PAIN FREE HOSPITAL INITIATIVE
INFORMATION & USER GUIDE
INTRODUCTION
The Pain Free Hospital Initiative is a one-year hospital-wide quality improvement initiative to
integrate pain treatment into service delivery by providing education for patients and staff, raising
motivation and awareness, documenting pain levels, improving medicine supply, and communicating
impact.
The Initiative is a low-cost intervention designed to demonstrate effectiveness and create local
champions for pain relief. The program will target hospitals where pain relief is available, but
remains under-prescribed. At the end of one year, participants in the Pain Free Hospital Initiative will
have created a model for incorporating pain treatment into clinical practice than can be replicated
throughout the country.
Goal: Implement a one-year program to integrate effective pain
treatment into hospital-based services
Objectives
The Pain Free Hospital Initiative has five main objectives:
1.
Motivate clinicians to evaluate and treat pain
2.
Supply appropriate drugs to treat pain
3.
Equip clinicians with the skills and tools to effectively treat pain
4.
Measure the impact of the program
5.
Communicate the impact of the program
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Table of Contents
Introduction ............................................................................................................................................ 1
How does the Pain Free Hospital Initiative work? ........................................................................................ 4
Materials ....................................................................................................................................................... 4
Cost and Staffing ........................................................................................................................................... 5
Treat the Pain................................................................................................................................................ 5
Experience..................................................................................................................................................... 5
Tools .......................................................................................................................................................... 6
Clinician Pain Knowledge and Attitude Assessment ..................................................................................... 6
Clinician Pain Knowledge and Attitude Assessment Analyzer ...................................................................... 7
Assessment Entry ...................................................................................................................................... 7
Assessment Scoring................................................................................................................................... 8
Pain Knowledge and Attitudes Among Clinicians Summary Table ........................................................... 8
Assessment Answer Key ............................................................................................................................ 8
Patient Pain Scores Survey ............................................................................................................................ 8
Sample Size Calculator .............................................................................................................................. 9
Data Sheet ................................................................................................................................................ 9
Patient Pain Scores Summary Table ....................................................................................................... 10
Calculations Worksheet .......................................................................................................................... 10
Daily Patient Pain Tracker ........................................................................................................................... 11
Continuing Medical Education Presentations............................................................................................. 11
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How does the Pain Free Hospital Initiative work?
Before launching, a team of hospital administrators will meet to tailor the Initiative to the unique needs
of the hospital. Hospital staff and implementation partners will work to develop a plan to integrate
effective pain treatment into ongoing service-delivery programs utilizing locally appropriate training
and promotional materials.
Prior to launching the Initiative, hospital leadership will set goals to reduce the median patient pain
score by the end of the year. Pain scores will be routinely recorded in patient charts as a vital sign
and clinicians will be trained to discuss pain with patients at each encounter. Throughout the program,
patients’ reported pain scores and hospital-level consumption of pain relief will be tracked and
reported.
Before trainings, the staff champion will conduct a brief survey among clinicians to determine
knowledge about pain and pain treatment. These surveys will be repeated after the trainings and the
data will be shared with staff. Regular continuing medical education programs and workshops will be
organized by the staff champion to address information needs identified in the regular surveys. This
may include standard classroom training but it could also include lunchtime sessions, brief afternoon
talks, or rounds.
Health administrators and hospital pharmacies should ensure that affordable, appropriate
formulations of essential pain medicines are available at all times.
To encourage improvement in clinician pain treatment knowledge and patient pain scores over the
course of the program, reference and training materials will be distributed widely, including pain
treatment guides, pocket pain scales, and prescribing information.
Materials
The materials necessary for implementing and measuring the Pain Free Hospital Initiative will be
provided by Treat the Pain. These materials include the pain treatment knowledge survey for
clinicians and a scoring program to understand which topics need addressing in the continuing medical
education sessions. Treat the Pain has also generated a random sampling tool to use to measure
median patient pain scores in the hospital at baseline and in quarterly follow-ups. There is also a tool
created to assist in incorporating patient pain scoring with vital sign measurements.
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Cost and Staffing
The Pain Free Hospital Initiative is a low-cost quality improvement intervention. The one-year
program varies in cost country-by-country. The cost accounts for the salaries of a local coordinator,
palliative care nurses, and a palliative care consultant. The budget also includes in-country travel for
the local coordinator and palliative care nurses. Finally, the development and production of clinical
training materials and the clinical training events are included in this cost.
The staffing of the Pain Free Hospital Initiative is largely based upon the current staff of the
implementation hospital. A staff champion will be identified before the start of the Initiative to lead
the program.
Treat the Pain
Treat the Pain is a project of the American Cancer Society to make effective pain control measures
universally available by 2020, in line with Target 8 of the World Cancer Declaration.
Treat the Pain’s work is focused in five key areas:
1.
2.
3.
4.
