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
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
Quality of Pain Management
• Effectiveness of Pain Relief
• Minimization of Side-Effects
• Minimization of Complications
A Victorian Quality Council presentation
Measuring and Recording Pain
Key Elements•Consistent tools used•Patient involvement•Baseline assessments•‘Standardised’ scoring system•Functional Activity Score•Core Chart Components
A Victorian Quality Council presentation
Patient Education Brochure
A Victorian Quality Council presentation
Pain Assessment
Pain Intensity•Subjective Scoring Systems
Functional Impact of Pain•Pain on Movement•Functional Activity Score
Monitoring For Side Effects and Complications…
A Victorian Quality Council presentation
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’
A Victorian Quality Council presentation
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…
A Victorian Quality Council presentation
Pain Assessment
Pain Intensity–Subjective Scoring Systems
Functional Impact of Pain–Pain on Movement–Functional Activity Score
Monitoring For Side Effects and Complications…
A Victorian Quality Council presentation
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.
A Victorian Quality Council presentation
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.
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
A Victorian Quality Council presentation
Tools for Monitoring Adverse Events…
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
Tools for Measuring and Managing Adverse Events
Sedation Score
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
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.
X
1
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
Motor Block Assessment– Special Analgesia Charting
Reportable– Depends on change– Consideration of clinical circumstances
A Victorian Quality Council presentation
Other Major Adverse Outcomes or Complications
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
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
A Victorian Quality Council presentation
Routine Ward Charting
A Victorian Quality Council presentation
Chart Modifications
VASNRSFacesBehavioral
A Victorian Quality Council presentation
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
I
II
III
IV
Information Pathways Toolkit
A Victorian Quality Council presentation
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
Top Related