a victorian quality council presentation acute pain

A Victorian Quality Council presentation

Acute Pain Management Measurement Toolkit

Wendy McDonald Acute Pain Nurse

St Vincent’s Hospital

Eliza BellAcute Pain Nurse

The Alfred Hospital


The Problem

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

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

• Effectiveness of Pain Relief

• Minimization of Side-Effects

• Minimization of Complications


Measuring and Recording Pain

Key Elements•Consistent tools used•Patient involvement•Baseline assessments•‘Standardised’ scoring system•Functional Activity Score•Core Chart Components


Patient Education Brochure


Pain Assessment

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

Visual Analogue Scale

Verbal Numeric Rating Scale

Faces Pain Scale

Behavioural Rating Scale

Worst PainImaginableNo Pain Worst PainImaginableNo Pain

All result in a 0 – 10 ‘Pain Score’


Beyond Pain Intensity…

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

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

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 ofcustomisation for each patient and this requires some learning of new skills by clinical staff.


Tools for Measuring Function

Functional Activity Score (FAS) This is an activity related score. Your patient is asked to (orattempt 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 LimitationB – Mild LimitationC – Severe Limitation* Relative to Baseline

The patient response to the chosen activity should berecorded with each pain score.


Tools For Measuring Function

Reporting TriggerIt was considered that two consecutive FAS scores of C would

reflect a sustained level of inadequate analgesia, sufficient tojustify seeking further assistance in managing the patient


Tools for Monitoring Adverse Events…


Adverse Events Associated With Acute Pain Management

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

Sedation Score


Sedation & Respiratory Depression

Standardized Sedation ScaleAn assessment of depth of ‘sleep’Routine Charting of Sedation ScoreReportable Thresholds

Bedside CareRoutine AuditIndicator

0 = Awake, Alert1 = Mild Sedation 1S = Asleep

2 = Moderate Sedation, unable to remain awake3 = Difficult to rouse

Easy to Rouse

Sedation Scale


Sedation Scale

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.

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1


Motor Block - Assessment

Neurological AssessmentBasic Assessment

Bromage Score• Widely used• Easy to consistently apply• Charting to detect change• Reportable events

Bedside CareRoutine AuditIndicator

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

Reportable– Depends on change– Consideration of clinical circumstances


Other Major Adverse Outcomes or Complications


Core Chart Components

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

All pain scores are now 0–10 no matter which tool is chosen to use with the patient

VAS

NRS

Faces

Behavioral

Special Analgesia Chart

Thermic Chart


Routine Ward Charting


Chart Modifications

VASNRSFacesBehavioral


Analgesia Treatment Summary Form

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.

QCIndicatorReporting

Inter-hospital Performance

Review

Hospital / APS Review

Ward or Unit Audit and Review

Bedside Assessment – Vital Observations

ANNUAL

ANNUAL

3-6 MONTHLY

DAILY

HOURLY

CONTINUAL

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IV

Information Pathways Toolkit


Where are we now?

• 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.

HoweverThis is the first important step to improved pain management

a victorian quality council presentation acute pain

Documents