Pain management is typically more developed in western countries compared to Asia. From the accreditation standard of the Joint Commission International (JCI), there is a broad scope for pain management. In 2008, our medical center established the pain management policy, and the goal is to be a pain-free medical facility. The Framework of Pain Management Policy including: 1. the rights of patients and family members 2. Employee education 3. Assessment of pain (screening, evaluating, monitoring) 4. Patient care of pain.
After implementation of pain management program, the compliance of pain assessment, the analysis of pain score before and after pain management and the analysis of Pain Management Index (PMI), all showed improvement in pain management program. The consumption of opioids usage steadily increased from 2010 to 2014. The success of our pain management program implementation could be attributed to the clear pain management policy, the firm support of higher leadership, the cooperation of IT department, and the quality control.
pain score; Pain Management Index;
Pain management has been established in the medical practice, such as control of cancer pain, postoperative pain, labor pain, etc. Traditionally, pain was considered a part of disease, so patients had to tolerate it during the recovery process. Pain management is typically more developed in western countries compared to Asia. From the accreditation standard of the Joint Commission International (JCI), there is a broad scope for pain management. In 2008, our medical center established the pain management policy, and the goal is to be a pain-free medical facility.
2. The framework of pain management policy
The rights of patients and family members
The health care professionals need to continuously communicate with patients and family members about pain management. In addition to educating patients on pain expression, educational material should also be publically exhibited and accessible in printing. The educational material is translated into different languages, such as English, Vietnamese and Malay.
The employees in the medical center are required to get education on pain management. There are different kinds of employee training programs in last few years. It was accompanied with the annual fire and disaster prevention program in two years and since two years ago, the program was set up online. Hospital employees need to take online test after studying the program annually. By educating employees, they can understand patients' emotional and medical needs. New employees are asked to take the pain management training during orientation.
Assessment of pain (screening, evaluating, monitoring)
According to the pain management policy, all inpatients and outpatients are required to get pain screening during the time of hospital admission, outpatient chemotherapy or outpatient surgery. If pain is present, the initial pain assessment needs to be done, including (1) the location, (2) severity and quality of pain, (3) timing, (4) exacerbating factors, (5) relieving factors, (6) previous management and effects, (7) the symptoms accompanied with pain. Since different populations need different assessment methods, the IT system of evaluation sheets is designed based on age groups. There are three categories: (1) age 12 or above, (2) age equal or above 1, but below 12, (3) below age 1. (Table 1)
Inpatients who completed the initial evaluation will be reassessed regularly. The IT system is designed to facilitate regular follow-up. Patients require repeated assessment every 8 hours if the severity of pain is mild (≦3 points), and every 4 hours if severity is moderate (≧4 points). After administering pain control medicine, patients need reassessing pain within 30 minutes if taken intravenously, or 1 hour if taken orally.
Patient care of pain
Health care professionals follow pain management guideline and every patient's needs to set up a pain control plan. Pain can be classified as acute pain or chronic pain. The management methods include non-pharmacological, pharmacological, invasive and surgical intervention. If pain is expected during invasive procedures or surgery, the patients need to be informed about the possibility of pain and the way to treat. (Fig. 1)
The compliance of pain evaluation and monitoring
After the implementation of pain management policy, 587 inpatients' charts were randomly reviewed during one month between September and October 2009. The criteria of adherence to the pain evaluation and monitoring include the following: (P1) Medication administration for pain score ≧ 4 points; (P2) For pain score ≧ 4 points, evaluation within 4 hours after single medication administration; (P3) For pain score ≦3 points, re-evaluation every 8 hours; (P4) Goal achievement rate (for pain score ≧ 4 points, and down to ≦3 points before discharging from the hospital) As the result shown in Fig. 2, the adherence rate of P1 and P3 is 93%, and the adherence rate of P2 and P4 is 99%.
The analysis of pain score before and after pain management
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Fig. 2. Adherence of pain evaluation and monitoring. P1: Medication administration for pain score ≧ 4 points; P2: For pain score ≧ 4 points, evaluation within 4 hours after single medication administration; P3: For pain score ≦3 points, re-evaluation every 8 hours; P4: Goal achievement rate (for pain score ≧ 4 points, and down to ≦3 points before discharge from the hospital).
Patients' pain score more or equal to 4 points were chosen to analyze the effect of pain management. The average pain score dropped by 4.4 points for general inpatients, and dropped by 5.6 points for inpatients with cancer. (Table 2)
The analysis of Pain Management Index (PMI)
PMI is calculated by subtracting the patient-rated pain score at time of initial clinic visit from the analgesic score. The analgesic score is defined by the World Health Organization (WHO) three-step analgesic ladder, and the patient-rated score is classified as 3 categories (1 to 3 points). PMI is used to evaluate the appropriate use of analgesic drugs. After analyzing 2016 electronic patient charts in 2010, the rate of appropriate analgesic drug use is at 64.6%, with overuse at 16.6%, and underuse at 18.8% (Table 3).
