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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition, offers practical advice on how tomeet The Joint Commission’s and Joint Commission International’s standards on assessing and treating pain. It featuresclinical leaders recounting how they developed and implemented their pain management activities and successfullyaddressed these standards.

This updated edition is a comprehensive and practical resource for health care organizations wishing to develop, evaluate, orimprove the way they assess and treat pain. In addition, the book includes the pain standards for international organizationsand introduces two international best-practice organizations describing their experiences in maintaining successful painmanagement programs.

Clinical leaders will benefit from the following:• Guidance on addressing challenging issues in pain management and committing an organization to improving its pain

program• Summaries of every Joint Commission and Joint Commission International pain assessment and management

requirement across most health care settings• Examples of policies, care plans, protocols, treatment guidelines, and education materials for patients, staff, and family• Plus, valuable “Online Extras” with additional information and case studies available only via the Web

Joint Commission Resources (JCR),

an affiliate of The Joint Commission

is the official publisher and educator

of The Joint Commission.

1515 West 22nd Street, Suite 1300W

Oak Brook, IL 60523-2082 U.S.A.

www.jcrinc.com

Order Code: APM10

About Joint Commission Resources

Joint Commission Resources (JCR) is an expert resource for healthcare organizations, providing consulting services, educationalservices, and publications to assist in improving quality and safetyand to help in meeting the accreditation standards of The JointCommission. JCR provides consulting services independentlyfrom The Joint Commission and in a fully confidential manner.Please visit our Web site at http://www.jcrinc.com.

Approaches to Pain ManagementAn Essential Guide for Clinical Leaders, Second Edition

ManagementPain Pain

Approaches to

An Essential Guide for Clinical Leaders

Second Edition

Foreword by

Daniel B. Carr, M.D., D.A.B.P.M.

Introduction by

Judith A. Paice, Ph.D., R.N.,

F.A.A.N.

This book features bonus information

on our Web site designed to provide

additional examples and

supplemental information.

About Joint Commission International

Joint Commission International (JCI) is a client-focused, results-oriented, premier source of knowledge for health care organizations,government agencies, and third-party payers throughout the world.It provides educational services, consulting services, and publicationsto assist in improving the quality, safety, and efficiency of health careservices. JCI offers international and country-specific accreditationprograms and other assessment tools to provide objective evaluationsof the quality and safety of health care organizations.

Senior Editor: Robert A. Porché, Jr.Project Manager: Andrew BernotasManager, Publications: Lisa AbelAssociate Director, Production: Johanna HarrisExecutive Director: Catherine Chopp Hinckley, Ph.D.Joint Commission/JCR/JCI Reviewers: Pat Adamski, Mary Brockway, Mary Cesare-Murphy, Catherine Hinckley, Sherry Kaufield, Michael Kulczycki, KellyPodgorny, Connie Yuska, Gina Zimmermann

Joint Commission Resources MissionThe mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of care in the United States and in the internationalcommunity through the provision of education and consultation services and international accreditation.

Joint Commission InternationalA division of Joint Commission Resources, Inc.The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision ofeducation, publications, consultation, and evaluation services.

Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of Joint CommissionInternational. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no specialconsideration or treatment in, or confidential information about, the accreditation process.

The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of suchorganization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval.

© 2010 The Joint Commission

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publishpublications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission.

All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher.

Printed in the U.S.A. 5 4 3 2 1

Requests for permission to make copies of any part of this work should be mailed toPermissions EditorDepartment of PublicationsJoint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace, Illinois 60181 U.S.A.permissions@jcrinc.comISBN: 978-1-59940-408-0Library of Congress Control Number: 2010932851

For more information about Joint Commission Resources, please visit http://www.jcrinc.com.For more information about Joint Commission International, please visit http://www.jointcommissioninternational.org.

Foreword ........................................................................................................................vDaniel B. Carr, M.D., D.A.B.P.M.

Introduction..................................................................................................................viiJudith A. Paice, Ph.D., R.N., F.A.A.N.

Acknowledgments ........................................................................................................ix

Chapter 1 Overview of Pain Management ..................................................................1

Chapter 2 Compliance with Joint Commission and JCI Standards ..........................31

Chapter 3 Allegheny General Hospital ......................................................................41

Chapter 4 Dar Al-Fouad Hospital ..............................................................................61

Chapter 5 The University of Wisconsin Hospital and Clinics ................................85

Chapter 6 Montefiore Residential and Community Services for Seniors ............111

Chapter 7 The Stone Center of New Jersey ..........................................................127

Chapter 8 Wattanosoth Hospital/Bangkok Cancer Hospital ................................141

Index ..........................................................................................................................155

iii

Table of Contents

T he Joint Commission has played a historic role indisseminating the principle that pain management is a

fundamental human right—an idea that continues to gainmomentum worldwide.1 This concept is not an empty,abstract one. To deliver on the promise of appropriate painassessment and treatment requires long-term commitment onthe part of institutions, led by internal advocates andimplemented by frontline clinicians on a daily basis for eachpatient. Therefore, it is most appropriate that The JointCommission, long a champion of patient-centered care, haslabored for well over a decade to establish requirements andstandards for pain assessment and treatment and to ensurecompliance with them.

