Changing acute pain management outcomes in surgical patients - Research

AORN Journal, Feb, 2003 by Gwen D. Sherwood, Jeanette A. McNeill, Patricia L. Starck, Geri Disnard

Clinicians worldwide long have pondered the problem of pain; however, inadequate pain management continues to be a pervasive clinical problem for hospitalized patients, resulting in physiological, psychological, and financial consequences. (1) Continuing pain is associated with morbidity and delayed discharge. Slowed healing, higher complication rates, anxiety, sleep disturbance, increased suffering, and lowered quality of life are significant sequelae. (2) Substantial economic impact results from longer lengths of stay in the hospital and unscheduled readmissions related to unrelieved pain. (3)

Though the principle of optimal pain management is accepted universally, pain management has a low priority in overall postoperative care. Changing the behavior of clinicians has been difficult. Postoperative monitoring of urine output, blood pressure, respiration, and temperature has been required for documentation, but monitoring of pain was not required until recent efforts were initiated to include pain as the fifth vital sign. Evidence-based guidelines to help clinicians monitor and manage pain have been distributed widely by concerned organizations, such as the American Pain Society; the Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research; and the Oncology Nursing Society. (4) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards say patients have the right to appropriate assessment and management of pain. (5)

Evidence indicates, however, that distribution of guidelines alone has not altered practice, leading many to question how to produce outcomes consistent with accepted guidelines. (6) A report from nine acute care hospitals revealed no difference in either short-term outcomes of patient-rated pain or patient satisfaction with pain management one and one-half years after the advent of AHRQ guidelines. A repeat measure two years later still indicated no difference. (7) Analgesics continue to be ordered for an on-demand or PRN regimen, leading to a peak and trough experience that contributes to inadequate pain relief. (8) The undertreatment of pain is so prevalent that it has been declared a medical error deserving the same attention as other incidents of error. (9)

Postoperative pain is a significant problem for hospitals, and the majority of patients who report pain are recovering from surgical intervention. What happens in the perioperative period has a significant effect on pain management outcomes, thus efforts to achieve successful outcomes must begin preoperatively and continue through discharge. This article presents the results of a secondary analysis of two studies that describe the pain experience and measure satisfaction with pain management outcomes of patients undergoing surgical intervention. By selecting postoperative patients from a larger sample, investigators were able to specifically examine the characteristics of the pain experience and patient satisfaction with pain management after surgery to develop more effective pain management for surgical patients.

INFLUENCES ON PAIN MANAGEMENT OUTCOMES

Evidence indicates that in spite of readily available pain management guidelines, the care of postoperative patients lags in effective pain management, surgical patients lack information, clinicians often misjudge pain intensity, and vulnerable populations remain at higher risk. Nonpharmacological interventions that enhance analgesics are underused. Patients continue to report that they expect pain after surgery and experience moderate to high pain levels, yet they report relatively high satisfaction overall.

Pain relief and patient satisfaction. Pain relief and patient satisfaction frequently are used to determine the effectiveness of pain management. Pain relief is evaluated by patient self-report of pain intensity, worst pain, interference with activities, and overall pain. Patient satisfaction measures how well patients' expectations were met and their overall perceptions of pain management. Patient satisfaction is an important but elusive outcome indicator, and informed patients may choose other providers if their expectations are not met. Neither measure alone can give an accurate picture. Patients who are in pain and who feel clinicians are paying attention may indicate they are satisfied with the care received if they do not know that better pain management is possible. Conversely, patients may report pain relief but not feel satisfied with the care received. (10)

Pain relief has been studied since ancient times, but patient satisfaction as an outcome measure is a recent focus in health care. (11) Both are subjective assessments but fairly good indicators of quality of care. Both are dependent on myriad factors and measured with similar scales (eg, 0% to 100%, zero to 10). Patient satisfaction rating is an intentionally subjective, personal evaluation of health care services and providers that cannot be determined by direct observation. Satisfaction scores are related more to psychosocial aspects of care (eg, communication) than to technical aspects, which are better reflected in pain relief measurements.