An institutional commitment to pain management.

PURPOSE: To share the development, implementation, and evaluation of a program called "An Institutional Commitment to Pain Management," which is based on the philosophy of organizational influence on pain management. METHODS: A tested pain education model was disseminated to 32 physician/nurse teams in settings throughout California, after which the 64 professionals returned to their institutions to serve as role models and catalysts to change the practice of pain management. Each team member completed a 39-item survey about knowledge and attitudes related to pain, which was developed by B.R.F. and colleagues, and also identified three goals for the implementation of course information. Precourse data also included administration of the knowledge and attitudes survey to participating physicians' and nurses' colleagues (10 physicians and 20 nurses per institution). Each team completed five chart audits using the pain audit tool (PAT), which was developed by B.R.F. and colleagues at the City of Hope National Medical Center. The PAT identifies how pain is managed currently at the institutional level. Final course evaluation 8 months after course completion included a summary of activities implemented by the teams as well as the factors that served as barriers and benefits to improve the quality of pain management. RESULTS: Two hundred seventy-two physicians and 629 nurses completed the survey about knowledge and attitudes related to pain, and 154 PATs were submitted. These results, as well as evaluation at the completion of the course, are discussed. CONCLUSION: The Institutional Commitment to Pain Management program is an evolving model that was developed to overcome barriers to pain relief by obtaining the commitment from institutions to improve the management of pain for their patients.

Survey of the provision of supportive care services at National Cancer Institute-designated cancer centers.

PURPOSE: The purpose of this survey was to determine the scope of supportive care services (SCS) designed to promote quality of life during cancer therapies at National Cancer Institute (NCI)-designated cancer centers. METHODS: A survey was mailed to the medical directors and nursing directors of 52 NCI-designated comprehensive (n = 26), clinical (n = 11), and planning cancer centers (n = 15) in the United States. Only one survey was completed from each institution. Survey questions identified services provided such as pain management, terminal care, psychosocial programs, and spiritual care. RESULTS: Thirty-nine questionnaires were received for a total response rate of 75%. Of the respondents, 45% were comprehensive cancer centers, 24% clinical cancer centers, and 29% planning centers. One center did not identify their NCI designation. Sixty-one percent of the centers reported research programs in supportive care. Outside funding was reported in 51% of the respondents, with 39% having American Cancer Society (ACS) or National Institutes of Health (NIH) funding and 28% having private industry funding. Overall SCS self-ratings improved from a 21% rating of excellent to very good 5 years ago to the current 54% rating. CONCLUSION: Survey results provide data on SCS across a representative sample of NCI cancer centers and can be used to develop standards for future cancer control programs.

Extrapituitary regulation of the circadian rhythm of plasma corticosteroid concentration in rats.

Intravascular injections of adrenocorticotropic hormone in hypophysectomized rats were approximately 3 times more effective in stimulating increases in plasma corticosteroid concentration when given at the offset rather than the onset of the daily photoperiod (12 h:12 h light-dark cycle). Reversal of the photoperiodic schedule produced a reversal in the corticosteroid response after 5 days. Similar temporal variations in androgen and T4 responses to LH and TSH were not obtained. Although plasma corticosteroid concentrations were maintained at normal intermediate levels in rats with adrenal autotransplants, daily variations were not demonstrable. These results indicate that the circadian rhythm of plasma corticosteroid concentration is regulated by way of neural pathways to the adrenal.

Extended follow-up in 212 long-term allogeneic bone marrow transplant survivors. Issues of quality of life.

