PAIN FREE HOSPITAL
The experience of the Veneto HPH network and perspectives in Italy
Marco Visentin * and Simone Tasso**
* Antalgic Therapy Unit of ULSS n 6, Veneto HPH Network, Project leader
** Medical Director, Castelfranco Veneto Hospital, USLL n.8 ; Italian Veneto Region HPH Coordinator
Introduction
The improvement of antalgic treatment is a very important aim since several studies (1,2,3) demonstrated
that pain control is poor for patients in Hospitals, as patients complaining of pain range from 43% up to 91%
These data deserve consideration since WHO maintain that pain can be effectively treated.in 90% of the
patients in hospitals.
Therefore standards and projects have been developed for improving the approach to the problem of pain.
Since years ’90 standards have been published by the American Pain Society that stress the need for:
- recognizing and treating pain readily
- disseminating information on the use of antalgic drugs
- informing patients on the importance and possibilities of treating pain
Projects against pain have been implemented by several hospitals, mainly in North America
In 1992, an innovating project was started at the St. Luc Hospital in Montreal (Canada), aimed at changing
the attitude and behaviour of health professionals as well of the inpatients (3). This project, named “toward a
pain free hospital”, received the official support by the Pan-american division of WHO and from Montreal
have been extended to other Countries and at present is being implemented by France, Swiss, Belgium,
Spain, U.S.A., and Italy under the coordination of the International association “ Ensemble contre la
douleur”.
In Italy this type of project has been activated firstly by the Vicenza Hospital in 1998 (4,5,6). During 2000, a
group of 20 other hospitals has been build in several regions. These carried out the initial phase of the
project, that consisted in the sistematic detection of pain and in the sensitisation of both citizens and health
professionals to the problem. It has been the first multicentric investigation representative of the whole
national territory, despite the limited number of cases. The data showed a surprisingly high prevalence of
pain, that was treated inadeguately. In particular it was shown that lack of antalgic treatment results in a very
high incidence of severe pain (46%). Moreover it was shown that pain therapy does not adhere to rational
guide-lines despite these had been codified in a easy and suitable way by WHO since more than 10 years.
The HPH Network and the Pain Free Hospital Project
Within the HPH Network the adeguate treatment of pain is considered a very important task for promoting
the wellbeing of patients.
This topic is exploited by both individual hospitals and the HPH Coordination Centre as shown by several
hospital which implemented a project against pain either individually or under the coordination of their
regional network.
The interest in this issue both at national and international level is shown by the number of parallel sessions
devoted to this issue in recent national and international Conferences ( Bratislava 2002, Castelfranco Veneto
2002, Florence 2003).
Facing this problem correctly means enacting the actions foreseen in the Ottawa Charter, as changing a
culture which often consider pain as an unavoidable event, beeing an integral component of the disease.
As the Budapest Declaration suggests, multisectorial actions on patients, staff and communities are due.
Health professionals , e.g. show severe lack of knowledge on pain and its treatment that they do not rate as a
priority in the medical practice:
 It is a firm belief that curing the diseases is the only task of medicine
 Pain is considered to be a symptom that might be dangerous to hide
 When pain is not due to a clear cause, nothing is done for understanding its origin, but is rather
disregarded
Hindrance do not spring from professionals only but from patients themselves. A survey carried on in St.
Bortolo Hospital in Vicenza of the inadeguate belief of patients on pain revealed that:
- 46% of patients were afraid of the side effects of antalgic drugs
- 38% were afraid to become dependent
- another 38% did not want to inconvenience the staff complaining of pain
- 16% wanted to show himself to be stoic
Il is quite clear that this require that the community should be involved for sensitising everybody to the
problem and changing his belief and behaviour.
The experience of the Veneto HPH Network
The experience of the Veneto HPH Network started from these bases, trying to build a project taking into
account the National (7) and Regional (8) Guide-Lines, the experience gained by collegues who worked in
the first national phase of the Project “Ensemble contre la douleur” and on the grounds of health promotion
described in the Chart of Ottawa and in the Budapest Declaration.
Policentric Study
The first step of the project was a policentric study carried out in the hospitals of 6 Health Trusts in Veneto
region ( ULSS n.1 Belluno; ULSS n.8 Asolo, ULSS n. 16 Padua, ULSS n. 17 Este, ULSS n. 18 Rovigo,
ULSS n. 21 Legnago). The study involved 1325 patients ( included some patients treated at home) and had
these main aims:
1. Measuring the prevalence and intensity of pain reported by the patients
2. Measuring the perception of the pain of these patients by the health professionals
3. Comparing these two figures so as the assess their concordance
4. Assessing the knowledge and the behaviours of staff on the pain (doctors and nurses)
This study was carried out in the last trimester of 2002 and involved 1636 health professionals beside the
above mentioned patients. To all of them questionnaires on the knowledge and behaviour toward pain were
administered.
The main results were as follows: prevalence of pain in inpatients 51,5% with an average pain value of 2,50
(standard deviation 3.09) using the Numerical Rating Scale (NRS) a scale that include 11 levels of pain
intensity from 0 (no pain) to 10 (unbearable pain).
The concordance between perception of pain by the patient and pain evaluation by the staff was assessed by
the K coefficent of Cohen which takes into consideration also the fortuitous concordance. The Cohen K was
0,3746: figures below 0.4 reveal poor concordance. The questionnaires on knowledge and behaviour toward
pain gave 51.2% right answers with a confidence interval (95%) from 50.5% and 51.9%.
Involvement of the Community
In the meantime a sensitisation action toward the problem of pain was carried out in the communities: stands
were prepared at the hospital entrance where highly trained professionals illustrated the project to the
bystanders and disseminate information sheets.. At the same time press bulletins were prepared by most
health trusts which led to articles in the local magazines. Attention has been paid on the publication of
information in the ULSS Journals.
For facilitating the implementation of the project and for creating synergies in the hospitals, one of the first
action of the Coordinating Centre was the development of Trust Working Groups, (with a Trust Referent)
that should coincide with the Trust Committee for Pain forecast by the actual regulations.
Educational training for staff (videocassette and hand-book)
Courses for the staff were realized with the aim of educating in the routine assessment of pain of hospital
patients. An educational videocassette was realized. It helps the trainer because it includes 3 short scenes
where actors (nurses, doctors and patients) plays the wrong (at first) and then the right ways to face a patient
having pain.
The cassette is shown to the staff and it permits to open the discussion on standard scenes, showing the
wrong and the right behaviour of the actors. Joined the cassette an hand book has been prepared: it contains
the scenes scripts and it helps on the discussion.
BIBLIOGRAPHY
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control in hospitalized patients, J Palliat Care 1993 Spring; 9 (1) :51-52.
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towards the approach and tratment of patients in pain , J Pain Symptom Manage 2001 Nov; 22 (1)
:925-930
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della Repubblica Italiana del 29.6.2001, Serie Generale n.149.
8. Delibera Giunta Regionale Veneta n.309 del 14.2.2003 “Regional Guidelines for a Pain Free
Hospital”