Pain management QI recommendations updated
They stress team, multimodal approach
To improve the quality of acute pain and cancer pain management, health care providers must do more than merely improve pain assessment and documentation, say new recommendations issued by the American Pain Society (APS) in Glenview, IL. Instead, a continuous quality improvement (QI) approach should emphasize a scientific team effort to change the way pain is treated — and pharmacists are a critical part of that team.
The 2005 recommendations on improving the quality of acute pain and cancer pain management are an update of the 1995 APS QI Guidelines. The new recommendations are based on a comprehensive literature review, experience, and expert consensus, says Debra B. Gordon, RN, MS, senior clinical nurse specialist in the Department of Nursing at the University of Wisconsin Hospital and Clinics in Madison. Gordon also acted as chair for the APS task force.
The data say that pain management still is inconsistent at best throughout the country, she reports. Although there has been "enormous progress in making pain visible," such as better screening and assessment of pain, health care is recognizing that some of its usual routines for pain management are inadequate and should be changed.
"We shouldn’t rely solely on prn or rely solely on unimodal drugs like Demerol [meperidine]," Gordon explains. "But what do you do then? How do we change the way we treat pain? That gets a little trickier."
"That’s the emphasis of the new recommendations to me," she says. "People now have to look at incorporating evidence-based regimens into clinical practice and change their treatment patterns."
To reach the final update, the recommendations received input from a wide range of health professionals. The 11-member task force that drafted the recommendations included four nurses, three physicians, two psychologists, one doctor of pharmacy and one pharmacologist — all APS members. The fifth draft of the recommendations was placed on the APS web site, and more than 3,000 APS members were invited to comment on it. In addition, five people with expertise in health care quality from organizations such as the Joint Commission on the Accreditation of Healthcare Organizations, the American Medical Association, and the National Committee on Quality Assurance served on an advisory panel that commented on the final draft. The final recommendations were published in the July 25 issue of the Archives of Internal Medicine.
The importance of a team approach
The recommendations emphasize the use of a multisystems approach within a health care organization, saying that individuals can rarely effect system and practice changes by themselves. Teams may be large executive committees or small "microsystems" of care, the guideline authors say.
Pharmacists are an important part of this team, Gordon says. "Medication safety is a huge priority in the health system, and as new analgesics come on board and more rational polypharmacy is required, the pharmacist is absolutely critical to making sure that the regimens are safe and appropriate." Pharmacists have the ability to get involved in pain clinics or pain consultation services as well.
The recommendations also stress the use of a multimodal therapy for treatment of acute pain and cancer pain. "The choice of analgesic should be based on the type and severity of pain, the impact of pain on physical and emotional functioning, and the individual’s response to empirical trials," the authors say. "Opioids and nonsteroidal anti-inflammatory drugs should be provided in an around-the-clock dosing schedule during the first several days after major surgery to prevent and control moderate-to-severe acute pain."
Cancer pain also should be treated in a proactive manner, the authors say. This should include in most situations "the use of both scheduled and as-needed analgesics, along with nonpharmacologic interventions such as teaching patients about pain control options, side effects, and realistic goals."
Simply giving more opioid in response to calls for action to improve pain management is a concern. "That was clearly not the message that was meant to be given by the APS or the JCAHO [pain management standards]," Gordon says, "and it can sometimes be inappropriate." For many people, the answer may be adjuvant analgesics, it may be patient education, or it may be nonpharmacologic interventions. "Customizing care to the needs of each individual patient is critical to effective pain management."
Current data, however, indicate that when opioids are used, they often have been underdosed. "Physicians will acknowledge they underprescribe," she says. "There is fear and concern over regulatory scrutiny, so we do tend to underuse opioids. But simply increasing the opioid and giving more people narcotics is not the answer."
Once again, pharmacists are needed to help measure the effectiveness of these multimodal regimens. "They will need to look at drug utilization reviews, for example," Gordon says.
"Whether you are at the bedside taking care of a patient or whether you are looking at setting up safe systems that drive people’s practices," she says, "it’s interdisciplinary at every level."
To improve the quality of acute pain and cancer pain management, health care providers must do more than merely improve pain assessment and documentation, say new recommendations issued by the American Pain Society (APS) in Glenview, IL.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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