A group of 235 allogeneic marrow recipients were contacted at least one year following their BMT to obtain information on their quality of life; 212 (90%) agreed to participate in this survey. A total of 162 adults and 50 pediatric survivors were interviewed during clinic visits (5%) or over the telephone (95%). Changes in productive activity and marital status at the time of interview were studied, as well as the presence of physical symptoms and perception of a general sense of well-being. Older transplant recipients were observed to have a significantly higher incidence of chronic graft-versus-host disease, common colds, and skin changes when compared with pediatric transplant recipients (P < 0.01). Older subjects were also more likely to require any type of regular medication. Younger survivors were rated with a higher Karnofsky performance status and global subjective score. There were no significant differences between patients who received TBI as part of the conditioning regimen and those who did not, with the exception of increased cataract development in pediatric patients receiving TBI (P < 0.008). We conclude that most allogeneic marrow transplant survivors, especially those individuals of younger age at the time of their transplants, are doing well in the domains tested.

Continuous extrapleural intercostal nerve block with continuous infusion of lidocaine after thoracotomy. A descriptive pilot study.

Continuous extrapleural intercostal block (EPIB) with bupivacaine has been reported to be an effective analgesic technique in patients after thoracotomy. We report a retrospective study of EPIB using a continuous infusion of 1% lidocaine hydrochloride at a dose of 1 mg/kg/h. A posterior parietal pleural pocket was created and cannulated with a 16-g polyethylene catheter. Lidocaine was perfused over a 3-day period following surgery. Patients also had access to morphine sulfate via patient-controlled analgesia. Eighteen consecutive posterolateral thoracotomies (in 17 patients) performed during a 6-month period were reviewed. Serum lidocaine exceeded the toxic level of 5 microgram/mL in only one patient, a 104.5-kg man who had a level of 5.9 micrograms/mL on postoperative day 2 but experienced no clinical toxicity. Pain was evaluated by verbal analog scores (0 = no pain and 10 = worst pain), which averaged 3.02, 3.14, and 2.8 in the 3 days following surgery. Mean total daily MS doses were 24.3, 37.75, and 34.32 mg (range, 0 to 94 mg). Sedation was scored on a 1 to 5 scale. Mean scores were 2.78, 2.56, and 2.6. No patient died or had a major respiratory complication. Continuous EPIB with lidocaine appears to be a promising adjuvant technique in the management of postthoracotomy pain. Effectiveness needs to be confirmed in a prospective randomized study.

Pain in the nursing home.

Pain is an understudied problem in geriatric medicine and especially among nursing home residents. The focus of this study was to describe the scope of the problem of pain in a long-term care facility. Ninety-seven subjects from a 311-bed multilevel teaching nursing home were interviewed, and charts were reviewed for pain problems and management strategies. Functional status, depression, and cognitive impairment were also evaluated. Results indicate that 71% of residents had at least one pain complaint (range, 1-4). Of subjects with pain, 34% described constant (continuous) pain and 66% described intermittent pain. Of 43 subjects with intermittent pain, 51% described pain on a daily basis. Major sources of pain included low back pain (40%), arthritis of appendicular joints (24%), previous fracture sites (14%), and neuropathies (11%). Moderately strong correlations were found between pain and infrequent attendance at recreational and social activities (r = .50). However, little correlation was observed between pain and the Yesavage Depression Scale, the Folstein Mini-Mental State Scale, or basic ADLs measured by the Katz Scale. Pain-management strategies consisted of analgesic drugs, physical therapy, and heating pads. Only 15% of patients with pain had received medication within the previous 24 hours. The findings suggest that pain is a major problem in long-term care. Strategies for pain management appear to be limited in scope and application in this setting. Important barriers were identified that influence the reporting and management of pain in this setting.

Fatigue in an older population.

