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Report on pain assessment for palliative care patients Bache, Tenny; Egglestone, Aja; Khoshnood, Neda; Soros, Kelly 2012

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Report on Pain Assessment for Palliative Care Patients Tenny Bache,ª Aja Egglestone,ª Neda Khoshnood,ª & Kelly Sorosª ªUBC School of Nursing Program 2012, Vancouver, BC Vancouver General Hospital: Nicole Wikjord UBC faculty partner: Helga Marshall Purpose: The purpose of this project is to provide evidence-based recommendations on specific pain measurement tools and flow sheets that would be appropriate for use in the Acute Palliative Care Unit at Vancouver General Hospital (VGH APCU). Through research and analysis of various pain assessment tools, consideration of peer-reviewed articles, performing a needs assessment of the unit and benchmarking with various health care facilities across BC and Canada, we have identified the effectiveness and usefulness of various pain assessment tools in the acute palliative care setting. Overview: We have identified and compiled a table of 22 pain measurement and assessment tools. A brief description of each tool is provided as well as the strengths, weaknesses, ease of administration, validity, and validity specific to palliative. Additionally, a needs assessment was conducted in order to address the gaps in the current pain assessment tool used at VGH APCU. This was achieved by performing chart reviews, interviews and questionnaires. Collaborative benchmarking of current palliative pain assessment tools from various health authorities (Fraser Health Authority, Providence Health, Calgary Health Region, Nova Scotia Health and the United Kingdom) is also provided. A table has been included that lists the tools utilized in each health authority along with their respective features, benefits, limitations and remarks. It is our hope that this project will facilitate the discussion around the implementation of new standardized pain measurement tools and documentation at VGH APCU. Background: Research shows that pain assessment in a clinical setting requires a systematic approach (Weissman, Griffie, Muchka, & Matson, 2000). This will avoid unnecessary complex assessment methods, ensure efficient use of resources, minimize the number of instruments used, create standardization of the tools, improve patient assessment and care, and improve documentation and communication between health care providers (Weissman et al., 2000). However, any systematic assessment tool must be considered in the context of the clients’ current situation, and variances in sources and perceptions of pain need to be addressed. Components of assessment tools which are most relevant for the clinician and the patient may vary along the disease trajectory and between patients (Kaasa et al., 2008). Therefore, selecting a flexible tool (eg. a tool that can be administered via a combination of self-reports, caregiver reports, and/or behavioural indications) may be the most efficient option particularly for those unable to verbally express pain. Literature Analysis: Health care professionals, patients, and families can use pain assessment tools to UBC Nursing Student Journal, Vol.1, Issue 1. 17 gather data through patient self-reporting and behavioural observation. If possible, self-reporting should be the primary source of information when completing a pain assessment as it “is still the most reliable indicator of pain” (Jaggar & Holdcraft, 2005, p. 81). The exception to self-reporting is with non-verbal, non-cognisant persons. For these populations, behavioural observations validated by family and caregivers should be the primary source of information for a pain assessment. Observational assessments can also be used routinely in order to reduce the patient burden of routine hourly pain checks. The pain assessment tools listed are either unidimensional or multidimensional. Unidimensional tools such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), and Verbal Analog Scale (VAS) are highly sensitive in assessing specific features (ie. pain intensity), but rarely address the other components of pain (Katz & Melzack, 1999). Unidimensional tools are quick to administer, easy to understand, and have been widely used and validated. A major criticism of these rating scales is that they “do not actually provide ration-level scaling of pain. Therefore, if a patient’s pain is reduced from 8 to 4 after treatment, it cannot be inferred that she or he has experienced a 50% reduction in pain” (Fillingham, 2005, p. 72). Multidimensional tools such as the McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), and Memorial Symptom Assessment Scale (MSAS) can be highly sensitive at assessing all of the common components of the pain experience (physical, psychological, social, cultural and spiritual). Many multidimensional tools have also been validated across cultures and languages and demonstrate a high level of consistency (Jagger & Holdcroft, 2005). Furthermore, because pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (IASP, 2011), a full assessment of pain therefore requires a multidimensional approach for pain evaluation (Jaggar & Holdcroft, 2005). However, multidimensional assessment tools require more time (from the patient and the person performing the assessment) than unidimensional scales and tend be harder to learn to administer and score, limiting their routine use in clinical settings. Multidimensional Palliative Pain Assessment Tool: The Edmonton Symptom Assessment System (ESAS) is a valid and reliable assessment tool to assist in the assessment of nine common symptoms experienced by cancer patients (Watanabe et al., 2011).  The original tool was developed by the Regional Palliative Care Program, Capital Health in Edmonton, Alberta, and is one of the key assessment tools used in the Palliative Care Integration Project initiated by Queen's University (2012).  The ESAS is designed to assist in the assessment of: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well being, and shortness of breath. One blank scale is available for patients to use to assess an “other problem” as needed.  