agencies are assessing the comfort level of their clinicians in this area. This gap analysis usually includes knowledge of adjuvant medications along with differentiating types of pain and recommending corresponding analgesics (Hansen and Gorski, 2004). After the clinical knowledge gap analysis has been completed a learning strategy and curriculum can be implemented.
Over the past 4-5 decades, pain management has improved, many say, because of awareness of how to use analgesics more effectively (Painter, J, 2006). Much of this knowledge has occurred because of the Hospice movement and the Agency for Healthcare Research and Quality. The latter organization has routinely published clinical practice guidelines. The Joint Commission states, “Unfortunately, through the 1990s, there continued to be reports of poor pain control for postoperative and trauma pain, cancer pain, and many chronic pain problems not related to cancer. Guidelines, professional curricula, and a multiplicity of professional education programs, per the Joint Commission (JC) were not improving the quality of pain management by themselves.” The Joint Commission also says its pain standards were its first evidenced-based standards. The pain standards directly identify recommendations of institutional responsibility provided in evidence-based guidelines developed by groups such as American Pain Society (APS) and the Agency for Healthcare Research and Quality (formerly the Agency for Healthcare Policy and Research).
The Basics: this article is a bare bones review of pain management
Your agency no doubt has researched or is researching the latest evidenced-based care policies and procedures adhering to your state QIO suggestions. In addition, excellent articles from the Center for Medication Safety and Clinical Improvement allow the clinician to have a broad perspective of well researched material to add to their clinical tool box.
How is Pain Defined?
McCaffey has stated that “Pain is whatever the experiencing person says it is, existing wherever they say it does” (McCaffey, M, 1968). It is the body’s signal of distress and remains one of the most common reasons people visit their physician or visit the hospital. Normal pain sensations involves transmission and interpretation termed nociception. The clinician must understand transduction, transmission, and perception as well as pain modulation in order to better care for the patient with pain. The types of pain are also evaluated when assigning ICD-9 CM codes to properly portray the patient condition.
Understanding Types of Pain is Essential
Acute pain: Defined as intermittent pain occurring for less than 90 days (Occupational Medicine Practice Guidelines, 2009) and resulting from trauma, impact, burns, or surgery. It is abrupt, intermittent, and nociceptive.
Chronic Pain: Defined as over occurring for at least 3 months by the AMA and over 6 months by the American Psychological Association. Both concur there is no active disease or unhealed tissue injury. This type of pain may be caused by faulty processing of sensory input by the nervous system. Pain interventions may be ineffective resulting in frustration, anger, and depression (Rosdahl, Chap 55, 2010).
Somatic Pain: Defined as localized pain that becomes increasingly uncomfortable with movement and very tender when palpated. It is sometimes referred and described as, per the Occupational Medicine Practice Guidelines, sharp, throbbing, shooting, pinching, and deep aching that includes bone, post-op, and muscle pain.
Neuropathic Pain: Defined as difficult to cite the source of pain as it tends to follow dermatome pathways. Palpation tends to send pain to nerve endings distally. This pain is described as burning, radiating, and numbing at times with limb “heaviness.” There may be swelling, redness, and mottling with skin temperature fluctuations (Occupational Medicine Practice Guidelines, 2008).
Visceral Pain: Defined as constant and localized but may be referred like diaphragmatic pain refers to the right shoulder and cardiac pain which can refer to the left arm and the jaw.
Cancer Pain: Defined as pain due to a malignancy which is described as very severe, chronic, and intractable causing resistance to many medications, thus long and short term analgesics are usually required to prevent “breakthrough pain) (Rosdahl, 2010). Hospice nurses are usually very skilled at pain management because of Cancer pain needs.
There are many factors that affect pain perception including pain threshold which is described as the lowest intensity of a stimulus that causes the subject to recognize pain. Another factor includes the release of endorphins by the patient which is specific to the individual. Finally, pain tolerance is considered one of the key perception factors and interventions are necessary to expand the medication tolerance times.