OBJECTIVES: Fatigue is a common symptom that has not been studied well in the older populations. The purpose of this pilot study was to examine the epidemiology of fatigue symptoms in relation to demographic and medical characteristics of older patients in a long-term care setting. DESIGN: A cross-sectional interviewer-assisted survey. PARTICIPANTS/SETTING: A total of 199 ambulatory older residents of a single residential care facility. MEASUREMENTS: Along with medical and demographic characteristics, the survey included mental status (Folstein), activities of daily living (Katz and Lawton), depression (Yesavage GDS), a 3-minute walk, a 7-item pain scale, and the modified Piper Fatigue Scale. RESULTS: One-hundred ninety-nine (65%) of 308 potential subjects completed the study (mean age 88 years, 82% female). Of these 199 subjects, 195 (98%) reported some fatigue symptoms (median duration 44 weeks). Significant (P < .0005) relationships were found between fatigue and GDS (r = 0.57), 3-minute walk (r = -0.29), Lawton IADLs (r = 0.31), pain (r = 0.36), and number of medications (r = 0.26). No significant relationships were found between fatigue and age, sex, Folstein score, or number of medical diagnoses. Multivariate regression analysis identified GDS, pain, number of medications and 3-minute walk as significant predictors of fatigue intensity (multiple R = 0.68, r2 = 0.46, P < .02). CONCLUSIONS: Fatigue is a symptom often found among older residents of a residential facility and has important implications for quality of life. Fatigue is poorly recognized and probably undertreated in older people.

The Sessing scale for assessment of pressure ulcer healing.

OBJECTIVE: To describe a new observational scale, the Sessing scale, for measuring the progression of pressure ulcers. CRITERION STANDARDS: Changes in Shea stage and the diameter of healing pressure ulcers. SUBJECTS: A cohort of 84 nursing home residents with pressure ulcers. RESULTS: There were strong relationships between changes in healing as measured by the Sessing Scale and those measured by the Shea Scale (Spearman's r = 0.90; P < .0001), and between changes in the Sessing scale compared with changes in ulcer diameter (Spearman's r = 0.64; P < .001). Test-retest reliability was good (Kappa = 0.84) in a sample of 50 subjects. CONCLUSION: The Sessing scale is a simple, easy to use, observational instrument with validity and reliability for the assessment of progression of pressure ulcers in a clinical or research setting. Findings indicate that the Sessing scale, with its description of granulation tissue, infection, drainage, necrosis, and eschar, measures an important domain of wound healing that is independent and perhaps as important to clinicians and researchers as either Shea stage or ulcer size.

Pressure ulcers among patients admitted to home care.

CONTEXT: Pressure ulcers are an understudied problem in home care. OBJECTIVE: To determine the prevalence of pressure ulcers among patients admitted to home care services, describe the demographic and health characteristics associated with pressure ulcers in this setting, and identify the percentage of these patients at risk for developing pressure ulcers. DESIGN: Cross-sectional survey of patients on admission to home care agencies. SETTING: Forty-one home care agencies in 14 states. PATIENTS: A consecutive sample of 3,048 patients admitted March 1 through April 30, 1996 (86% of all admissions). Subjects had a mean age of 75 years; 63% were female and 85% white. MAIN OUTCOME MEASURES: Demographic, social, and clinical characteristics, functional status (Katz activities of daily living scale and Lawton instrumental activities of daily living scale), mental status (Katzman Short Memory-Orientation-Concentration test), pressure ulcer risk (Braden Scale), pressure ulcer status (Bates-Jensen Pressure Ulcer Status Tool), and a checklist of pressure-reducing devices and wound care products being used. RESULTS: In the total sample of 3,048 patients, 9.12% had pressure injuries: 37.4% had more than one ulcer and 14.0% had three or more ulcers. Considering the worst ulcer for each subject, 40.3% had Stage II and 27% had Stage III or IV injuries. Characteristics associated with pressure ulcers included recent institutional discharge, functional impairment, incontinence, and having had a previous ulcer. About 30% of subjects were at risk for new pressure ulcers. Pressure-relieving devices and other wound care strategies appeared to be underutilized and often indiscriminately applied. CONCLUSIONS: There is substantial need for pressure ulcer prevention and treatment in home care settings.

The Geriatric Pain Measure: validity, reliability and factor analysis.