The benefits of optimal pain control in a variety of clinicalcircumstances are now unquestioned. Quality of life andclinical outcomes benefit from appropriate pain control andsuffer when pain control is substandard. However, agreementon general principles does not make all the processesnecessary to achieve shared goals fall into place bythemselves. This revised monograph and its prior editionoffer indispensable, practical guidance that is hard to find inone place in the clinical research literature. They directlyaddress the gap between evidence—knowing in a general waywhich techniques and interventions are in aggregateefficacious when applied to groups of patients—and how tooptimize pain control for the varied individuals in one’s ownspecific context where resources, clinical needs, patientpopulations, staff training, capacity to provide and monitorspecialized interventions, and culture all may differ from themean.2

The gap between theory and practice is often underestimated.When organizing an acute pain service over 20 years ago, Inaively believed that because they were so desirable, everythingconnected with such services should fall into place with littleeffort. Such was not the case. My colleagues and I foundourselves having to rewrite institutional policies; deal with

entrenched attitudes that often belittled the importance ofpain; introduce new duties to clinicians who already feltoverburdened; draft order sheets and assessment forms thatrequired submission to, discussion with, and approval frommultiple committees; and justify the institution’s financialinvestment.

Learning from my peers in the “pain community” that everyone of them had faced challenges, my self-doubts as to why Iwas so ineffective evolved into an understanding that anyimplementation of a complex process involves much time andeffort to overcome changing and often unanticipated obstacles.As the military strategist Carl van Clausewitz pointed out in hisclassic work On War, all campaigns involve unpredictableevents, imperfections in execution, and the independent will ofthe opposition. He wisely observed that “theories are there to beused as needed . . . never as laws and standards, but only—asthe soldier does—as aids to judgment.”3

The unique value of this monograph lies in its success storiesfrom an extraordinarily broad range of settings around theglobe. Its detailed accounts of how clinicians took generalprinciples of pain assessment and treatment and applied themsuccessfully in diverse contexts bring to mind the case-studyteaching method and (from personal experience) the classicworkbooks on which students of mathematics or science havelong relied. Posing a series of problems and walking throughtheir solutions in a step-by-step fashion, these workbooksallow readers to become comfortable applying abstract theoryto a number of examples, no two of which are identical. TheJoint Commission has long provided user-friendly resourcesto guide the application of evidence in clinical practice (e.g.,Putting Evidence to Work: Tools and Resources, 2003) and toimprove the quality of pain management (e.g., Improving theQuality of Pain Management through Measurement and Action,2003). Now, readers of the varied accounts in this volumeshould be even more prepared to deal with most if not allpain-related challenges facing them and their institutions.

v

Foreword

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vi

Yet unlike exercises in science or mathematics, the problemsfaced by clinicians treating pain involve people who sufferand toward whom we feel compassion. The aggregate ofwisdom shared by the clinicians whose efforts are presentedherein constitutes a powerful collective narrative.4 Humans’sense of empathy reflects the function of a system of mirrorneurons, premotor neurons that discharge when an animalacts and when the animal observes the same actionperformed by another animal.5 The mirror neuron systemallows us to refine our actions by letting us visualize andinternalize the success or failure of the actions of others. Byproviding examples of how clinicians from around the world

successfully attained shared goals by applying distinctstrategies tailored to local circumstances, The JointCommission has continued to foster a shared sense ofcommunity among pain clinicians worldwide. In so doing, itdeserves the gratitude not only of patients and their familiesbut also of we who care for them.

Daniel B. Carr, M.D., D.A.B.P.M.Saltonstall Professor of Pain ResearchDepartment of AnesthesiaTufts University Medical CenterBoston

References

1. Brennan F., Carr D.B., Cousins M.: Pain management: A fundamental human right. Anesth Analg 105:205–221, Jul. 2007.2. McNutt R.A., Livingston E.H.: Evidence-based medicine requires appropriate clinical context. JAMA 303:454–455, Feb. 2010.3. Howard ME, Paret P (eds and translators). Carl von Clausewitz On War. [originally published in 1832 as Von Kriege]. Princeton, New Jersey:

Princeton University Press, 1984: 158.4. Gundel H., Tolle T.R.: How physical pain may interact with psychological pain: Evidence for a mutual neurobiological basis of emotions and

pain. In Carr D.B., Loeser J.D., Morris D.B. (eds.): Narrative, Pain, and Suffering: Progress in Pain Research and Management, vol. 34. Seattle:IASP Press, 2005, pp. 87–112.

5. Rizzolatti G., Sinigaglia C.: Mirrors in the Brain—How Our Minds Share Actions and Emotions. New York City: Oxford University Press, 2006.

Providing excellent pain management is not easy. Thebarriers to addressing and relieving this syndrome can

seem overwhelming. As health care professionals, many of ushave had little practical training regarding pain assessmentand management. Our health care system can provideobstacles, largely related to difficulties with access to care.These difficulties include inadequate availability of painspecialists, regulations that limit access to opioids, andinadequate reimbursement for hospitals and centers trying todeliver true multidisciplinary pain care. Patients, theirfamilies, and the public at large struggle with the dual andconflicting messages they receive from childhood about thebenefits of stoicism, the need to suffer, and the more recentmedia messages of the latest celebrity becoming addicted topain medications.

