Pain: The Fifth Vital Sign
Hospitals Adopt New Pain Management Measures

When Wendy Roberts was admitted to St. Luke's Hospital for back surgery, she knew pain would be unavoidable.

"Back surgery is painful - I'd always heard that," she said.

Yet when the 12-hour surgery was over, Wendy experienced surprisingly little pain, thanks to the pain-relieving medications she took during her six-week recovery.

"One pain pill provided wonderful relief for about four hours, and then the pain would begin to creep back in. So I'd take another pill, as prescribed, and the pain would back off," she said.

While Wendy initially was concerned about becoming "hooked" on painkillers, her doctor assured her that she would quit the pills when the pain subsided. And she did. After a six-week course of Darvocet, Wendy was free of pharmaceuticals, and needed not even a single aspirin.

Wendy's experience was ideal, yet millions of Americans suffer every day because pain is routinely ignored or undertreated.

According to the American Pain Foundation, 50 million Americans suffer from chronic pain. In addition, 40 percent of cancer patients and 50 percent of post-surgery patients receive inadequate pain relief.

Starting Jan. 1 of this year, the nation's hospitals were required to make a major change to address this problem. New standards set forth by the Joint Commission on Accreditation of Healthcare Organizations now require hospitals to measure patients' pain regularly, from the time they check in until the time they are discharged - and proper pain relief provided or the hospitals risk losing their accreditation.

Until now, no such standards have existed.

"Pain is now the fifth vital sign to be measured routinely during a hospital stay, like its four predecessors - blood pressure, pulse, body temperature and respiration," says American Pain Society President-elect Dr. Christine Miaskowski. "If pain is detected, patients need analgesics to treat the pain, just as they need antibiotics to treat infections."

Several techniques are used to measure pain. Patients usually are asked to rate how they're feeling on a scale of zero to 10, with zero being no pain and 10 being the worst pain imaginable. Small children are shown drawings of faces with expressions mirroring various levels of pain, and are asked to choose the face that describes how they're feeling. Detecting pain in infants is trickier because the tiniest patients can't yet talk, but rapid heartbeat and inconsolable crying are telltale signs of infants' pain.

Once pain is measured, hospitals must take the necessary steps to alleviate, or at best, manage the pain.

The new standards are so important that some hospitals are handing out leaflets to patients, informing them of their right to proper pain assessment and treatment, and encouraging them to complain if a doctor or nurse doesn't help.

And it's not just hospitals that must take the new steps but also nursing homes, outpatient clinics, home care agencies and behavioral health facilities accredited by the Joint Commission. The commission adopted the standards more than a year ago but gave facilities until Jan. 1, 2001 to comply.

While many centers across the nation are still scrambling to implement the new measures, hospitals in the Texas Medical Center are ahead of the game.

Texas Children's Hospital, for example, formed a steering committee on pain three years ago, long before the new standards came out. Made up of doctors, nurses, physical and occupational therapists, child life specialists, pharmacists and others representing various health care disciplines, the committee's charge is to ensure that no child suffers needless pain, explains Dana Nicholson, director of nursing.

"What we're saying is that any child in pain will be assessed promptly, and their pain will be managed in an individualized and therapeutic manner," she says.

Four subcommittees have sprung out of Texas Children's Pain Steering Committee, including: the Patient/Family Education Subcommittee, designed to educate children and their parents about pain relief; a Staff Education Subcommittee to provide ongoing education about pain control management to health workers who aren't pain specialists; a Pain Protocols Subcommittee that developed a pocket-sized card given to medical residents, which lists appropriate dosages of pain medications for children; and a Standards Subcommittee, which constantly is on the lookout for ways to improve pain management and ensure compliance with regulatory standards.

In addition, Texas Children's hosts two one-day pain management conferences each year, and a Red Hot Summer Series in which parents share their experiences managing their children's pain with hospital staff.

Pharmacologic and nonpharmacologic methods for managing pain are stressed, Nicholson says.