BACKGROUND: Pain is a multidimensional experience that should be evaluated beyond an estimate of intensity. A multidimensional pain measure has not been developed for older persons undergoing comprehensive geriatric assessment. OBJECTIVE: To develop and evaluate validity and reliability of a multidimensional pain assessment instrument for older persons. RESEARCH DESIGN: A series of steps in instrument development and evaluation. SUBJECTS: A total of 176 subjects (mean age 84 +/- 6.0 years) in ambulatory geriatric clinics; 64% were women, and 73% had a history of chronic pain. MEASUREMENTS: Measurements included the Geriatric Pain Measure (GPM), the McGill Pain Questionnaire, Yesavage GDS, Katz ADLs, Lawton IADLs, Tinetti Gait and Balance, Folstein MMSE, and other demographic and clinical characteristics from interview and chart review. RESULTS: The GPM demonstrated a standardized alpha = 0.9445, homogeneity ratio =0.457, and average inter-item correlation =0.415. A subgroup of 50 subjects demonstrated concurrent validity of the GPM in comparison with the McGill Pain Questionnaire (Pearson's r correlation 0.6269 (P < .0000). Test-retest reliability was demonstrated in another subgroup of 50 subjects who repeated the GPM within 48 to 72 hours (Pearson's r = 0.9018; P < .0000). Factor analysis revealed five clusters of components: Pain Intensity, Disengagement, Pain with Ambulation, Pain with Strenuous Activities, and Pain with Other Activities. CONCLUSIONS: The GPM is a 24-item questionnaire that is easy to administer and has significant validity and reliability in older persons with multiple medical problems. The GPM may be a useful addition to the multidimensional geriatric assessment process.

Cost-effectiveness of low-air-loss beds for treatment of pressure ulcers.

BACKGROUND: Cost-effectiveness of low-air-loss beds for the healing of pressure ulcers was analyzed in the nursing home setting. A statistical model of pressure ulcer healing was used to estimate cost-effectiveness based on patient and ulcer characteristics. METHODS: Results of a previous randomized trial (84 patients from three nursing homes in Los Angeles) were reanalyzed and combined with estimates of costs to calculate the cost-effectiveness in dollars per added day free of pressure ulcers achieved by the use of low-air-loss beds compared to conventional foam mattresses. RESULTS: The cost-effectiveness of the low-air-loss bed was $26 per added day free of ulcers for our standard patient. Results were sensitive to low-air-loss bed lease costs and patient and wound healing characteristics. Results were less sensitive to expected mortality, daily wound care costs, and time-frame of consideration. Low-air-loss beds were more cost-effective for patients with good healing characteristics and mild ulcers. CONCLUSIONS: Findings support the expanded use of this technology for patients with mild pressure ulcers and good healing characteristics. For these patients, the cost-effectiveness of low-air-loss beds is comparable to other accepted health treatments. For patients with severe ulcers and poor healing characteristics, low-air-loss bed cost-effectiveness compares poorly with other accepted health treatments unless the lease cost can be substantially reduced, or unless life with a pressure ulcer is valued close to death.

An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH).

BACKGROUND: Currently, there is no instrument that provides an accurate and simple method of monitoring pressure ulcer healing in clinical practice. This article reports the two studies that were conducted to assess the validity of the Pressure Ulcer Scale for Healing (PUSH) as a tool to monitor healing of stage II-IV pressure ulcers. METHODS: Subjects in both studies (N = 103 and N = 269) were elderly (mean Study 1, 75 years, mean Study 2, 80 years), and the majority were women (Study 1, 51%, Study 2, 70%). Study data were extracted from patients' permanent records. RESULTS: Principal components analysis confirmed that the PUSH tool accounted for 58% to 74% of the wound healing variance over a 10-week period in Study 1 and 40% to 57% of the wound healing variance over a 12-week period in Study 2. In addition, multiple regression analysis, used to measure the sensitivity of the model to total healing, showed PUSH accounted for 39% of the variance in 6 weeks and 31% of the variance over 12 weeks (p <.001; Studies 1 and 2, respectively). CONCLUSIONS: Data from these two studies confirmed that the PUSH tool, with the components of length times width, exudate amount, and tissue type, is a valid and sensitive measure of pressure ulcer healing. It is a practical approach that provides clinically valid data regarding pressure ulcer healing. Further testing is needed to confirm these findings.