The survey of inpatient pain management
After 2010, the American Pain Society Patient Outcome Questionnaire-Modified (APS-POQ-Modified) is used to survey inpatients' outcome of pain management annually. The instrument measures six aspects of quality including: (1) pain severity and relief; (2) impact of pain on activity, sleep, and negative emotions; (3) side effects of treatment; (4) helpfulness of information about pain treatment; (5) ability to participate in pain treatment decisions; and (6) use of nonpharmacological strategies. 547 hospitalized patients were surveyed at the third quarter of 2010, 87% of patients were satisfied by the health care professionals' pain management plan. 91% of patients considered that the pain education given by health care professionals is important. 61% of patients waited for less than 10 minutes to get pain control medication when pain presented. (Fig. 3)
The survey on the usage of opioids
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Fig. 3. The result of the American Pain Society Patient Outcome Questionnaire-Modified (APS-POQ-Modified). 3.1. Patient satisfaction with physician pain management. 3.2. Patient satisfaction with nurse pain management. 3.3. Patient satisfaction with overall pain management. 3.4. Longest time waited for medication.
Opioid usage was analyzed to evaluate the effect of pain management policy from 2010 to 2014. The analgesic medications include oral morphine, fentanyl patch, IV morphine, IV fentanyl, IV meperidine (Table 4). After converting to the morphine equivalent dose2 (MED), we found that the total use of opioids was increasing every year. Usage rose to 131% from 2010 to 2014. The trend can be seen in Fig. 4, the usage of IV morphine and IV fentanyl is increasing every year while there is no increase in the number of beds. On the contrary the use of IV meperidine is decreasing every year. (Fig. 4).
The effectiveness of pain management policy is very successful from the result of this report. The frequency of reassessments after given pain medication is high. Most patients can get analgesics within 10 minutes after complaining pain, and they are satisfied with our pain management. The result is comparable with international report.1
The concept of PMI was initiated by Cleeland, et al,3 and it can be used to evaluate the appropriateness of pain management. Most studies focus on cancer patients' pain management by using PMI, and several studies focus on hospitalized patients' pain management. From the evidence-based-medicine (EBM) review, 51% of patients' pain was undertreated.4 There were only 18.8% of undertreated (PMI < 0) patients in our facility, which is better than the EBM review. Most undertreated patients in our medical center have a misunderstanding of analgesic drugs. The reasons why they reject analgesics is shown in Fig. 5. Some patients worry about the dependence of analgesic drugs, which shows how important proper education is. By giving further education, we believe the percentage of undertreated patients will decrease (Fig. 5).
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Fig. 5. Reasons why patients reject to use analgesic drugs. C1 Analgesic drug does not stop the pain. C2 Analgesic drug can develop a dependency. C3 I would rather have the pain than the side effects. C4 I am afraid of tolerability of analgesic drugs. C5 I want to prevent to mention my pain feeling. C6 If I complain about pain, my doctor will not focus on my disease. C7 Pain is the symptom of disease exacerbation.
WHO recommends to evaluate the effect of pain management by morphine consumption, especially for cancer pain management.5 From the analysis by WHO, the morphine usage is related to the development of a country.6, 7Although the usage of morphine in Taiwan is similar to other countries in Asia,8 the rate is still lower than developed countries in Europe and North America.9 From 2010 to 2014, the usage of morphine is increasing in our medical center without changing the number of hospital beds, and this indicates the improvement of pain control after implementing the pain management policy.
The experience of pain management in our medical center is very successful. The success is due to the clear pain management policy, the firm support of higher leadership, the cooperation of IT department, and the quality control. Due to the leadership, all health care professionals committed in pain management. The pain management policy makers revise the content of policy regularly to ensure effectiveness. The computer network makes the pain management efficient. The computer can remind health care professionals when to complete analysis before ordering medications and it also recommends the appropriate analysis tool for health care professionals. The electronic data gives relevant information to make health care professionals easier to approach their patients. The department of quality control takes survey from patients and health care professionals regularly, and the result is very important for improvement of revision of policy.
The quality of pain management was enhanced after the implementation of policy. Due to the different needs and goals of different patients, the individualization is very important part for pain management. Besides, the psychological support for the pain patients and their family members is also important. The next step of our hospital will focus on patients with difficult pain, such as adult with cancer or chronic pain. The clinical care program will be set up according to the international guideline, such as NCCN guideline for adult cancer pain.10 Different specialties will collaborate to further improve pain management in our medical center.
Conflicts of interest
No conflict of interest to declare.