5.
Supporting governments
Creating a network of envoys
Coordinating country-specific education and awareness-raising campaigns
Advocating on a global level
Providing direct staffing support to health ministries.
Experience
Treat the Pain has successfully implemented the Pain Free Hospital Initiative in four hospitals in India,
the country ranking 2nd highest for deaths in pain in the world. The project has also started in Nigeria,
Kenya and Tanzania.
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TOOLS
Treat the Pain has developed a set of tools that can be used by any hospital wishing to implement the
Pain Free Hospital Initiative. The tools are designed to be user-friendly, but full explanations of how
to use the tools are given here to answer any questions that may arise.
Clinician Pain Knowledge and Attitude Assessment
The Pain Knowledge and Attitude Assessment is a tool designed to help hospitals and their clinicians
understand where their strengths and weaknesses lie in pain treatment knowledge and attitudes.
The assessment is comprised of twenty-two (22) true/false questions, fourteen (14) multiple-choice
questions, and two (2) case studies. The questions included in the assessment are the result of
collaboration between pain management experts and educators, and have been validated to serve in
their current format.
The assessment is administered in its entirety to clinicians before training and is re-administered in its
entirety after training to track progress. Clinicians take the assessment under an identification number
rather than their name to protect anonymity. The results, as analyzed by the Pain Knowledge and
Attitude Assessment Analyzer can be shared with each department after each administration so that
clinicians know their progress.
The assessment is used to understand which departments struggle or excel in understanding certain
facets of pain treatment, and determines which continuing medical education presentations should be
used.
Step-by-step instructions
Before starting the Pain Free Hospital Initiative,
1. Print enough copies of the Pain Knowledge and Attitude Assessment for each clinician at the
training.
2. Gather the clinicians and distribute the Assessment, giving one copy to each clinician. If you’d
like to measure scores by a subset of clinicians, ask them to mark their group in the upper right
corner. You can use whatever group you’d like, like N for nurses, RO for radiation oncology,
SO for surgical oncology, O for other, etc.
3. Ask the clinicians to fill out the Assessment without consulting with each other or any reference
materials.
4. When all clinicians have completed the Assessment, collect the completed forms and write a
sequential number (IDNO) in the upper left corner of each completed assessment (i.e. 1, 2, 3)
5. Enter the results into the Pain Knowledge and Attitude Assessment Analyzer (see below).
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Repeat Steps 1-5 every three months.
Clinician Pain Knowledge and Attitude Assessment Analyzer
The Pain Knowledge and Attitude Assessment Analyzer makes it easy for administrators to score
department performances on the Pain Knowledge and Attitude Assessment. Each clinician takes the
assessment using a unique identification number, so that identities are concealed but the results can be
analyzed by department.
Assessment Entry
The answers reported by each clinician are input into the Assessment Entry tab by a hospital
administrator, with each row corresponding to one clinician. Entering the responses into this data table
allows the program to analyze the correct response rate for each question and mean scores by
department.
Step-by-step instructions
1. Open the Knowledge Assessment Excel file, called Knowledge assessment.xls
2. At the top of the Assessment Entry tab, type in the date, the hospital name, and the name of
the person entering the data.
3. Now you are ready to start entering the clinicians’ responses to the Pain Knowledge and
Attitude Assessment. Each clinician gets his or her own row in the Excel spreadsheet. In Cell
A4, enter the identification number of the first clinician. The rest of the row is used to fill in the
responses the clinician gave as answers to each question. In Cell B4 type in the answer that
the clinician gave for the first question, in Cell C4 type in the answer that the clinician gave for
the second question, etc. Skipped questions can be left blank. You can use either capital or
lowercase letters-it doesn’t matter. At the end of the row, you can enter the group, if you
collected it, to get a summary by group.
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4. Continue filling in the clinician responses across the row. The first twenty-two (22) cells should
either be filled with a T or an F, the next fourteen (14) cells should be filled with either an A,
B, C, or D, depending on what the clinician marked on the Assessment. The cell under the
column marked 37 will be filled with a letter. The cell under the column marked 38 will have
a number. The cell under the column marked 39 will be filled with a letter. The cell under the
column marked 40 will be filled with a number. Check over the entered data. If something
looks amiss, you can check it against the paper form, using the IDNO to figure out which form
to check.
5. Once you have entered all of the first clinician’s responses, continue entering the other
clinicians’ responses, giving each clinician a new line in the Excel file.
6. Save the file in a folder with the date or rename the file as Knowledge Assessment
[Date].xlsm, like this: Knowledge Assessment June 2014.xlsm If you do assessments separately
for nurses, you can save the file as Knowledge Assessment Nurses June 2014.xlsm
7. Send the file and any questions to Zelalem Gizachew: gizachew@treatthepain.org and
Gobena Godana: gobenago@yahoo.com
Assessment Scoring
You do not need to do anything on the Assessment Scoring tab. This tab automatically scores the
physician responses for you.