Ethical dilemmas in pain management.

The purpose of this study was to survey the membership of the American Pain Society and the American Academy of Pain Medicine to determine their beliefs about ethical dilemmas in pain management practice. Respondents rated ethical dilemmas for their importance as well as their own competence in dealing with these ethical issues. The survey also included an open-ended question that asked respondents to describe clinical situations in which they had encountered ethical dilemmas. A total of 1,105 surveys were analyzed, with physicians (N = 612), nurses (N = 189), and psychologists (N = 166) representing the professions with the greatest response. Management of pain at the end of life, general undertreatment of pain, and undertreatment of pain in the elderly were the most frequently encountered dilemmas. Qualitative data were analyzed to identify ethical issues in the case examples provided by the respondents. Major themes included inappropriate pain management, barriers to care, interactions and conflicts with others, regulatory/legal issues, euthanasia, assisted suicide, and research issues. We conclude that ethical dilemmas are common in pain management practice and that resolution of these dilemmas requires commitment by individual professionals as well as health systems.

Pain in cognitively impaired nursing home patients.

Pain is an understudied problem in frail elderly patients, especially those with cognitive impairment, delirium, or dementia. The focus of this study was to describe the pain experienced by patients in skilled nursing homes, which have a high prevalence of cognitive impairment. A random sample of 325 subjects was selected from ten community skilled nursing homes. Subjects underwent a cross-sectional interview and chart review for the prevalence of pain complaints, etiology, and pain management strategies. Pain was assessed using the McGill Pain Questionnaire and four unidimensional scales previously utilized in younger adults. Thirty-three percent (33%) of subjects were excluded because they were either comatose (21%), non-English speaking (3.7%), temporarily away (sick in hospital) (4.3%), or refused to participate (3.7%). Of 217 subjects in the final analysis, the mean age was 84.9 years, 85% were women, and most were dependent in all activities of daily living. Subjects demonstrated substantial cognitive impairment (mean Folstein Mini-Mental State exam score was 12.1 +/- 7.9), typically having deficits in memory, orientation, and visual spatial skills. Sixty-two percent reported pain complaints, mostly related to musculoskeletal and neuropathic causes. Pain was not consistently documented in records, and pain management strategies appeared to be limited in scope and only partially successful in controlling pain. None of the four unidimensional pain-intensity scales studied in this investigation had a higher completion rate than the Present Pain Intensity Scale of the McGill Pain Questionnaire (65% completion rate). However, 83% of subjects who had pain could complete at least one of the scales. We conclude that cognitive impairment among elderly nursing home residents present a substantial barrier to pain assessment and management. Nonetheless, most patients with mild to moderate cognitive impairment can be assessed using at least one of the available bedside assessment scales.

Cost issues related to pain management: report from the Cancer Pain Panel of the Agency for Health Care Policy and Research.

The clinical problem of unrelieved pain has received much attention over the previous decade with a major focus on cancer pain and acute postoperative pain. Organizations such as the World Health Organization (WHO), the National Cancer Institute, the American Pain Society (APS), and others have addressed the previously neglected areas of pain assessment, pharmacologic treatment, and the knowledge and attitudes of health-care providers. Health-policy issues related to pain, including areas of cost, access to care, regulatory perspectives, and ethical and legal issues, have likewise been neglected. To explore the costs associated with pain, the following framework has been developed through the Agency for Health Care Policy and Research (AHCPR) pain panel. This 13-point framework is an attempt to isolate specific cost issues, identify what is known in these areas, and address implications for future research. A brief synopsis of these 13 areas of cost analysis is provided including comments regarding work in progress by the panel and directions for future health-policy research related to pain management.