The severity at the time of assessment of each symptom is rated from 0 to 10 on a numerical scale; with 0 meaning that the symptom is absent and 10 that it is the worst possible severity. The ESAS was designed so that the patient, or his/her family caregiver, could self-administer UBC Nursing Student Journal, Vol.1, Issue 1. 18 the tool, and ideally, the patient and family should be taught how to complete the scale. It is the patient’s opinion of the severity of the symptoms that is the gold standard for symptom assessment, and the ESAS provides a clinical profile of symptom severity over time. It provides a context within which symptoms can be understood. However, it is not a complete assessment in itself and must be used as one part of a holistic clinical assessment. A Needs Assessment: A needs assessment is a critical component in understanding and addressing concerns expressed by the staff, clinicians, and management surrounding pain assessment at VGH APCU. To analyse the current pain assessment tool in use (a  flowsheet used VGH-wide which was developed originally for use in acute medicine); chart reviews, questionnaires, and clinician interviews were conducted to identify possible gaps, effectiveness, accuracy and adherence to using the tool. After careful review of charts and documentation records on the APCU, it was evident the major use for the pain assessment flow sheet was as a medication administration record.  Specifically, the scheduled and breakthrough pain medications and doses were recorded on the flow sheet, while subjective pain data was rarely recorded. This type of documentation does not provide a  full clinical picture of client circumstances prior to medication administration, raising a number of issues related to documentation practice standards as put forth by the College of Registered Nurses of British Columbia (CRNBC, 2012) such as communication, safe and appropriate nursing care, and professional and legal practice standards After a chart review, seventeen questionnaires were administered to staff including registered nurses, licensed practical nurses, medical residents, and physicians. The questions investigated the perspectives of the staff surrounding: (1)  the usefulness of the flow sheet in use,  (2) information that should be be added or removed, and (3) concerns addressing gaps in the current pain tool and documentation method. The data collected from the interviews and questionnaires were congruent with the information collected from the chart and documentation review. Several reasons suggested by staff members provide a rationale for the method of documentation evident in the  chart review. First and foremost, staff nurses and physicians appreciated that the current tool allowed a clear visualization of the trends in medication administration over a period of time. Second, respondents reported that staff were reluctant to use the tool regularly because they felt that due to the patient burden incurred during assessment, clients could possibly be annoyed or disturbed by self-report pain on a frequent basis (eg. every one hour). Recognizing and understanding the patients’ perspective is an important issue to address, because in order to achieve optimal health outcomes, patients need to be active partners in their care. We suggest that further research be carried out to determine patient satisfaction with participating in frequent pain assessments at VGH APCU. Thirdly, all staff members indicated that including a section for respiratory distress medications would be helpful because currently there is no space to write it on the flow sheet, so they were recording these medications on the flow sheet in a section designated for pain intensity, respiration rate, sedation UBC Nursing Student Journal, Vol.1, Issue 1. 19 score, and side effects. Forthly, respondents felt that the addition of a section indicating the 24 hour medication totals would be beneficial. Overall, the staff members were pleased with the current pain assessment flow sheet and found it useful in monitoring pain control, titrated medications, and medication trends over time. These interviews and questionnaires were crucial to understanding the perspective of the staff, which will help select a relevant and appropriate pain assessment tool and documentation flow sheet, and improve clinician adherence to utilizing the tool and improving pain- related documentation in the future. Benchmarking: Part of this project involved contacting a number of local and national health authorities to determine what kinds of documentation and pain assessment tools are used in other jurisdictions. The following health authorities were contacted: Providence Health Care, Fraser Health Authority, Calgary Health Region, Capital Health (Nova Scotia), and NHS in the United Kingdom. Victoria Hospice was contacted regarding this project however we received no reply.  All health authorities’ documentation was reviewed and analysed for features, benefits, limitations and remarks (see the benchmarking table for details).  The remark section includes information given from the various health authority contacts regarding the subjective usefulness and features of the documentation. The conclusion from the collaborative benchmarking indicates that while no health authority uses the same pain assessment tool, there are several contributing factors which determine an effective and efficient tool.  Such factors include simplicity and efficiency for both health care provider and patient.  Additionally, in order to achieve optimal outcomes, a visualization of the trends over time and the various interventions used should be illustrated. Recommendations: Based on our literature analysis, needs assessment and benchmarking, we recommend that (1) a comprehensive, multidimensional tool be administered upon admission to VGH APCU, while (2) continuing to use a unidimensional tool (eg. NRS) for assessing patients’ pain prior to any intervention. 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