Pain Knowledge and Attitudes Among Clinicians Summary Table
You do not need to do anything on the Summary tab. This page shows the data summary tables for
the results of the assessments.
Assessment Answer Key
You do not need to do anything on the Assessment Answer Key tab. This tab contains a list of all of
the correct answers to the questionnaire so that Excel can score the assessment.
Patient Pain Scores Survey
An important part of the Pain Free Hospital Initiative is reducing patient pain scores to the target
levels set by hospital administrators at the beginning of the intervention. To track progress, the
Patient Pain Scores Survey is administered at the beginning of each month.
Step-by-step instructions
1. Open the Excel file Pain Assessment.xlsm
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2. If you see a message at the top of the screen about Macro security, click ‘Enable Content’.
3. If you get a ‘Circular Reference’ warning that says Excel is unable to calculate a formula, click
OK
Sample Size Calculator
The Sample Size Calculator can be used to determine how many patients you need to survey each
month.
Step-by-step instructions
1.
2.
3.
4.
In the Excel file Pain Assessment.xslm, click on the Sample Size Calculator tab.
In Cell C3 enter the required Standard Deviation.
In Cell C4 enter the required Margin.
Cell C6 will tell you how many patients you need to survey in your hospital.
Sample Size Calculator:
"Sample Size for One Sample, Continuous Outcome." Power and Sample Size Determination. Boston
University School of Public Health, 12 May 2013. Web. Accessed 25 February 2014.
http://sphweb.bumc.bu.edu/otlt/MPH-Modules/BS/BS704_Power/BS704_Power3.html
Data Sheet
Measure patient pain scores on or around the first day of the month.
Step-by-step instructions
1. On the ‘Data Sheet’ tab, fill in the hospital name, the date of assessment, and the name of
person doing the assessment.
2. In cell B4, enter the total number of beds in the hospital.
3. In cell B5, enter the number to sample. This number is the number generated from the Sample
Size Calculator in the previous tab.
4. Click on the button ‘Recalculate’ to draw a random sample of beds and sort it in order. The
program will automatically add 20% extra to account for empty beds.
5. Select the rows with a bed number and columns A-D and print out a data collection form.
6. Use the printed form and a pain scale bracelet to record the pain scale from 0-10 for each of
the patients in the beds listed in Column B. If a patient is absent from their bed, simply make
a note in Column D and leave their pain score blank.
7. After recording the pain scores of all patients in the beds listed in Column B who are present
at the time of the survey on the printed data collection form, enter the data into the Excel file,
on the ‘Data Sheet’ tab.
8. Save the file and rename the file as Pain Assessment [Date].xlsm, like this: Pain Assessment
June 2014.xlsm
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Send the file and any questions to Zelalem Gizachew: gizachew@treatthepain.org and Gobena
Godana: gobenago@yahoo.com
Patient Pain Scores Summary Table
A summary of the patient pain scores will be automatically generated in the Patient Pain Scores
Summary tab. You do not need to edit anything on this page.
The summary table is the main tool to quantitatively track the changes in patient pain scores over the
course of the Pain Free Hospital Initiative. The data show the mean patient pain score and its
standard deviation. This data point is the main interest of hospital administrators in terms of trying to
reach the mean patient pain score goal set at the outset of the initiative. The patient pain scores are
also broken into quartiles to show more descriptive data.
The second section analyzes what percentage of patients reported low pain scores and what
percentage of patients surveyed reported moderate to severe pain, the level at which the WHO
recommends administering opioid analgesics.
The third section analyzes the patient responses by even narrower categories, dividing the
percentages of reported pain scores by tighter intervals so that more nuanced information about the
progress of the hospital can be understood from the results.
Calculations Worksheet
You do not need to make any edits in the Calculations Worksheet tab. This page calculates the
patient pain scores summary table from the data inputted to the Data Sheet tab.
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Daily Patient Pain Tracker
The daily patient pain tracker is printed and added to medical records. Clinicians incorporate
conversations about patient pain into their regular rounds and record patient pain scores when they
record vital signs. The clinician asks the patient to rank his or her pain on a scale of one to ten (1-10)
in the morning, mid-day, evening, and bedtime of each day. The clinician marks the patient’s
reported pain score as well as whether or not medication is prescribed for the pain. This tool is
intended to increase awareness of patient pain in the hospital and encourage patients to seek help to
control their pain.
Continuing Medical Education Presentations
In order to improve physician pain treatment knowledge scores, the staff champion will organize
continuing medical education sessions on pain treatment. The continuing medical education may
include standard classroom training but it could also include brown bag lunch meetings, brief
afternoon talks, or rounds according to what best fits the particular hospital. The sessions can be
tailored to address gaps in knowledge identified in the physician Pain Treatment and Attitude
Assessment.
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