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Postgraduate Education Corner: CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE |

Structured Approaches to Pain Management in the ICU FREE TO VIEW

Chris Pasero, MS, RN-BC; Kathleen Puntillo, RN, CNS, DNSc; Denise Li, PhD, RN, CNS; Richard A. Mularski, MD, MSHS, MCR, FCCP; Mary Jo Grap, PhD, RN; Brian L. Erstad, PharmD; Basil Varkey, MD, FCCP; Hugh C. Gilbert, MD; Justine Medina, RN, MS; Curtis N. Sessler, MD, FCCP
Author and Funding Information

*Independent Pain Management Educator and Clinical Consultant (Ms. Pasero), El Dorado Hills, CA; Critical Care/Trauma Program Department of Physiological Nursing (Dr. Puntillo), University of California, San Francisco, CA; Department of Nursing and Health Sciences (Dr. Li), College of Science, California State University, East Bay, Hayward, CA; The Center for Health Research (Dr. Mularski), Kaiser Permanente Northwest and Oregon Health and Science University, Portland, OR; Adult Health and Nursing Systems Department (Dr. Grap), School of Nursing, Virginia Commonwealth University, Richmond, VA; The University of Arizona College of Pharmacy (Dr. Erstad), Department of Pharmacy Practice and Science, Tucson, AZ; Division of Pulmonary and Critical Care (Dr. Varkey), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; Northwestern University Department of Anesthesiology (Dr. Gilbert), Feinberg School of Medicine, Chicago, IL; Professional Practice and Programs (Ms. Medina), American Association of Critical Care Nurses, Aliso Viejo, CA; and Virginia Commonwealth University Health System (Dr. Sessler), Richmond, VA.

Correspondence to: Chris Pasero, MS, RN-BC, Pain Management Educator and Clinical Consultant, 1252 Clearview Dr, El Dorado Hills, CA 95762; e-mail: cpasero@aol.com


No conflict of interest exists for any of the authors.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(6):1665-1672. doi:10.1378/chest.08-2333
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Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

Despite decades of pain research, guideline development and distribution, and intense educational efforts, pain continues to be undertreated in patients who are critically ill.1 It is estimated that as many as 70% of patients experience at least moderate- intensity procedural-related or postoperative pain during their stay in the hospital ICU.2,3 This article addresses the process of improving pain management in the ICU through the implementation of structured approaches.

Barriers to Effective Pain Management

Entrenched beliefs and practices that interfere with optimal pain treatment abound and often are attributed to the following three origins: the patient, the health-care team, and the health-care system.4,5 Among the most common obstacles to overcome are a failure to assess and acknowledge the existence of pain, outdated prescribing habits, inadequate quality improvement monitoring, and a lack of accountability for unsatisfactory outcomes related to poorly managed pain. In addition, barriers specific to the ICU setting underscore the urgency of change in this clinical area. Clinician-related barriers, including knowledge deficits regarding pain assessment and management principles, personal and cultural bias, and communication difficulties between the patient and the health-care team, contribute considerably to suboptimal pain management in the hospital ICU (Table 1).

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Table 1 Evidence of Pain Management Barriers in Acute Care Settings
Pain Management Improvement Process

The American Pain Society6 issued quality improvement guidelines in 2005 and recommended evaluation of current practices as a first step in addressing the problem of mismanaged and undertreated pain. The ultimate goal of improvement activities is to ensure that the health-care team can provide safe, efficacious, patient-centered, timely, efficient, and equitable pain management (Table 2).

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Table 2 American Pain Society Quality Improvement Recommendations*

*Adapted from American Pain Society Quality of Care Task Force. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med 2005; 165:1574–1580. Copyright 2005 American Medical Association.

The necessary changes in pain management practices in the ICU setting are best accomplished through the work of a multidisciplinary process improvement team whose core members are physicians, nurses, and pharmacists.4,7 Other individuals can serve as consultants to the team as problems are identified and their knowledge and skills needed. The team's core members should have firsthand knowledge of the unique characteristics and customs of the hospital's ICU and an understanding of current pain research and best practices (Table 3).