Other added tensions are even more difficult to address. Ourtraining places great emphasis on objective data, yet painremains a subjective phenomenon, often with no obviousoutward signs. Simply put, we cannot “see” another’s pain.And although most health care professionals enter this fieldbecause they are compassionate individuals who truly want tohelp others, this tension can present ethical, and very human,dilemmas. Is the patient who is advocating firmly for reliefseeking analgesia or euphoria? Is the patient asking for aspecific agent and dose manipulating the clinician to escapehis or her emotional difficulties? How do we helpprofessionals see the sometimes subtle differences betweenseeking analgesia versus aberrant behaviors? No one,particularly health care professionals, wants to feel lied to orduped. How do we help professionals balance these fears andthis lack of certainty so the many patients with pain are notdisregarded to suffer silently?

Education alone is not enough. Standardized approaches areimperative. The Joint Commission has advanced the practiceof pain management immeasurably in these past decades byendorsing the need to treat pain and by developing standardsto support these efforts. Despite the sometimes overwhelmingcomplexity of providing excellent care, institutions can employvery specific strategies to improve the state of pain care in theirhealth care settings. This guide provides an exceptionalframework for health care leaders as they work to implementstrategies to improve pain care.

The first chapter provides an essential overview of pain,methods for comprehensive assessment, and techniques forprevention and management. The second chapter isindispensable for all clinical leaders, administrators, qualityimprovement experts, and others devoted to improving painmanagement in their settings in that it provides a step-by-step plan for meeting The Joint Commission and JointCommission International pain standards. Six chapters thatprovide extraordinary examples of institutions that haveimplemented these standards using comprehensive, and oftennovel, methods then follow these foundational chapters. Thediverse natures of these settings, including inpatient hospitals,outpatient centers, and extended care facilities, allow thereader to learn approaches that can be adapted for his or herown population of patients and site of care.

Another innovative feature of this text is the inclusion of twointernational efforts, one in Egypt and the other in Thailand.Reading about the efforts employed in centers around theworld can inspire clinical leaders to envision creative strategiesfor their own institutions. Despite very different health caresystems and cultures, we can all strive to alleviate the pain andsuffering of those entrusted to our care.

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Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition

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The exemplars in these chapters propose universal themes,and it is crucial that anyone working to improve painmanagement in his or her institution carefully consider thefollowing subjects: • Any efforts to address pain must be interdisciplinary. Any

professional who interacts with patients must be engaged,including nurses, physicians, pharmacists, physical/occupational therapists, chaplains, social workers, andothers. Consideration of the patient and family should beat the core of all these efforts.

• Assessment must be ongoing and incorporate the wholepatient, including physical, emotional, cultural, andspiritual domains.

• Therapy should be evidence-based and multimodal,employing pharmacologic and nonpharmacologictechniques to meet the patient’s individual needs.

• Pain strategies should address the entire continuum of care,from the physician’s office to inpatient departments,outpatient centers, home care programs, skilled nursingfacilities, and rehabilitation facilities. Electronic medicalrecords, if facile and accessible, allow this provision ofcontinuity of care.

• Although education alone is insufficient to promoteenhanced pain care, it is one pillar of any painmanagement program. Mentoring programs thatincorporate role models and coaches are crucial to moldingexcellent practices. Other creative educational solutionsinclude written pocket cards, posters, toolkits, in-services,more extensive courses, online educational programs, andtelevision programs directed to patients and their familymembers. All materials should be easy to locate. At

Northwestern Memorial Hospital, we have created a “painicon” on our intranet that allows professionals to accesspain-related materials in one easy location.

• Evaluation of outcomes must be ongoing and in real timeas much as possible; otherwise, leaders cannot measurechanges in time to foster improvements or address declines.

• All these interventions require institutional commitment.

Pain management has advanced astonishingly in the past fewdecades. Evidence for this progress includes the reduced useof inappropriate drugs, such as meperidine, propoxyphene, orplacebos. Additional support for this evolution includes thedevelopment of tools to assess pain in special populations,such as neonates and infants; children; cognitively impaired,ventilated patients; and those with dementia. And largely dueto efforts of The Joint Commission, more regular assessmentand documentation of pain occur.

Now we must more effectively act on this information. Thisbook is an outstanding reference for all medical, nursing,pharmacy, quality improvement, and other leaders workingto relieve pain within their settings of care. For thosepassionate in their quests to relieve pain, this book providesan essential guide or road map, making a complexphenomenon much easier to address.

Judith A. Paice, Ph.D., R.N., F.A.A.N.Director, Cancer Pain ProgramDivision of Hematology-OncologyFeinberg School of Medicine, Northwestern University

Pain. It can come on suddenly, disappear quickly, last formonths, or come and go. It can mildly disrupt a daily

routine or completely derail a person’s way of life. It can bedull or strong, tolerable or intolerable. Although theadjectives that apply to pain vary as much as the differenttypes, pain is fundamentally a complex and multidimensionalexperience that involves physical, psychological, emotional,and social factors.1,2

The International Association for the Study of Pain definespain as an unpleasant sensory and emotional experiencearising from actual or potential tissue damage or described interms of such damage.3 Although this is a commonlyaccepted definition, it focuses on the reaction to an injury.When couching the term from the perspective of the patient,Margo McCaffrey offers another definition that has becomethe “gold standard” of pain definitions is: “whatever theexperiencing person says it is, existing whenever he or shesays it does.”4(p.3) This definition implies that pain is subjectiveand open to interpretation. Unlike other physical indicators,such as temperature, blood pressure, lung capacity, and so on,pain cannot be measured directly or quantified neatly.Everyone experiences pain differently and just as every personis unique, so is his or her overall response and reaction topain. The pain experience, including an individual’sinterpretation of, response to, and level of suffering frompain, is strongly affected by that person’s attitudes, beliefs,and personality. Pain can be influenced by anxiety,depression, unpredictability, anticipation, loneliness, lack ofcontrol, and desire for attention.

