Twenty years ago, the American Pain Society labeled pain as “the 5th vital sign,” elevating it to the status of body temperature, pulse and respiration rates, and blood pressure as essential indicators of a patient’s well-being.
The underlying message was that health care providers needed to do more to assess patients for pain and do everything possible to ensure that they received adequate treatment to manage their discomfort. The Department of Veterans Affairs later adopted it, along with other organizations and health care providers.
Today the phrase has fallen under intense scrutiny in the wake of a long and steady increase in the number of opioid medications prescribed to control both acute and chronic pain and an accompanying rise in the number of people addicted to the medications and in opioid-related overdose deaths. The American Medical Association, for example, this summer quietly called for eliminating pain as a 5th vital sign from professional standards.
In July, the Centers for Medicare and Medicaid Services proposed removing pain management questions in its inpatient HCAHPS survey as factors in calculating hospital reimbursement, a tacit recognition that a hospital that manages pain safely and effectively might not necessarily satisfy its patients’ expectations.
If there is a positive outcome from the human toll claimed by the prescription painkiller epidemic, it’s that it has spurred a much broader re-evaluation of pain, which after all, has not gone away. What is pain? What causes it? How best to assess it? How to treat it in a way that recognizes the individual needs of patients while keeping them safe? These fundamental questions are being addressed at University of Colorado Hospital in practical ways.
The work includes offering inpatients non-medicinal pain-relief options – handheld massagers, aromatherapy, sleep masks, earbuds, and more – delivered on rolling “Comfort Carts.” Piloted in 2015 on the Medical/Surgical Progressive Care (MSPCU) and Pulmonary units, the carts are now used on all inpatient units and have been positively received by both patients and providers, said Aurora Davis, RN, associate nurse manager on the Orthopedics Unit and co-chair of the hospital’s Pain Champions Committee.
“The carts have been so much more popular than we expected,” Davis said. Massagers, for example, are especially popular with labor-and-delivery patients. Pods of QueaseEase, an anti-nausea aromatherapy product, are heavily requested on the Oncology Unit. High demand for the items means that providers use the carts on request, rather than as a routine option.
The carts, she said, were a response to “feedback we heard from patients that they were not offered adequate exposure to non-pharmacologic pain options,” she said.
Ashleigh Anderson, RN, a charge nurse on the MSPCU, originally developed the idea of a “Comfort Menu” with options for patients to choose on an ad-hoc basis. That progressed to the cart idea, which contain some, but not all, of the items patients can choose from the full menu. The Patient Experience team plays a key role in keeping the carts stocked and the Patient Services Department pitched in with regular funding to keep the service going.
With the roll-out of the menus and carts across the inpatient house, the Pain Champions recognized that staff needed education about their purpose and importance, said Sheryl Kleven, MSN, RN-BC, a direct-care nurse on the Pulmonology Unit and Davis’s committee co-chair. She developed a “Tip Sheet” to help current staff. For new arrivals, Kleven said she updated her “Pain and Sedation” lecture for clinical orientation with information about the Comfort Menu.
The menus and carts may have played a role in the hospital improving its scores on pain management questions included in the HCAHPS inpatient surveys, said Echo Vogel, project manager for the Office of Patient Experience. Among other tasks, Vogel coordinates the quarterly restocking of the carts.
Between November 2015 and June 2016, the percentage of patients who agreed that their pain was controlled often and that staff did everything they could to manage their pain rose from 68.7 percent to 71.8 percent. The hospital’s overall percentile ranking during that period climbed from 36th to 58th, Vogel said. During the same period, the hospital’s scores on questions related to communication with nurses and communication about their medications also rose significantly, placing both above the 75th percentile.
The improvement in communication scores carries an important message about helping patients with pain, Vogel believes.
“We’ve gotten great feedback from front-line staff about taking the time to sit with patients and be purposeful in talking with them,” she said. “It gives patients time to open up a conversation with their nurses about how they can be more comfortable and the alternatives they have for managing their pain.”