Nurses' knowledge about cancer pain: a survey of five countries.

Surveys of nurses' knowledge of cancer pain management were conducted in five countries: Australia, Canada, Japan, Spain, and the United States. The results reveal that, in all countries, serious knowledge deficits exist that could adversely affect the care of patients with cancer pain. It appears, however, that the longer a country has been engaged in efforts to educate health-care professionals and the public and to establish palliative care programs, the more likely are nurses from that country to possess correct information about cancer pain. Nevertheless, survey results in all countries strongly suggested the need to continue aggressive measures to educate nurses, who are the cornerstone of palliative care.

Nurses' knowledge of pain assessment and management: how much progress have we made?

Undertreatment of pain and lack of knowledge about pain management have been evident for approximately two decades. Because nurses are often the cornerstone of pain management, nurses' knowledge in this area is especially important. This paper explores indications of progress in the level of nursing knowledge about basic aspects of pain management. The literature is reviewed and findings from recent (1995) surveys of nurses' knowledge are compared with results of similar surveys conducted beginning in 1988. Improvements in nurses' knowledge of pain assessment, opioid dosing, and likelihood of addiction seem to have occurred. However, knowledge deficits continue. Fewer than one-half of the nurses surveyed understand that the patient's self report of pain is the single most reliable indicator of pain and that the nurse should increase a previously safe but ineffective dose of opioid. Findings from surveys on addiction reveal that the longer the patient receives opioids the more concerned nurses become about causing addiction. Nevertheless, results of current knowledge surveys of nurses suggest that educational efforts probably have been beneficial and should continue. To maximize the impact of educational efforts, content in basic and continuing education courses should be prioritized and critically evaluated for relevance and accuracy, especially content related to addiction. Early in the education of nurses, responsibility for pain assessment and use of analgesics must be instilled.

Pain and addiction: an urgent need for change in nursing education.

Lack of education of health care professionals, including nurses, is frequently cited as a major reason for undertreatment of patients with pain. A reason for undertreatment of pain with opioid analgesics is the irrational fear of creating opioid addiction. To characterize the information nurses receive in their basic education that could contribute to misinformation about this issue, the authors reviewed 14 nursing textbooks, published since 1985, including 8 pharmacology texts and 6 medical surgical texts. An analysis of content revealed that only one textbook correctly stated the definition of opioid addiction and its likelihood following use of opioid analgesics for pain control. Almost all of the texts used confusing terminology, and some erroneously promoted the fear of addiction when opioids are used for pain relief. A simple solution to this problem is to encourage nursing educators to use the American Pain Society publication "Guidelines for Analgesic Use" until textbooks have the opportunity to incorporate correct information.

The role of patient-controlled analgesia in the management of cancer pain.

The technology of patient-controlled analgesia (PCA) has gained wide acceptance for use in cancer pain management. Assessment of technological innovations is necessary in order to evaluate the most appropriate use from the perspective of the individual patient and broader health policy perspective. This paper reviews the literature related to PCA use in chronic cancer pain, appropriate and inappropriate uses of PCA, as well as several professional issues and directions for future PCA use. Professional dialogue regarding the standard of PCA care is necessary for optimum use of this technology for relief of chronic pain.

The experience of chronic nonmalignant pain.

This article reports the results of a survey of 204 persons with chronic nonmalignant pain who were members of a national self-help organization. The survey evaluated the organization, explored the perceived effect of pain on quality of life, and assessed experiences with and perceptions of health-care providers. Response rate was 40%. Of survey respondents, 50% reported inadequate pain relief. Respondents identified depression as one of the worst problems caused by their chronic pain: 50% reported that they had considered suicide due to feelings of hopelessness associated with their pain, 51% reported taking only as much medication as prescribed, and 44% reported taking less medication than prescribed. Further investigation is needed to describe the personal impact of chronic nonmalignant pain.