In this chapter, we introduce the topic of pain, describing notonly its characteristics and treatment options but also theconsequences for undertreating pain, barriers to adequateevaluation and treatment, and systematic approaches toimproving pain management throughout an organization.

The Characteristics of PainWhen receiving care and treatment for an injury or illness, itis common for patients of all types to experience mild,moderate, or severe pain. Pain often begins as a biologicalevent in which electrical and chemical processes occur withinthe body as a response to noxious stimuli.5 A stimulus ofintensity sufficient to threaten tissue damage activatesspecialized nerves, termed nociceptors. Commonly, butinaccurately, such specialized nerve endings are called painreceptors, and the stimuli they generate are referred to as painstimuli. These terms are imprecise designations, because pain,as mentioned before, is a subjective experience.

Pain is sometimes present without an obvious source orcause. Inability to report or describe pain or to verbalize atall—such as in preverbal infants or people with troublecommunicating, including intensive care unit (ICU)patients—does not preclude the presence of pain.

Different Types of PainMany different types of pain exist. For example, pain can bethought of as chronic or acute. Chronic pain is typicallydefined as pain that occurs intermittently or persistently andlasts for at least three months.6 Such pain is debilitating andcan cause several negative impacts to the patient, includingreduced mobility, poor sleep, loss of strength, immuneimpairment leading to disease susceptibility, depression,anxiety, poor concentration, and impaired relationships withothers. In some cases, chronic pain can lead to pain-medication addiction. In addition, chronic pain has aneconomic impact, because it can lead to increasedabsenteeism from work and, ultimately, job loss.

Chronic pain occurs across all patient populations and mayor may not be associated with different diseases, recurringinjuries, and illnesses. In the United States, 76.5 million

3

Overview of Pain Management

Chapter 1

Ensuring a comprehensive, organizationwide approach topain management requires a clear commitment to the

many aspects and activities involved in pain management atevery level of the organization. To help foster thatcommitment, The Joint Commission and Joint CommissionInternational (JCI) have several standards related to painmanagement.* Spread across several chapters in eachprogram's accreditation manuals, these standards address thefollowing topics: • Patient rights regarding pain management (RI.01.01.01,

PFR.2.4, PFR.2.5)• Assessment and reassessment (PC.01.02.07, PC.8.10

[behavioral health], AOP.1.7, AOP.1.8)• Managing patient pain according to the treatment plan

(PC.02.01.01, COP.6, COP.7.1)• Ensuring comprehensive pain management after surgery

(PC.03.01.07)• Addressing pain in the hospice setting (PC.01.03.01)• Patient education about pain (PC.02.03.01, PFE.4)• Staff and licensed independent practitioner training and

competency (HR.02.02.01, HR.01.04.01, MS.03.01.03,COP.6, SQE.3)

• Discharge communication regarding pain management(PC.04.02.01, ACC.3)

The purpose of this chapter is to take a further look at whatThe Joint Commission and JCI require and to equiporganizations to meet those requirements. This chapterincludes information on the requirements that apply acrossall programs and highlights different requirements that applyto specific programs, including behavioral health

organizations, long term care organizations, hospitals, andhome care programs. Although this chapter includesstandards numbers related to the different topics discussed,organizations should consult their specific program's currentcomprehensive accreditation manual for the verbiage anddetailed requirements associated with these standards.

Patient Rights Regarding Pain Management (RI.01.01.01, PFR.2.4, PFR.2.5)Whenever a patient enters a health care organization, he orshe can and should expect to have certain rights respected.These include the right to be treated in a dignified andrespectful manner, the right to receive effectivecommunication from health care providers, the right to havehis or her cultural perspective respected and valued, and theright to have his or her privacy maintained. One criticalelement in respecting a patient's rights is ensuring that his orher pain is assessed, addressed, and managed. This isimportant for not only critical and chronic care but also careassociated with the end of life. The standards requireinternational and U.S. organizations to address the right ofpain management. Ambulatory care, critical access hospital,hospital, home care, and long term care organizations mustall address this issue.

To ensure a patient's rights to pain management arerespected, all health care providers should be committed toassessing, treating, and responding to changes in a patient'spain. As discussed in Chapter 1, these efforts should consider

33

Compliance with Joint Commission and JCI Standards

Chapter 2

* Note: The standards numbers referred to throughout this chapter are applicable to The Joint Commission’s 2010 comprehensive accreditation manuals for the various programsmentioned. Other standards numbers noted in this chapter that begin with the chapter abbreviations ACC, PFR, AOP, COP, PFE, or SQE, are from Joint CommissionInternational Accreditation Standards for Hospitals, Third Edition. (The fourth edition of the JCI hospital standards were published in July 2010 and are effective startingJanuary 1, 2011.) Refer to the most current editions of each manual for the exact wording of the standards discussed.

Approaches to Pain Management: An Essential Guide for Clinical Leaders, Second Edition

34

the patient's needs, cultural perspectives, and concerns. Thoseindividuals caring for a patient should be his or her bestadvocate in ensuring that pain is acknowledged andaddressed.