"Analgesics and narcotics are often essential, but other less traditonal methods may be helpful, such as massage or physical therapy, imaginary or diversional play, and other anxiety-reducing activities," she says.

Because of the type of patients The University of Texas M. D. Anderson Cancer Center sees in its clinic and hospital, Anderson has been involved in pain management for decades, said Katharine Luther, director of quality improvement.

"A year ago, when the Joint Commission came out with its new pain standards, we began tweaking what we've done all along to ensure we comply with the standards," she explains.

A survey was conducted to gauge patients' thoughts about how their pain was managed. Based on the survey's outcome, a new cancer pain management guideline was drafted, as was a pain management algorithm - a flowchart that walks clinicians step-by-step down the path to pain relief through a series of questions, i.e. "Was the patient's pain relieved? If yes, do this, if no, do that."

A series of seminars was developed to enlighten physicians and nurses, as well as patients, about pain management, and M. D. Anderson went so far as to reprint its patient bill of rights to add the verbage found in the Joint Commission's new pain standard, "You have the right to management of your pain …"

That sounds so common sense, but many patients don't realize that they don't have to suffer, and think pain is part of the package during hospitalization. This is simply not true, says Dr. Maureen Simmonds, a researcher specializing in pain management at Texas Woman's University's Institute for Health Sciences in Houston.

"Pain is avoidable, and there is no virtue in suffering needlessly. In fact," Dr. Simmonds says, "pain can hinder healing, making recovery time longer."

So don't worry about `bothering the doctor' or being a `difficult patient,'" she advises. "If you're in pain, complain."

The Veterans Affairs Medical Center in Houston takes pain so seriously that it is drafting a proposal to fund a new chronic pain center. The hospital views pain assessment and management as a day-to-day activity, says Beverly Green-Rashad, associate chief of surgical nursing, and is partnering with the federal VA Health Administration and the Institute for Health Care Improvement to improve pain management for veterans and promote compliance with the new Joint Commission standards. Among the changes being initiated by the VA are: Developing an online pain assessment template for use by health care providers in the computerized medical records system; assessing the staff's educational needs and adding more seminars on pain; updating the plan nurses use to assess patients' pain upon admission; developing a booklet in English and Spanish for patients that addresses pain concerns; and placing education videos about pain management on the hospital's closed-circuit TV channels. Last October, the hospital sponsored a number of activities during pain awareness week.

Roy Hultburg is The Methodist Hospital's director of nursing for orthopedic services, and is acutely aware of the pain that post-surgical patients can potentially suffer.

"Orthopedic surgery, because it often involves cutting through bone or manipulating muscles and joints, can be among the most painful of surgeries," he explains.

Hultburg, who says he deals with pain management "every hour of every day," leads Methodist in its efforts to raise awareness and education in pain issues. The hospital will launch a new series of education seminars about pain this spring and is busily hosting similar seminars for all Methodist Hospital employees who have direct contact with patients.

"Whether you're a nurse, housekeeper, doctor or clergyman, you need to be aware of patients' concerns, and pain is always an overriding concern," Hultburg says.

The hospital's mission statement and patient bill of rights have been amended to include verbage about patients' rights to pain management, and videos about pain are currently in production.

Shriners Hospital for Children, which specializes in pediatric orthopedic surgery, is a leader in pain management for children who undergo complicated orthopedic surgical procedures. Small children face huge challenges adults never have and never will experience. It's not uncommon for infants to remain Shriner's patients until adulthood, and by the time they reach age 18, many have undergone as many as 20, even 25 surgeries, says Administrator Steven B, Reiter.

"We watch children grow up here - they become members of our extended family," he said.

At Shriners, children are encouraged regularly to communicate any pain they experience. And although the tiniest patients can't talk, their pain is evidenced by prolonged crying, rapid pulse and heartbeat, and "pulling away" of a painful arm or leg when it is touched.

The hospital, along with the other 21 Shriners Hospitals located throughout North America, is initiating a study which, when completed, will provide medical personnel with new information about how to manage pain.

