Pain & HIV/AIDS
Monitoring the Quality of Pain Management
Recommendations:
- To assure optimal pain management, formal means should be developed and
used within each institution for evaluating pain management practices and for
obtaining patient feedback to gauge the adequacy of its control. The quality of
pain management should be evaluated in all settings where patients with cancer
receive care.
- The quality of cancer pain management should be evaluated at points of
transition in the provision of services (e.g., from the hospital to the home)
to determine that optimal pain management is achieved and maintained.
- For pain management to be effective, each practice setting should designate
who will be responsible for pain management.
- Policy and standard procedures, which define the acceptable level of
patient monitoring and appropriate roles and limits of practice for health care
providers, should govern the use of specialized analgesic technologies.
- To assure optimal pain management, formal means should be developed and used within each institution for evaluating cancer pain management practices,23;
349 and
should include feedback regarding the adequacy of pain relief. Optimal pain
management requires the interaction of all members of the health care team
including the patient. A formal process should be developed to evaluate the
quality of pain management across all stages of the disease and across all
practice settings.
Quality pain management begins with an affirmation by health care professionals
that patients should have access to the best level of pain relief that can
safely be provided. In any setting, the quality of pain control is influenced
by the training, expertise, and experience of clinicians. Practice settings
vary considerably in size, complexity, resources, and patient populations. In
addition, the goals of pain management may differ depending on the cause of the
pain and the stage of the disease. Different pain management programs are
therefore suitable in different practice settings, but the responsibility for
pain management should always be assigned to the clinicians most knowledgeable,
experienced, interested, and available to respond to patients' needs quickly.
One aspect of pain management that should be considered when evaluating quality
of care is the multiplicity of settings where cancer care is provided. Patients
with cancer receive care in ambulatory care centers, clinicians' offices,
hospitals, their own homes, nursing homes, and hospices. Pain management should
be evaluated at points of transition in the provision of services to ensure
that optimal pain management is achieved and maintained.
The key items to consider when developing a formal program to monitor the
provision of pain relief are:
- Patients' satisfaction with pain management and its impact on their
quality of life.
- Family satisfaction with pain management and its impact on their
quality of life. The designation of who is responsible for pain management. The
systematic assessment of cancer-related pain in all settings where patients
receive care.
- The accuracy of diagnostic approaches for common cancer pain
syndromes.
- The range and appropriateness of pain management options available
within a particular practice setting.
- The effectiveness of pain management options utilized to prevent and
treat pain.
- The prevalence and severity of side effects and complications
associated with pain management.
- The quality of pain management across points of transition in the
provision of services.21; 329;330
The implementation of this guideline requires collaboration across disciplines
and among clinicians. Three elements are essential for interdisciplinary
collaboration: A common purpose, diverse professional skills and contributions,
and effective communication and coordination of services.433 The
common purpose is the relief of the patient's pain. To meet this goal, the
diverse and complementary skills and contributions of each health care
professional should be recognized and used. At times, however, interpersonal
issues of power, leadership, and conflict can hamper efforts to relieve pain.
Competent leadership and attention to conflict resolution are vital for
building teams,
and keeping them focused on their shared purpose. The following elements will
help ensure effective communication and collaboration:
Clarity among professionals about what they can and will contribute (e.g., who
will coordinate pain management--the primary nurse and attending physician or a
specialized pain control team? Can consultants write prescriptions or
orders?).
Decision making that reflects the input and preferences of the patient and
family, such as providing a number of pain control choices that include
pharmacologic and nonpharmacologic options.
Contingency planning, including orders to avert or treat possible side
effects; a range of analgesic doses to deal with varying pain intensity;
ongoing followup of cancer-related pain problems; and clear directions about
whom the patient or caregiver should notify if changes in the plan are
required.
In institutional settings, regular interdisciplinary meetings of clinicians to
maximize communication and information sharing and to ensure appropriate
planning. The following recommendations (adapted from American Pain Society,
1992) should be implemented in every practice setting where patients with
cancer receive care:
- Promise patients attentive care. Patients should be informed, orally and in
writing, that effective pain management is an important part of their
treatment, that talking about unrelieved pain is important, and that health
care professionals will respond quickly to reports of pain. It should be made
clear to patients and families, however, that the total absence of any
discomfort is not always an achievable goal.
- Assiqn responsibility for pain management to clinicians most knowledgeab-le,
experienced, interested, and able to respond to patients' needs in a timely
fashion.
- Document the assessment of pain and its relief. An assessment of pain
intensity and pain relief should be recorded, regularly reviewed by members of
the health care team, and incorporated into the patient's permanent record. The
intensity of pain should be assessed and documented regularly (depending on the
severity of pain) and with each new report of pain. The degree of pain relief
should be determined after each intervention, once a sufficient time has
elapsed for the treatment to reach peak effect. A simple, valid measure of
intensity and relief should be selected, and the patient and family should be
instructed in the use of the tool. For children, age-appropriate measures
should be used.
- Define pain and relief levels to trigger a review. Each practice setting
should identify values for rating pain intensity and pain relief that will
elicit a review of the current pain therapy. The proposed modifications in
treatment should be documented, and the effectiveness of the modified treatment
should be reviewed subsequently. Cleeland, for example, has shown that when
patients indicate a level of "5" or above on a scale from 0 to 10, the
patient's ability to function is markedly affected.91
- Survey patient satisfaction. At regular intervals, as defined by the
practice setting and the quality improvement committee (if available), each
setting should assess a randomly selected sample of cancer patients who have
pain. Patients should be asked to rate their current pain intensity, the worst
pain intensity in the past 24 hours, the degree of relief obtained from
interventions, side effects associated with pain management, satisfaction with
relief, satisfaction with the responsiveness of clinicians, and the extent to
which their preferences in pain management were taken into account.
- Analqesic drug treatment should comply with two basic principles:
Oral analgesics and other noninvasive routes of administration are used
whenever possible and administered in accordance with the principles expressed
in the WHO analgesic ladder.
Analgesics are titrated to maximally effective doses or the appearance of
dose-limiting side effects before specialized invasive analgesic approaches are
used.
- Monitor use of specialized analgesic technologies. The administration of
intraspinal opioids, systemic or intraspinal PCA, continuous opioid infusion,
local anesthetic infusion, and conscious or deep sedation should be governed by
policy and standard procedures that define the acceptable level of patient
monitoring and appropriate roles and limits of practice for all health care
professionals involved. The policy should include definitions of physician and
nurse accountability, physician and nurse responsibility to the patient, and
the role of the pharmacist.
- Offer nonpharmacoloqic interventions: Physical modalities and cognitive- and
behavior-based interventions can provide substantial pain relief. Such
interventions generally should be used to supplement, not replace,
pharmacologic interventions.
- Monitor the efficacy of pain treatment. Periodically review pain treatment
procedures using the practice setting's quality improvement mechanisms.