Assessment and Reassessment(PC.01.02.07, PC.8.10 [behavioralhealth], AOP.1.7, AOP.1.8)The identification and treatment of pain are importantcomponents of the plan of care. To that end, providers mustscreen patients to identify those in pain. When pain isidentified, the patient should be further assessed based on hisor her clinical presentation and in accordance with the care,treatment, and services the organization provides.

The goal of assessment is to determine the care, treatment,and services that will meet the patient's initial andcontinuing needs. Joint Commission standards—viaPC.01.02.07—require all programs except laboratories toperform initial assessments to determine the presence of pain.JCI standards address this topic in AOP.1.7 and AOP.1.8.

The pain-screening process is critical. In some cases, healthcare providers, such as home care providers, are the onlypoint of contact a patient has with the health care system. Aneffective screening process allows providers to identifypatients in pain and ensures they receive higher levels ofassessment and subsequent treatment when warranted.

Typically, a pain screening is part of the initial assessmentprocess. Should pain be identified within a screening, a morecomprehensive pain assessment is necessary. This can be donewithin the organization, or the organization can refer thepatient elsewhere for such an assessment. For example, if abehavioral health organization recognizes that painmanagement is an important part of its patients' care but also

recognizes that it lacks the skill to thoroughly assessindividuals who report pain, it may choose to refer suchindividuals to a local clinic and then coordinate as a team toaddress the individuals’ physical and mental health issues.This concept is addressed in PC.8.10 for behavioral healthorganizations.

Should an organization conduct the comprehensive painassessment, it must be consistent with the scope of care,treatment, and services the organization provides as well asthe patient's condition. This assessment must use methods toassess pain that are consistent with the patient’s age,condition, and ability to understand. As mentioned inChapter 1, each organization must develop and define itsown criteria for assessment based on the needs of its patients.Some possible elements to assess for include pain intensity,location, quality, temporal characteristics, aggravating andalleviating factors, present pain regimen and effectiveness,pain management history, effects or impact of current pain,meaning of pain, patient goals and expectations, and physicalexam/observation of the site of pain (see Sidebar 2-1 on page35).

Using pain-screening tools, such as those discussed inChapter 1, can help meet Joint Commission and JCIrequirements regarding assessment, although specific tools arenot required. When choosing appropriate assessment toolsand strategies, organizations should keep in mind theindividuals they are assessing. For example, assessment toolsfor children will vary from those used on adults. Likewise, anassessment of chronic pain in the ambulatory setting willdiffer from that of acute pain in the intensive care unit.

A critical element in the assessment process is reassessment.Because of the changing nature of pain and the constantinput of physical, psychological, emotional, and culturalfactors, the presence of pain and its intensity, duration, andquality must be regularly reassessed. The depth and frequencyof assessment depends on a number of factors, including thepatient's needs, the program goals, and the care, treatment,and services the organization provides. Organizations mustdefine the depth and frequency of assessment for themselves.

Documenting AssessmentTo help ensure consistent pain management that responds topatient needs, organizations should consider documentingpain assessments. A variety of ways to document painassessment and management activities is available. Some

To help address communication about pain, an organization may

want to place posters in exam rooms, asking if patients have pain

and, if so, urging them to discuss it with their health care

providers. Such posters are especially appropriate in clinic

settings where providers may be less likely to ask patients about

pain—for example, in eye, immunization, or well-baby clinics.

TIP

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The University of WisconsinHospital and Clinics

Chapter 5

SettingThe UWHC is a 493-bed tertiary care medical center, aLevel 1 Trauma Center, and a National CancerInstitute–designated comprehensive cancer center located inthe Midwest. It serves patients in Wisconsin and thesurrounding states, offering a wide array of medical andsurgical services. The hospital annually admits, on average,nearly 25,000 inpatients and logs approximately 40,000emergency department (ED) visits.

The UWHC is one of three major organizations, along withthe University of Wisconsin (UW) School of Medicine andPublic Health and the UW Medical Foundation, thatcompose the UW Health organizations.

Clinical ServicesUWHC pain specialists diagnose and treat pain syndromes ofall types, including muscular, skeletal, neuropathic,postoperative, and cancer pain.

A full range of clinical services in pain management isoffered. The Inpatient Pain Consultation ManagementService optimizes pharmacologic and nonpharmacologictreatments. The Anesthesiology Acute Pain Service assists in

the management of acute pain due to surgery, trauma, orother medical conditions. Palliative Care and SymptomManagement includes pain and symptom management forpatients with cancer and/or terminal illness as well asadvanced care planning and emotional support of patientsand families. The Addiction Medicine Consultation Serviceoffers inpatient and outpatient consultation for alcohol andother drug assessments. Integrative Medicine offers acombination of conventional and complementary medicine,including acupuncture, therapeutic massage, and mind-bodytherapies. The UW Pain Treatment and Research Center is acomprehensive outpatient facility, the goal of which is toreduce or eliminate pain while improving patient well-being,physical function, and independence.

The UW Health pain clinics offer the same broad range ofpain management treatments as the hospital does, only on anoutpatient basis. Health care professionals must refer patientsto enter the UW Health pain clinics. Teams of physicians,midlevel providers, rehabilitation therapists, psychologists,and nurses who work in concert toward pain reduction andfunctional restoration treat outpatients. Physiatrists andneurologists are active participants in pain care, andinterspecialty referrals are readily available when furtherexpertise is needed.

