A Victorian Quality Council presentation
Acute Pain Management
Measurement Toolkit
Wendy McDonald
Acute Pain Nurse
St Vincent’s Hospital
Eliza Bell
Acute Pain Nurse
The Alfred Hospital
The Problem
A Victorian Quality Council presentation
There are long standing and well-recognised concerns regarding
Acute Pain Management
(Acute Pain Management: the Scientific Evidence, 2005)
• Inadequate provision of analgesia
• Inconsistent strategies throughout hospitals for the assessment
and recording of acute pain
• Side-effects and complications relating to acute pain
management strategies
Ö Inadequate information regarding the quality of care
The aim of the Toolkit:
• addresses the need for a range of measurement and analysis
• tools appropriate for the diverse needs of pain assessment, and
the
• evaluation of pain management from an individual to an
institutional level
Quality of Pain Management
A Victorian Quality Council presentation
• Effectiveness of Pain Relief
• Minimization of Side-Effects
• Minimization of Complications
Measuring and Recording Pain
A Victorian Quality Council presentation
Key Elements
•Consistent tools used
•Patient involvement
•Baseline assessments
•‘Standardised’ scoring system
•Functional Activity Score
•Core Chart Components
Patient Education Brochure
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Pain Assessment
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Pain Intensity
•Subjective Scoring Systems
Functional Impact of Pain
•Pain on Movement
•Functional Activity Score
Monitoring For Side Effects and Complications…
Subjective Tools for Measuring Pain
A Victorian Quality Council presentation
Visual Analogue Scale
Verbal Numeric Rating Scale
Faces Pain Scale
Behavioural Rating Scale
All result in a 0 – 10 ‘Pain Score’
No Pain
Worst Pain
Imaginable
Beyond Pain Intensity…
A Victorian Quality Council presentation
The ability of patients to function (perform rehabilitation, physiotherapy
or just move about) is widely recognised as a key outcome of
effective acute pain therapy.
Without effective pain relief enabling function, recovery will not be
facilitated.
In it’s most basic form this involves assessment of patient pain scores
when moving or coughing, however there may be inconsistency in
patient ratings and rehabilitation targets differ from patient to
patient.
“The benefits of effective pain relief will not be realised unless
[postoperative] care plans are optimised to take advantage”
Henrik Kehlet
Thus a three-level ‘Functional Activity Score’ (FAS)
was developed…
Pain Assessment
A Victorian Quality Council presentation
Pain Intensity
– Subjective Scoring Systems
Functional Impact of Pain
– Pain on Movement
– Functional Activity Score
Monitoring For Side Effects and Complications…
Tools for Measuring Function
A Victorian Quality Council presentation
Functional Activity Score (FAS)
This is a new concept which involves use of patient’s
reported discomfort during activity appropriate to their
rehabilitation to be integrated with observed ability to
perform that activity.
Thus the application of the score involves some degree of
customisation for each patient and this requires some
learning of new skills by clinical staff.
Tools for Measuring Function
A Victorian Quality Council presentation
Functional Activity Score (FAS)
This is an activity related score. Your patient is asked to (or
attempt to) perform a task appropriate to their painful injury or
rehabilitation requirements and then rated on how pain effects
their ability to perform this task.
Observe your patient during the chosen activity and score A,B or C.
A – No Limitation
B – Mild Limitation
C – Severe Limitation
* Relative to Baseline
The patient response to the chosen activity should be
recorded with each pain score.
Tools For Measuring Function
A Victorian Quality Council presentation
Reporting Trigger
It was considered that two consecutive FAS scores of C would
reflect a sustained level of inadequate analgesia, sufficient to
justify seeking further assistance in managing the patient
A Victorian Quality Council presentation
A Victorian Quality Council presentation
Tools for Monitoring
Adverse Events…
Adverse Events Associated With Acute Pain
Management
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Minor Morbidity
• Nausea and Vomiting
• Pruritus
• Urinary Retention
Potentially Major Morbidity
• Leg Weakness/Motor Blockade
• Hypotension
• Sedation
Critical Adverse Outcomes
• Respiratory Depression
• Loss of consciousness requiring high dependency or intensive care
• Epidural Abscess
• Epidural Haematoma
• Permanent Neurological Injury
• Death
Tools for Measuring and Managing Adverse
Events
A Victorian Quality Council presentation
Sedation Score
Sedation & Respiratory Depression
A Victorian Quality Council presentation
Standardized Sedation Scale
An assessment of depth of ‘sleep’
Routine Charting of Sedation Score
Reportable Thresholds
Sedation Scale
0 = Awake, Alert
1 = Mild Sedation
1S = Asleep
Easy to Rouse
2 = Moderate Sedation, unable to remain awake
3 = Difficult to rouse
Bedside Care
Routine Audit
Indicator
Sedation Scale
A Victorian Quality Council presentation
X
The optimal aim is for a sedation
score of 0 or 1. Sedation score
should be documented in the
sedation score section of the
Special Analgesia Chart or row
of the Thermic Observation
Chart.
1
Motor Block - Assessment
A Victorian Quality Council presentation
Neurological Assessment
Basic Assessment
Bromage Score
•
•
•
•
Widely used
Easy to consistently apply
Charting to detect change
Reportable events
Bedside Care
Routine Audit
Indicator
Bromage Motor Block Score
0 – (None) Full flexion of hip, knees and feet
1 – (Partial) Just able to move knees and feet
2 – (Almost Complete) Only able to move feet
3 – (Complete) Unable to move feet or knees
Motor Block Assessment
– Special Analgesia Charting
A Victorian Quality Council presentation
Reportable
– Depends on change
– Consideration of clinical circumstances
Other Major Adverse Outcomes or
Complications
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Core Chart Components
A Victorian Quality Council presentation
All Hospital Vital Sign Charts (TPR / Thermic)
– Pain Intensity Score
– Functional Activity Score
– Sedation Score
Design
– Incorporate into existing designs
– Adopt ‘Templates’ offered
Frequency of Observations
– On admission
– Minimum once per shift
– Post-intervention frequency per institution
Pain Score
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Thermic Chart
All pain scores are now
0–10 no matter which tool is
chosen to use with the patient
Special Analgesia Chart
VAS
NRS
Faces
Behavioral
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Routine Ward Charting
Chart Modifications
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VAS
NRS
Faces
Behavioral
Analgesia Treatment Summary Form
A Victorian Quality Council presentation
This form may address the larger
picture of the effectiveness of
acute pain management within
an organisation.
This is achieved through collation
and analysis of aggregated
patient-level data.
Toolkit
Information Pathways
IV
QC
Indicator
Reporting
III
Inter-hospital
Performance
Review
CONTINUAL
ANNUAL
Hospital / APS Review
ANNUAL
II
Ward or Unit Audit and Review
3-6 MONTHLY
DAILY
I
Bedside Assessment – Vital Observations
HOURLY
Where are we now?
A Victorian Quality Council presentation
• Tools that provide for patient education
• Tools to assist in pain measurement
• Tools to help direct intervention
Leads to a better system for patient care and an improved
process for auditing and reporting.
We are still a long way to the final product and many more
processes have yet to be tackled.
However
This is the first important step to improved pain management