Pain Management: An Integral Part of Effective Healthcare
This article was first published in Health View, June 2001.
We're hurting. And the pain isn't going away. It's a dull ache between the shoulder blades... a sharp stabbing sensation in the back... a short-term result of surgery... a chronic response to arthritis. And it's not getting better.
According to a Gallup poll and an Arthritis Foundation survey, four in 10 Americans suffer pain daily and one in three adults experience frequent or constant pain. With all the medical resources available today, why is it that people continue to hurt? That's a question that's come to the forefront for healthcare providers, and one that Carolinas Hospital System is making a priority.
"I deal with pain every day, both acute and chronic," said Michael Flynn, Director of Anesthesia at Carolinas Hospital System and chairman of the hospital's pain management committee. "And I don't want my patients hurting because I wouldn't want to hurt." When he asked to join the committee six months ago, the charge was to improve communication in regard to pain and to educate everyone involved in the management of pain. That includes patients, future patients, physicians, and personnel in every department of the hospital. "We want every staff member who walks into a patient's room, whether it's a nurse or respiratory therapist or housekeeper or volunteer, to recognize that a patient may be in pain. They may not know exactly what to do for the patient, but they can get someone who does," said Lynn Kennedy, RN, Director of Education at Carolinas and a member of the pain management committee. "Our goal is to make pain management everyone's responsibility."
The approach to pain began undergoing a shift in 1995 when the American Pain Society challenged all healthcare systems to make pain the fifth vital sign - along with pulse, temperature, blood pressure and respiration. A couple of years later, a project was launched in Missoula, Montana to take on that challenge and to improve the way pain was assessed and treated. The Missoula Demonstration Project has been the most intense and most successful in educating both healthcare providers and the public, and has served as a resource for the committee at Carolinas Hospital System.
Surveys in Missoula found that much of what people believed about pain was based on faulty assumptions. One such fallacy was revealed in that 36 percent of the people surveyed felt that pain medication should only be taken when the pain is severe. "That's a misconception. You need to take medication a lot sooner or you're just playing catch-up," said Flynn. Thirty-two percent of survey respondents erroneously felt that pain medication taken over time would lead to addiction in most patients. "We want to educate people and allay their concerns of addiction," Flynn said.
Another issue that came to light in Missoula was that 30 percent of cancer patients surveyed reported inadequate relief of their pain, along with an overwhelming seventy-five percent of surgical patients. Why were these patients continuing to suffer? Part of the problem was that they weren't telling their caregivers that the medication provided was not doing the job. "I think that in our society people were brought up to believe they had to grin and bear it. Yet everyone has the right to appropriate pain management," said Kennedy. Other factors come into play as well. "In some cultures, admitting to pain is showing a sign of weakness or considered God's will. The nurse has to understand pain from a holistic view: the family, the patient's stress level, their tolerance to pain, their culture. A patient's beliefs may result in him or her not taking the medication," Kennedy said.
Ask patients about their pain and each one is going to describe it in a slightly different manner. The pain management committee saw the clear need for a consistent, objective tool to assess pain. The same tool could be used by every staff member who works with a patient, and could enhance communication between the physicians prescribing the pain medication and the staff who administer the drugs and monitor patients throughout their stay. "We needed to establish a common pain language. In order to do that, we needed to have a universal pain rating scale to describe the intensity of pain," Flynn said.
Carolinas uses the above pain index/scale
to help patients communicate their level of pain.
After careful study of a number of pain scales, the committee adopted one that rates pain on a scale of zero to ten. A series of faces (ranging from a wide grin to a teary countenance) is also included for those who can't read or non-English speaking patients. An accompanying color scale benefits patients who find it helpful to equate the intensity of their pain with color. "There are certain colors that are very soothing and pleasant like yellow, so a very pale yellow indicates hardly any pain. Red, which has been proven over time to be related to danger, is at the other end of the scale," explained Kennedy. Laminated copies of the new pain scale will be put in every patient room and each treatment room in the Emergency Department. "We want patients to be able to identify this pain scale very easily," said Flynn.
Carolinas Hospital System staff members are attending in-service training on assessing pain with the new scale, as well as on addressing barriers that keep patients from getting the doses that can help them and utilizing alternate approaches to pain management. Kennedy stressed that there is no one appropriate way to treat pain. Non-pharmacological options, including guided imagery, words of comfort, massage and distraction, can play a role as well. "Medication should not always be the only thing we choose if a patient continually complains of pain. In addition to medications, we need to look at what else we can do," she said. Kennedy also pointed out that pain management is not total pain relief. A mutually set goal between the patient and practitioner is to utilize measures that reduce pain to the desired level. "The scale is a very objective measurement of pain that will help us as healthcare providers, instead of the patient saying, 'It hurts real bad' or 'It's the worst pain I ever had' or 'It hurts more in the morning,'" Kennedy added.
With certain patient populations, such as children and those who are non-verbal or comatose, staff cannot rely solely on the pain scale. Strong assessment skills and clear communication between physicians, staff and family member are essential in such situations, Kennedy noted. For patients that can take an active role in the pain management process, Flynn said that they "have a responsibility to report their pain, to pay attention to pain, to ask questions." And patients at Carolinas Hospital System will have ample opportunity to address pain management concerns "from the time they walk in to the time they are discharged," Flynn added. From an initial assessment, to an explanation of their right to pain management, to educational literature in their room, patients are going to find pain management an integral part of their healthcare treatment.
The staff at Carolinas Hospital System will also continue an on-going learning process on a new way to look at pain. "Some professionals believe that if powerful medications are not helping, the problem must be with the patient," Kennedy said. She explained, "Pain is not a complaint, but it's really a symptom of something that's going on. I look at pain like I look at low blood sugar. I investigate until I find the cause. "Everyone has to adopt one attitude: pain is what the patient says it is. We have to work with that patient until we find the answer to it and help them obtain the relief they need."
For more information, visit the following website, Partners Against Pain.
By Diane J. Epperly, Contributing Writer
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