The University of Wisconsin Hospital and Clinics (UWHC) is a recognized leader in pain management. It is not only aMagnet Hospital but a recipient of the American Pain Society’s Center of Excellence Award. What started in 1991 asan effort to improve pain management has evolved into a campaign to institutionalize it. The standards for painassessment and management for all patients are now part of routine care at all UWHC settings. Nearly two decadeslater, the Patient Care Pain Team continues to keep pain management at the forefront by examining andreexamining pain management issues and practices with the goal of continuous improvement. Key elements of theprogram are the use of champions, evidence-based practice guidelines, and outcomes monitoring. Today, numerouspain management variables are measured and monitored through a combination of daily, monthly, and annualformats.

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Organizational CommitmentThe UWHC’s commitment to pain management began in1991, when a group of interested nurses, physicians, andpharmacists formed a pain management quality improvement(QI) team. A pain management clinical nurse specialist(CNS) and physician co-lead the Patient Care Pain Team,which still exists today. It comprises approximately 50 staffmembers from across the organization, including nurses,pharmacists, physicians, social workers, psychologists, andother staff from inpatient and outpatient settings.

The team’s goal is to improve pain management througheducation, research, and the development of programsintended to improve clinical practice. The approach is tointegrate pain management into existing structures andprocesses rather than to create pain programs in isolation.The American Pain Society (APS) QI guidelines,1 which havesince been updated, were used as a framework for the team’swork plan.

In addition to revising numerous policies and procedures, theteam developed an educational campaign and a longitudinaloutcomes monitoring program. The standards for painassessment and management for all patients have becomepart of routine care.

The team’s efforts snowballed into a sustained program toinstitutionalize pain management. Key elements of theprogram at the UWHC have been the use of champions(both peers and leaders), evidence-based practice guidelines,and outcomes monitoring. An approach calling for a broad,long-term plan combined with smaller, problem-focusedprojects has continued to keep a variety of staff interestedand active in the team’s work nearly two decades later.

See “Use Evidence to Ensure Standardized, AppropriateTreatment” in Chapter 1, page 9, for a description ofevidence-based practice.

Today, UWHC staff aim to reduce pain severity patientsexperience through the following elements:• An interdisciplinary work group that examines and

reexamines pain management issues and practices with thegoal of continuous improvement

• A standard for pain assessment and documentation toensure that pain is recognized, documented, and treatedpromptly

• Information about analgesics and nonpharmacologicalinterventions that is readily available to clinicians as theyplan care

• Clearly defined accountability for pain management• Ongoing educational opportunities in pain management

for staff, patients, and families• Explicit policies and procedures to guide the use of

specialized techniques for analgesic administration• Continuous outcome evaluation and improvement

This work aims to provide a multilevel evidence-basedsystems approach to fulfill Joint Commission pain assessmentand management standards as well as the institutionalresponsibilities for pain management set forth by the Agencyfor Healthcare Research and Quality and the APS, fromwhich Joint Commission standards were developed.

Beyond UWHC FacilitiesThe UWHC’s commitment to pain management extendsbeyond its facilities. Staff routinely lecture on pain care topicsat hospitals throughout the region and also present lectureson pain care and offer rapid consultations to local health carenetworks and group practices, including nursing facilities andthe state correctional system.

The UWHC hosts the annual five-day Comprehensive PainBoard Review Symposium, which has been offered since2002. More than 100 physicians from across the countryattended the symposium in 2009. It also presents a courseabout basic pain management skills specifically for primarycare providers.

Staff have served on regional and national pain society boards.Specifically, UWHC staff members served on the WisconsinPain Initiative, which was responsible for getting all three majorhealth care state licensing boards to approve and post positionstatements on their respective Web sites, including the MedicalExamining Board of Wisconsin, the Wisconsin Board ofNursing, and the Wisconsin Board of Pharmacy.

UWHC staff have served on various task forces to writepolicies and guidelines for local, state, and national pain care.As an example, staff members were involved in thedevelopment of guidelines on chronic pain for the WisconsinMedical Society and the APS clinical practice guideline onfibromyalgia and acute postoperative pain. Staff membersalso serve on the APS Quality of Care Task Force responsiblefor national pain QI guidelines. Staff members work with

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Medical record audits and patient surveys are conducted toexamine staff practice patterns and patient outcomes. As anexample, in 2009, the most frequent diagnostic category ofpatients seen was medical-surgical (noncancer), as depicted inFigure 5-7, above. Seventy-six percent of consults hadhistories of chronic pain, consistent with the previous fouryears of data. Medical record audits are used to track thenature and frequency of documented pain assessment andanalgesic prescribing as well as staff administrative practices.For example, Figure 5-8, page 108, shows the percentage ofpain interventions recorded within 24 hours of admission forpatients seen between September 2009 and May 2010. Inaddition, patients are routinely surveyed regarding theirexperience of pain intensity and relief, the impact of pain ontheir function and mood, the helpfulness of information theyreceived about pain treatment, their ability to participate inpain treatment decisions, their satisfaction with painmanagement, and their use of nonpharmacological strategies.As an example, Figure 5-9, page 109, shows the percentage of

pain relief recorded within 24 hours of admission for patientsseen between September 2009 and May 2010.