Those few extra minutes offer nurses opportunities to discuss with patients what they can realistically expect from their care, Davis said. Severe post-surgical pain is a fact of life on the Orthopedics Unit, and opioids can play an important role in relieving it. But it’s vital that patients understand pain in a broader context than simply taking medications to make it go away, she said.
“We got into this mess with opioids in part because of larger societal expectations that we as providers have to ‘fix’ patients’ pain,” Davis said. “It’s our job to talk with patients and educate them openly about benefits and risks of the medications we give them.”
The long-standing practice of basing patients’ goals for pain relief on a 0-to-10 scale is being replaced by identifying more tangible “comfort/function” goals, Davis said. Those might include walking, going to the bathroom, taking deep breaths or coughing without debilitating pain, she said. With that, nurses can talk with patients about options to meet those goals. They might include Comfort Cart items; the Care Channel available on each television, which offers guided relaxation techniques; and other non-medicinal choices, like ice packs, pillows and repositioning.
The subject is pain relief, but the broader context is making patients active participants in their recovery, Davis said.
“When we involve patients in the plan of care, listen to them and let them have a say, we can decrease pain scores without changing their medication regimens,” she said.
Modifying the meds
Efforts to minimize opioid treatment are not meant to trivialize or downplay the very real pain that hospitalized patients regularly endure, noted Robert Montgomery, DNP, ACNS-BC, an advanced practice nurse in Anesthesiology and clinical coordinator of the Acute Pain Service at UCH. The service provides specialty consults for providers in managing patients with complex post-surgical pain issues as well as those dealing with chronic pain problems.
“Sharp knives and surgery hurt,” Montgomery said.
The aim is to not to eliminate opioids as a pain management option, but rather to minimize their use and find alternatives, he said. In the short term, the worry is not so much about addiction but the side effects of the medications, which include constipation, nausea, itching, and sedation, all of which can slow recovery. Dosed high enough, opioids can lead to respiratory depression and dangerous changes in cognition, Montgomery said.
For patients undergoing surgical procedures, “the expectation of achieving zero pain is not always realistic or safe,” added Olivia Romano, MD, an anesthesiologist and a lead physician with the Acute Pain Service. Opioids can offer important temporary relief, Romano said, but their side effects can essentially immobilize patients.
“If a patient can’t get out of bed because of the medications, we’re not doing them any favors,” she said. “If we can minimize side effects and help them to meet their recovery milestones, they can get out of the hospital and back to their regular lives sooner.”
No one-shot deals
It’s most productive to treat pain management as part of a broad continuum rather than a moment in time, Romano said. For example, she noted, much can be done to manage pain perioperatively, with ultrasound-guided nerve blocks and epidurals. After surgery, “cocktails” of medications, including Tylenol and anti-inflammatories, can provide relief while reducing the use of narcotics, she said.
Nurses offering non-pharmaceutical treatments – including those on the Comfort Carts – and helping patients set reasonable expectations also play a big role in the strategy, generally summed up as “multi-modal therapy,” Montgomery said.
“In the acute-pain world, that term has been around for about 20 years,” he noted. “It’s now creeping into the vocabulary of other teams. There is a heightened awareness that it can be beneficial in improving pain scores and patient satisfaction and decreasing the amount of opioids patients receive.”
The acceptance has been strengthened not only by worries about addiction and drug-seeking, but also by a growing understanding that long-term use of opioids frequently increases patients’ sensitivity to pain. “We’re just now beginning to appreciate the significant problems and hazards that these drugs can cause,” Montgomery said.
New points of view
Romano noted that Anesthesiology has developed evidence-based protocols to help providers manage pain in patients undergoing thoracic, abdominal and total joint surgeries. These can guide providers away from overreliance on the quick pain fix that opioids offer. But she emphasized that providers can’t solve the pain problem alone.
“It’s not just physicians that have to get out of the mindset of prescribing opioids; it’s also patients,” Romano said. “It requires education on both sides of the options that are available.
For Aurora Davis, it’s important that she and fellow Pain Champions integrate discussions of pain management into patient-provider interactions, making them even more meaningful.
“Our biggest goal is improving communication with nurses,” she said. “That’s tied to everything, and it correlates most highly with all our HCAHPS questions. If we improve that number, we improve everything else.”