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Table 3 Pain Improvement Process

The process improvement team's efforts are directed toward answering the following questions: What do we do? Why do we do what we do? How do we know it works? How can we do it better?6 Review of current policy and procedure and data collection through random medical record audits are the first steps toward answering these questions.4 Pain measurement and management increasingly are viewed as valid targets for improved clinical care delivery;812 therefore, a focus on initial and ongoing pain assessment and whether pain treatment plans are adjusted based on patient response is essential.6

A review of medication prescribing habits and patterns will help the process improvement team to determine the quality of current pain management in the hospital's ICU, including the identification of irrational polypharmacy and use of analgesics, such as meperidine, and other medications that are not recommended for the management of pain and analgesic side effects.4 Both positive and negative patient outcomes must be examined to identify practice patterns that should be retained, perfected, changed, or eliminated.

The process improvement team should review initially and periodically patient and family satisfaction data, bearing in mind that patients often report satisfaction with pain treatment despite experiencing severe pain, a high incidence of side effects, and inadequate pain treatment.13 Surveying physicians and nurses for satisfaction also can provide insight into areas of practice that need change.

Knowledge and attitude surveys administered to physicians, nurses, and pharmacists will uncover gaps in knowledge as well as uncover personal beliefs that may be contributing to the undertreatment of pain. The initial responses to such surveys form the basis for a comprehensive, multidisciplinary education plan (Table 4).4 Repeat surveys reveal improvements in these areas and the need for further education.14,15

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Table 4 ICU-Specific Pain Management Education Content
Structured Approaches to Pain Management

After the process improvement team identifies its hospital ICU's specific problems in pain management, it can move to the next step of developing and implementing solutions. The solutions the team develops must reflect the principles of interdisciplinary collaboration,7,16 which are an appreciation that no single care provider can address all of the complexities of patient care and that each provider makes a unique and valuable contribution to care delivery. This collaboration supports nonhierarchical relationships, shared responsibility, access to resources, and decision making based on clinical preparation and ability.16

The process of developing and implementing solutions begins with a review of the literature to identify best practice in ICU pain management. Structured approaches, such as the implementation of evidence-based guidelines, protocols, and clinical paths (care maps), have met with success as part of a multifaceted improvement effort in a variety of health-care settings.1724

Evidence-Based Guidelines and Algorithms:

Guidelines are systematically developed statements that assist clinicians and patients in making appropriate health-care decisions. The current emphasis on evidence-based practice requires that guidelines be developed using a science-based methodology combined with expert clinical judgment. Clinical protocol or algorithm is a specific procedure articulated by a series of steps for the purpose of solving an identified problem. Both structured approaches may be helpful in directing pain management in the ICU setting.

A guideline based on a wellness model and the World Health Organization's20 multimodal analgesic ladder approach was shown to be effective for pain treatment after major cardiac surgery. The guideline was implemented after the improvement team streamlined care and treatment processes to aggressively address pain, nausea, constipation, respiratory compromise, and immobility with the assumption that patients who are free of these problems will participate more fully in an accelerated recovery program. A paradigm shift for the hospital ICU was required. Where pain had previously been treated with as-needed analgesics, one of the primary goals of the new guideline was to prevent pain through the administration of analgesics in scheduled doses around the clock and before procedural pain. Algorithms and preprinted order sets guided decision making. Data on 120 patients over a 3-month period revealed that 95% had effective pain relief on every ICU staff shift for the first 6 days after surgery or through the postoperative stay. Profiles of side effects improved dramatically, and median length of stay after bypass surgery was 5 days and after valve replacement or repair surgery, 6 days. (Preguideline implementation length of stay data were not provided.)20 Similarly, implementation of a protocol at the University of Iowa22 in the medical ICU resulted in a decrease in ventilator days from 10.3 to 8.9 and a reduction of average hospital cost by $10,500 per patient, with an institutional savings over a 26-month period of $1,984,500.

The examination of published literature reviews and evidence-based guidelines may facilitate development of institution-specific guidelines and algorithms.2325 The American Pain Society2628 (http://www.ampainsoc.org) regularly publishes principles of analgesic use and pain management clinical practice guidelines for specific patient populations. A novel, Web-based program called PROSPECT29 (Procedure Specific Postoperative Pain Management) [http://www.postoppain.org] provides graded evidence-based algorithms and recommendations for best surgical pain management to assist the health-care team in making appropriate decisions.