Documentation of pain reassessments is monitored daily. Thedata are fed back to nurse managers and CNSs to share withunit-based pain resource nurses so that they can worktogether to address practice deficiencies. On a monthly basis,the types of pain interventions being provided and levels ofpain relief reported by patients are summarized in graphicdisplays by level of nursing unit and are available in an onlineshared network file. These data—along with quarterlysummaries of Press Ganey, Inc., patient satisfaction surveys ofpain care and results from specific QI projects—are sharedannually with nursing and medical leadership in the form ofa pain management report card. Indicators for utilization ofpain services, which measure the volume and nature ofinpatient pain consults, also are provided as an annual reportto track trends in the nature of pain management issues andas secondary referrals to pain specialists.

Figure 5-7. Principal Diagnosis, 2009

Source: The University of Wisconsin Hospital and Clinics. Used with permission.

In 2009, the most frequent diagnostic category of patients seen was medical-surgical (noncancer). Seventy-six percent ofconsults had histories of chronic pain, consistent with the previous four years of data.

Surgical Cancer

5%Psychiatry

6%

Medical Non-cancer

52%

Medical Cancer

6%

Surgical Non-cancer

31%

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Examples of more specific ad hoc measures obtained infocused pain QI studies performed in 2009 include time-to-analgesia in the ED, the methods of analgesia provided forreduction of dislocation and fracture in the ED, the types ofgoals patients had in watching specialized televisionprogramming designed to help alleviate pain and anxiety, andthe impact of using this programming.

Progress on all avenues of pain improvement is reflected inmonthly team meeting minutes, which are distributed toapproximately 50 interdisciplinary staff and 45 pain resource

nurses, who are expected to disseminate the information totheir colleagues.

The Nursing Quality Council now tracks and reportsNursing Sensitive Outcome indicators, including patientsatisfaction with pain management, in a newsletter titled Focus on Quality, which is shared with all nursing staff.

The Pain Service CNSs and pharmacist review and report allPatient Safety Net events related to analgesics to theMedication Safety Committee on a quarterly basis.

Figure 5-8. Percentage of Pain Interventions, 24 Hours

Source: The University of Wisconsin Hospital and Clinics. Used with permission.

This measure is the percentage of pain interventions recorded within 24 hours of admission for patients seen betweenSeptember 2009 and May 2010. The unit arrival date/time is used if present. Population includes inpatient direct care unitsonly. It excludes first-day surgery, ED, and all ambulatory care areas. (IM, intramuscular; IV, intravenous; PCA, patient-controlled analgesia; subcu., subcutaneous)

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References

1. Gordon D.B., et al.: American Pain Society recommendations for improving the quality of acute and cancer pain management: American PainSociety Quality of Care Task Force. Arch Intern Med 165:1574–1580, Jul. 2005.

2. Waters D., Sierpina V.S.: Goal-directed health care and the chronic pain patient: A new vision of the healing encounter. Pain Physician9:353–360, Oct. 2006.

3. Farrar J.T., et al.: A comparison of change in the 0–10 numeric rating scale to a pain relief scale and global medication performance scale in ashort-term clinical trial of breakthrough pain intensity. Anesthesiology 112:1464–1472, Jun. 2010.

4. Paice J.A., et al.: Efficacy and safety of scheduled dosing of opioid analgesics: A quality improvement study. J Pain 6:639–643, Oct. 2005.5. Management of Postoperative Pain Working Group: VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain. Veterans

Health Administration, Jul. 2001. Updated May 2002. http://www.healthquality.va.gov/pop/pop_fulltext.pdf (accessed Aug. 5, 2010).6. Registered Nurses’ Association of Ontario: Assessment and Management of Pain. 2002. http://www.rnao.org/Page.asp?PageID=924&ContentID=720

(accessed Mar. 31, 2010).7. Waddell D.L., Dunn N.: Peer coaching: The next step in staff development. J Contin Educ Nurs 36:84–89, Mar.–Apr. 2005.8. Personal communication, Dec. 18, 2009.

Figure 5-9. Percentage of Pain Relief, 24 Hours

Source: The University of Wisconsin Hospital and Clinics. Used with permission.

This measure is the percentage of pain relief recorded within 24 hours of admission for patients seen between September2009 and May 2010. The unit arrival date/time is used if present. Population includes inpatient direct care units only. Itexcludes first-day surgery, emergency department, and all ambulatory areas. (PRN, as needed)

As cancer treatments grow more technologicallyadvanced, increasing numbers of patients are turning to

low-tech, complementary therapies to combat their pain(from the disease and the treatments) and other cancer sideeffects that can limit quality of life. Studies have shown thatapproximately 70% to more than 90% of cancer patientshave used at least one form of complementary or alternativemedicine.1,2

However, when patients seek such treatments on their own, itcan be difficult to determine which therapies andpractitioners can truly help and which cannot—and whichcould even exacerbate the patients’ conditions. Additionally,physicians should know about any complementarytreatments a patient is receiving: A 2007 AARP survey ofpeople over 50 found that 63% of respondents usedcomplementary medicine, but nearly 70% of those peoplehad not told their physicians about it. The most commonreasons cited were that the physician never asked, that thepatients did not realize that they should tell the physician,and that there was not enough time during the visit.3

Therefore, some forward-thinking hospitals are incorporatingcomplementary therapies into their traditional treatmentprograms so patients and physicians know the therapies aresafe and effective and will work in tandem with other clinical

treatments. Wattanosoth Hospital/Bangkok Cancer Hospitalis one such facility, offering its patients a wide range ofcomplementary medicine, education, and self-managementstrategies to manage their pain.

