American Pain Society Recommendations for Improving the Quality of Acute and Cancer Pain Management

Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, United States
Archives of Internal Medicine (Impact Factor: 17.33). 08/2005; 165(14):1574-80. DOI: 10.1001/archinte.165.14.1574
Source: PubMed


The American Pain Society (APS) set out to revise and expand its 1995 Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain and to facilitate improvements in the quality of pain management in all care settings.
Eleven multidisciplinary members of the APS with expertise in quality improvement or measurement participated in the update. Five experts from organizations that focus on health care quality reviewed the final recommendations. MEDLINE and Cumulative Index to Nursing and Allied Health Literature databases were searched (1994-2004) to identify articles on pain quality measurement and quality improvement published after the development of the 1995 guidelines. The APS task force revised and expanded recommendations on the basis of the systematic review of published studies. The more than 3000 members of the APS were invited to provide input, and the 5 experts provided additional comments. The task force synthesized reviewers' comments into the final set of recommendations.
The recommendations specify that all care settings formulate structured, multilevel systems approaches (sensitive to the type of pain, population served, and setting of care) that ensure prompt recognition and treatment of pain, involvement of patients and families in the pain management plan, improved treatment patterns, regular reassessment and adjustment of the pain management plan as needed, and measurement of processes and outcomes of pain management.
Efforts to improve the quality of pain management must move beyond assessment and communication of pain to implementation and evaluation of improvements in pain treatment that are timely, safe, evidence based, and multimodal.

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Available from: Debra B Gordon, May 27, 2014
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    • "Nurses often underestimate patients' pain (Idvall et al., 2005; Sloman et al., 2005) and vital signs can be influenced by other factors besides pain (Arbour and Gelinas, 2010; Gelinas and Arbour, 2009). Several guidelines advise healthcare professionals to administer additional analgesics when patients report an NRS score greater than 3 or 4 (Gordon et al., 2005; Hartrick et al., 2003; Max et al., 1995; VMS, 2009). In a previous study, we reported that patients with NRS scores of 4, 5, or 6 vary in the interpretation of their score (Van Dijk et al., 2012). "
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    ABSTRACT: In postoperative pain treatment patients are asked to rate their pain experience on a single uni-dimensional pain scale. Such pain scores are also used as indicator to assess the quality of pain treatment. However, patients may differ in how they interpret the Numeric Rating Scale (NRS) score. This study examines how patients assign a number to their currently experienced postoperative pain and which considerations influence this process. A qualitative approach according to grounded theory was used. Twenty-seven patients were interviewed one day after surgery. Three main themes emerged that influenced the Numeric Rating Scale scores (0-10) that patients actually reported to professionals: score-related factors, intrapersonal factors, and the anticipated consequences of a given pain score. Anticipated consequences were analgesic administration-which could be desired or undesired-and possible judgements by professionals. We also propose a conceptual model for the relationship between factors that influence the pain rating process. Based on patients' score-related and intrapersonal factors, a preliminary pain score was "internally" set. Before reporting the pain score to the healthcare professional, patients considered the anticipated consequences (i.e., expected judgements by professionals and anticipation of analgesic administration) of current Numeric Rating Scale scores. This study provides insight into the process of how patients translate their current postoperative pain into a numeric rating score. The proposed model may help professionals to understand the factors that influence a given Numeric Rating Scale score and suggest the most appropriate questions for clarification. In this way, patients and professionals may arrive at a shared understanding of the pain score, resulting in a tailored decision regarding the most appropriate treatment of current postoperative pain, particularly the dosing and timing of opioid administration. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Aug 2015 · International journal of nursing studies
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    • "We have used the concept of chronic cancer pain as described in the WHO document Normative Guidelines on Pain Management (World Health Organization, 2007b), and the usually agreed upon 3-month limit to include patients as chronic pain (Merskey and Bogduk, 1994), which may not be completely adequate for cancer patients, given that pain control may follow similar guidelines from its onset. However, our set covers most of recommendations established by the American Pain Society for improving the quality for both acute and cancer pain management (Gordon et al., 2005). "
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    ABSTRACT: Background Pain is among the most important symptoms in terms of prevalence and cause of distress for cancer patients and their families. However, there is a lack of clearly defined measures of quality pain management to identify problems and monitor changes in improvement initiatives.Methods We built a comprehensive set of evidence-based indicators following a four-step model: (1) review and systematization of existing guidelines to list evidence-based recommendations; (2) review and systematization of existing indicators matching the recommendations; (3) development of new indicators to complete a set of measures for the identified recommendations; and (4) pilot test (in hospital and primary care settings) for feasibility, reliability (kappa), and usefulness for the identification of quality problems using the lot quality acceptance sampling (LQAS) method and estimates of compliance.ResultsTwenty-two indicators were eventually pilot tested. Seventeen were feasible in hospitals and 12 in all settings. Feasibility barriers included difficulties in identifying target patients, deficient clinical records and low prevalence of cases for some indicators. Reliability was mostly very good or excellent (k > 0.8). Four indicators, all of them related to medication and prevention of side effects, had acceptable compliance at 75%/40% LQAS level. Other important medication-related indicators (i.e., adjustment to pain intensity, prescription for breakthrough pain) and indicators concerning patient-centred care (i.e., attention to psychological distress and educational needs) had very low compliance, highlighting specific quality gaps.ConclusionsA set of good practice indicators has been built and pilot tested as a feasible, reliable and useful quality monitoring tool, and underscoring particular and important areas for improvement.
    Full-text · Article · Jan 2015 · European journal of pain (London, England)
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    • "Outcomes The primary study outcome was the relation of the patient's postoperative NRS pain score at rest and at movement to the expressed need for additional opioids. It was considered that NRS scores #4 should relate to no wish for additional opioids, whereas NRS score >4 should relate to an expressed need for additional opioids (American Pain Society, 1995; Gordon et al., 2005). Otherwise, the combination was regarded as discordant. "
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    ABSTRACT: Guidelines for postoperative pain treatment are based on patients' pain scores. Patients with an intermediate Numeric Rating Scale (NRS) score of 5 or 6 may consider their pain as either bearable or unbearable, which makes it difficult to decide on pain treatment because guidelines advise professionals to treat pain at NRS > 4. Educating patients in using an NRS score for pain might improve adequate pain treatment. A quasi-randomized controlled trial was conducted in which 194 preoperative patients watched the educational film and 183 the control film. Pain scores were considered discordant when patients reported an NRS ≤ 4 and wanted additional opioids or when patients reported an NRS > 4 and did not want additional opioids. Beliefs, fear, and knowledge of pain; pain assessment; and pain treatment were measured by questionnaires. No significant differences in discordant pain scores between the groups were found: relative risk (RR) 0.73, confidence interval (CI) 0.47-1.15 at rest and RR 0.96, CI 0.72-1.28 at movement. Patients in the intervention group had lower NRS pain scores than patients in the control group. In the intervention group, patients had significantly more knowledge and lower barriers to pain management compared with the control group. We did not find a statistically significant reduction in discordant pain scores when comparing the intervention group with the control group. However, patients in the intervention group had significantly lower pain scores, lower barriers, and more knowledge of pain treatment than patients in the control group.
    Full-text · Article · Sep 2014 · Pain Management Nursing
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