Clinical Paths:

Clinical paths provide a consistent timeline methodology for planning individualized patient care. The path guides the entire course of care for a specific medical condition on a daily and sometimes hourly basis, addressing various categories such as patient problems, multidisciplinary interventions, and expected outcomes.30 Some clinical paths are initiated before hospital ICU admission (eg, in the emergency department) and continue past discharge.4

Given the high incidence of pain in the ICU setting, all critical care clinical paths should address the need for analgesia; prevention of pain should be the hallmark of recommended interventions. Appropriate analgesics should be administered preoperatively, whenever possible, to minimize postoperative pain and the likelihood of postsurgical chronic pain. Trauma pain should be managed aggressively to prevent further harm and risk of ongoing pain. Procedural pain should be addressed, with recommendations for preemptive treatment (Table 5). Further, the management of preexisting chronic pain must be optimized to prevent the patient from experiencing additional stress and pain while staying in the ICU.

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Table 5 Anticipating and Managing Procedural Pain

Clinical path development can be challenging. Often, wide variability exists in practice, indicating the need for a comprehensive analysis of institutional and patient data when making decisions about interventions, expected outcomes, and the timeline for accomplishing both. For the clinical path to be successful, all disciplines responsible for its implementation must be consulted during its development. It is critical that the final path reflect a consensus of opinions derived from careful consideration of specialist recommendations.4,30

Checklists:

A checklist is a systematic arrangement of action items or criteria. Checklists differ from protocols because they verify the completion of a task without necessarily leading to a specific conclusion.31 Checklists can be a valuable tool in the hospital ICU, where multiple tasks are performed and the risk for patient harm is significant when errors are made. They can be used as part of daily rounding to help balance life-saving ICU therapy with meeting palliative care needs, such as unmanaged pain.32,33

Daily Goals:

To improve communication about patient care goals and to make rounds more patient centered, one teaching hospital34 used a daily goals form completed in an interdisciplinary fashion during rounds and articulated the 24-h care plan for each patient in its ICU. The health-care team reviewed and updated the form systematically during each 24-h period. Before implementation of the form, < 10% of the residents and nurses understood the daily goals of therapy; after implementation, 95% understood the daily goals. A 50% decrease in length of ICU stay also was associated with the use of the form. Others31 have reported similar findings in improvements in overall patient outcomes and decreased length of hospital ICU stay with this approach. Identifying pain control as a daily goal may be a particularly effective method for ensuring that necessary pain interventions are performed.

Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE):

The current focus on patient safety and efficient administration of care3539 has brought about the introduction of the EHR to patient care. The EHR is a comprehensive, patient-centered clinical information system that contains data from multiple care settings as well as from the patient.38 Three specific applications—CPOE, electronic medication administration records, and clinical documentation—have decreased incorrect and unnecessary treatments and medications and improved timeliness of care.36 The EHR can discourage outdated and dangerous pain management practices and promote more appropriate choices. Carefully placed prompts remind clinicians to take a proactive approach and prevent analgesic gaps that occur when pain medication is delayed or missed entirely.40

Challenges exist in identifying and implementing the best EHR, given the unique needs of patients who are critically ill.3739,41 Although CPOE applications have been shown34 to improve care in specialty-care environments by increasing clarity, specificity, and efficiency, significant errors resulting in patient harm can occur.41 Careful evaluation of a variety of available systems3740 as well as an analysis of the workflow requirements of the particular ICU setting42 before implementation of the EHR are highly recommended.

Referral and Consultation

The availability of referral sources, such as a formal anesthesia-based pain service, can improve outcomes and potentially reduce the burden for ICU physicians and nurses struggling with the management of patients with complex conditions and multiple risk factors for undertreated pain. A review of nearly 6,000 patients43 demonstrated that those managed by an acute pain service experienced less pain and fewer side effects than those who were not. An extensive literature review44 (outcome data of 84,097 patients) evaluated the effects of acute pain services on postoperative patient outcomes and concluded that acute pain services improved pain relief, pulmonary function, and patient satisfaction.

Creative referral approaches have been used to meet the pain needs of patients staying in the hospital ICU. One anesthesia department45 implemented a combined critical care outreach and acute pain service to address patients with a high-risk postoperative status. This consultative approach reduced serious adverse events, such as postoperative myocardial infarction, from 23 per 100 patients to 16 per 100 patients, and the 30-day mortality rate decreased from 9 to 3%.