SettingBangkok Hospital Medical Center (BMC) is a privatemedical campus that provides comprehensive medical carethrough multidisciplinary teams of specialists. With its fourhospitals, 398 beds, and 3,000 daily outpatients visiting abroad range of specialized clinics, BMC is equipped with awide range of diagnostic and treatment facilities not generallyavailable at local hospitals in Thailand, such as computedtomography (CT) scans, magnetic resonance imaging, digitalmammograms, and positron-emission tomography(PET)/CT scans utilizing a cyclotron.

One hospital in the medical center is WattanosothHospital/Bangkok Cancer Hospital, which is entirely devotedto providing cancer patients with a combination of traditional,modern, and complementary cancer treatment therapies as wellas clinical research of the disease. This is Thailand’s first privatehospital focused solely on the treatment of cancer.

Chapter 4 of this book discusses the efforts of anotherinternational hospital—Dar Al-Fouad in Cairo, which in

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Wattanosoth Hospital/Bangkok Cancer Hospital

Chapter 8

A cancer diagnosis is the beginning of an emotionally and physically painful journey for patients and families.However, treating the physical pain can ease the mental stress, and providing emotional and spiritual support canmake the physical pain more tolerable. Knowing this, caregivers at Wattanosoth Hospital/Bangkok Cancer Hospitalsought to create a program that treated the whole patient, helping him or her to manage his or her pain through acombination of traditional medicine, complementary therapies, and mood elevation and moral support. The result is aprogram that addresses medical and emotional needs for inpatients and outpatients. Patients not only feel less pain,they feel that their caregivers are listening to them and answering their concerns, and they feel empowered to maketheir own pain management decisions.

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2005 received accreditation from Joint CommissionInternational. It became the first hospital in Egypt andAfrica to do so.

Palliative Care ServiceMost cancer patients suffer from pain, so the palliative caredepartment plays an important role in treatment. Thedepartment includes traditional pain management therapiesalong with complementary medicine, as well as programsdesigned to educate patients and families about theirtreatments so they may take control of their health care.

The Pain Management Program includes the following:• Acute and chronic pain assessment of symptoms• Patient-controlled analgesia consultation• Medication and adjuvants• Pharmacy consultation• Symptom management• Nutrition management• End-of-life care

Additionally, says Virginia Maripolsky, assistant chiefexecutive officer, Nursing Affairs, for WattanosothHospital/Bangkok Cancer Hospital, the pain managementprogram includes nonpharmacological established therapies,such as acupuncture, exercise, and massage, as well as thefollowing newer strategies that have given patients positiveresults in pain management.

DistractionPalliative care providers have found that distraction, or takinga patient’s mind off the pain, can be very helpful, particularlywhile the patient is undergoing chemotherapy. Some of thedistractions provided include the following:• Craft kits for patients to work on while they receive

chemotherapy; they may continue the crafts during theirnext scheduled visits. Nurses are trained to teach the crafts.Most popular are crystal embroidery beads that make keychains, toy animals, and other small items.

• Individual televisions and headsets for each patient

• A variety of magazines and books in a variety of languages aswell as puzzles, such as crosswords or Sudoku. A selection ofBuddhist, spiritual, and inspirational books is also available.

• A particular brand of sour hard candy, a Thai specialtytreat that offers a blend of sweet, sour, and salty flavors tohelp reduce nausea and vomiting (not offered to patientswith diabetes or kidney problems)

AromatherapyAromatherapy is the treatment or prevention of disease by theuse of essential oils. Two basic mechanisms are offered toexplain the purported effects. “One is the influence of aromaon the brain, especially the limbic system through theolfactory system,” Maripolsky explains. “The other is thedirect pharmacological effects of the essential oils. Becausemany essential oils are potent antimicrobials, they can beuseful in the treatment of infectious disease.”

The modes of application of aromatherapy include thefollowing:• Aerial diffusion: For environmental fragrance or aerial

disinfection • Direct inhalation: For respiratory disinfection,

decongestion, and expectoration as well as psychologicaleffects

• Topical applications: For general massage, baths,compresses, and therapeutic skin care

Following are the benefits that aromatherapy is believed toproduce:• Aromatherapy massage helps increase basal metabolic rate;

induce relaxation; increase excretion of toxic products;increase circulation and lymphatic drainage; reduce anxiety,stress, and pain; and increase skin integrity.

• Inhalation helps respiratory problems, promotes expulsionof secretions from respiratory infections, reduces stress andanxiety, and promotes a good feeling.

• Aromatherapy baths help promote relaxation, reduce stressand anxiety, reduce heat and inflammation, increasecirculation and lymphatic system, and reduce pain andinflammation.

• Topical application reduces fluid and serum; reduces heat,pain, and stress; and promotes relaxation.

• Sitz baths and soaking help infections of the urinary andgenital area.

• Creams promote healing, act as lubricants, and maintainhumidity.

A short overview of another non–U.S. hospital offering a range of

both pharmacologic and nonpharmacologic treatments is available

in the Online Extras at http://www.jcrinc.com/APM10/Extras/.

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