Like many of the hospitals in the Texas Medical Center, The Institute for Rehabilitation and Research has been involved in pain management for decades. To address the Joint Commission's new standards, TIRR started developing a formal pain management program last spring that stresses patient and family education, physician and staff education, and policies and procedures that spell out how pain is documented on forms, how often pain is checked, etc…

"We see the Joint Commission's news standards as speaking strongly to the importance of regular assessment and follow up of pain concerns," said Celeste McLaughlin, executive director of nursing at TIRR. "Patients whose pain goes unrelieved have a hard time participating in rehabilitation and achieving optimal function. Pain must be relieved before steps toward recovery can be taken," she said.

"In examining the steps Texas Medical Center hospitals are taking to comply with the new standards, education is a common thread, and perhaps one of the most important components of any compliance plan," said Dr. Jack Waymire, professor of neurobiology and anatomy at The University of Texas Medical School at Houston.

Teaching health workers who aren't pain specialists how to treat pain can be challenging, he said.

"In the past, some doctors have inappropriately shunned narcotics because they feared patients would get hooked on them," Dr. Waymire said. "But for people who have never abused drugs, hardly any become dependent on pain medication. The risk is minimal, yet there is a continuing misconception about painkillers and addiction," Dr. Waymire said.

To counter this misconception and heighten awareness of pain management, St. Luke's Episcopal Hospital will begin offering continuing medical education courses this March. Additionally, new hospital employees at every level receive a pain management overview during orientation.

St. Luke's recently completed surveying its patients about their perception of how adequately their pain was relieved. Subsequently, the hospital changed the way it transitions patients from IV pain management to oral drugs, and modified the use of PCA pumps so they are programmed based on drug volume versus volume.

In early 1999 when the Joint Commission's standards for pain were newly published, the Memorial Hermann Healthcare System established a team at its Southwest hospital to implement a pain management program. Last year, Joint Commission surveyors visited the hospital and declared the program successful, citing increased patient satisfaction and clinical improvement. The program's success served as a benchmark for all other hospitals in the Memorial Hermann System, which have followed suit and adopted the program.

Specifically, Memorial Hermann has placed pain rating scales in all patient rooms; begun assessing pain upon admission and discharge; developed a pain information sheet given to families during admission and used as a check for discharge instructions; incorporated a pain lecture into its nursing orientation; written new standing orders for pain management of specific populations such as geriatrics and pediatrics; and begun using a patient satisfaction survey tool to rate the hospital's success in pain management on an item-by-item basis and comparing those scores with other hospitals' scores across the nation.

The steps the Harris County Hospital District is taking to ensure its hospitals comply with the new standards echo those of the aforementioned hospitals - use of pain rating scales, patient handouts, assessment of pain upon admission and discharge; and seminars for professionals. However, the hospital district also is addressing the potential problem of the small number of patients who have addictive personalities and are at increased risk of becoming dependent on painkillers. A task force is investigating this issue, and will make a report at a later date.

Overall, the steps being taken by all the hospitals are extremely positive because they acknowledge that patients have pain, and make a commitment to doing something about it, affirms Dr. Simmonds.

But the Joint Commission's standards should be looked upon as only the first step in addressing pain, not a final ending, she says.

"We eventually need to do more than ask patients to rate their pain based on a scale. Pain is multi-dimensional, and everyone has a different pain threshold," Dr. Simmonds explained.

"How often does your pain interfere with your daily activities?" and "How has your pain influenced your relationships?" are among the questions that should someday be asked, she says.

Pain is complicated and often misunderstood, Dr. Simmonds says, and underrepresented in medical and nursing school curricula. She advocates more extensive training of faculty, so that faculty may better train their students in pain management.

While pain is traditionally viewed as "bad," it serves a useful purpose, adds Dr. Waymire.

"Pain is our body's way of telling us that something is wrong. Removing the pain may result in removal of a crucial warning signal. You can't get help if you don't know you have a problem."

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©2006 Texas Medical Center

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