A poor patient outcome prompted clinicians in another hospital46 to analyze current practices; develop pain management guidelines; and implement a nurse-based, anesthesiologist-supervised, acute pain service that was available to members of the health-care team. This approach resulted in increased staff education and significant improvements in the quality and safety of pain management for postoperative patients.

Another innovative approach is the Pain Resource Nurse program.4 The bedside nurse who has received additional pain management training serves as a resource to other nurses, particularly in the care of patients with complex conditions. In addition to 24-h clinical support, these nurses provide patient, family, and staff pain management education.

In hospitals where such consultative resources are not available, the process improvement team may want to present the achievable benefits of these resources to administrative decision makers. The availability of a group of individuals trained and dedicated to manage complex pain problems has the potential to increase the appropriate use of advanced analgesic approaches; ensure safety of administration techniques; improve patient, staff, and physician satisfaction; provide much-needed pain management education for staff; reduce workload at the bedside; and improve communication between patients and their caregivers as well as between services.4,47

Comprehensive Multimodal Rehabilitation Programs

Even the most sophisticated pain-relieving methods and approaches will not affect patient morbidity and mortality rates unless they are housed within a comprehensive multimodal rehabilitation framework.4,18,29,44 Such a program requires the entire health-care team to focus on reduction of the stress response, heat and blood loss, immobilization and muscle wasting, immunosuppression, and GI dysfunction in addition to reduction of pain.4,44,47 This comprehensive approach depends on an institutional commitment to change the way patient care is administered and a health-care team that will continuously strive to combine effective pain control techniques with state-of-the-art care interventions and well-defined discharge criteria.4,29

Ongoing Improvement of Pain Care

Creating an organizational culture that embraces pain management can be a slow and challenging process; therefore, patience and perseverance are crucial.48 The realization of improved care extends beyond the implementation of structured approaches to pain management, so the key is to measure care provided continuously once various approaches are implemented. After initial changes are made, ongoing collection and analysis of patient-specific data and functional outcomes and knowledge of evolving pain management techniques and evidence-based recommendations are required. Systematic review of daily practices; institutional policy and procedure; and all structured care approaches with a focus on safety, efficacy, and interdisciplinary collaboration help to ensure that appropriate and timely modifications to original plans are made. Continuous multidisciplinary pain education helps to ensure enthusiastic involvement of all disciplines essential to the delivery of high-quality pain management in the hospital ICU.

Summary

Despite decades of pain improvement initiatives, pain is common and often undertreated in the patients who are critically ill. The systematic and multidisciplinary implementation of evidence-based structured approaches and a rigorous continuous quality improvement plan are recommended to improve the way pain is managed in this vulnerable population. Future research that identifies and articulates best practices is needed to ensure that this effort continues in ICU settings worldwide.

CPOE

computerized provider order entry

EHR

electronic health record

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Gelinas C, Fillion L, Puntillo K, et al. Validation of a pain observation tool (POT) in critically ill adult patients. Am J Crit Care. 2006;15:420-427. [PubMed]
 
Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, et al. Pain and distress related to tracheal suctioning in acutely and critically ill adults. Intensive Crit Care Nurs. 2008;24:20-27. [PubMed]
 
Woolf CJ, Chong M. Preemptive analgesia: treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg. 1993;77:362-379. [PubMed]
 
Cepeda MS, Carr DB, Lau J, et al. Music for pain relief. Cochrane Database of Systematic Reviews 2006, Issue 2. Article CD004843. DOI:10.1002/14651858.CD004843.pub2.
 
Suls J, Wan CK. Effects of sensory and procedural information on coping with stressful medical procedures and pain: a meta-analysis. J Consult Clin Psychol. 1989;57:372-379. [PubMed]
 
Johnson JE. Effects of accurate expectations about sensations on the sensory and distress components of pain. J Pers Soc Psychol. 1973;27:261-275. [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 Evidence of Pain Management Barriers in Acute Care Settings
Table Graphic Jump Location
Table 2 American Pain Society Quality Improvement Recommendations*

*Adapted from American Pain Society Quality of Care Task Force. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med 2005; 165:1574–1580. Copyright 2005 American Medical Association.

Table Graphic Jump Location
Table 3 Pain Improvement Process
Table Graphic Jump Location
Table 4 ICU-Specific Pain Management Education Content
Table Graphic Jump Location
Table 5 Anticipating and Managing Procedural Pain

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