Purugganan Keian Justin F.

BSN III 2

08-23-13

Pain on medical wards in a district general hospital

Background. Little attention has been paid to pain on medical wards, with publications limited to the management of surgical patients. We wanted to establish the prevalence and severity of pain in the general medical setting, and how this compared with other clinical specialties. Methods. All consenting adult inpatients were assessed daily for 5 days. Patients recorded the occurrence and severity of pain, and whether their pain was bearable. The pain team reviewed patients with unbearable pain. Results. 1594 questionnaires were completed, representing 54% of the target population. 887 patients reported pain, 17% with pain scores over 6, and 10% with unbearable pain. The distribution of pain was similar for all ward types with 52% of patients on medical wards reporting pain. Of these, 20% reported severe pain and 12% unbearable pain. When patients with pain scores over 6 were analysed by consultant specialty, elderly care, general medicine, and general surgery scored highest. In each specialty 2025% of patients with pain reported a pain score over 6. In patients reviewed by the pain team, reasons for poor analgesia included inadequate information, pain assessment, analgesic prescribing, and administration and patient reporting. Conclusion. Patients in all hospital specialities experience pain. Until the issue of pain management in medical patients is fully addressed the situation will not improve. Br J Anaesth 2004; 92: 2357 Key words

pain, acute; pain, management; patient, medical Previous SectionNext Section Accepted for publication: July 8, 2003 Previous SectionNext Section Relief of pain is and will remain one of the most important roles of health professionals. It is not a new concept but it is only recently that services have been developed with the specific aim of managing pain as a symptom. In secondary care these services have concentrated their resources and development in three areas; palliative care, chronic pain and postoperative pain. Little is written about the occurrence of pain in other areas of the hospital, for example the medical wards, and the acute pain ward round rarely ventures onto these wards. In the UK publications on the management of pain have come from the Royal College of Surgeons, the Royal College of Anaesthetists, the Audit Commission, and the Clinical Standards Advisory Group.14 Even the latest report by The Clinical Standards Advisory Group entitled, Services for Patients with Pain actually states in their methods section, The study of acute pain services was limited to pain

relief after surgery or other trauma. It is also interesting to note that the Royal College of Physicians has no guidelines on the management of acute pain. We were interested in determining the prevalence and severity of pain in the general medical setting, and how this compared with other clinical specialties. Previous SectionNext Section Methods The study was approved by the local ethics committee. All in patients who were willing and able to participate in the study were assessed daily for 5 consecutive days. Patients in the maternity and Accident and Emergency departments were excluded. Patients completed a daily questionnaire asking whether they had pain. If the answer was yes, a pain score out of 10 was recorded on a verbal rating score and the patients asked whether their pain was bearable or unbearable. Patients with pain scores over 6 or who reported unbearable pain were reported to the clinical ward staff, and were reviewed by the pain team. At the end of the 5day period, patients were asked to prioritize one aspect of their pain management that they would improve. This allowed an opportunity for feedback and suggestions. The survey team consisted of members of the pain team, Clinical Audit Department, Department of Anaesthesia, and temporary staff recruited from an outside agency. A covering letter was given to all patients explaining the survey, and assuring confidentiality and anonymity. Previous SectionNext Section Results The number of questionnaires completed was 1594, representing 54% of the adult inpatient population. Data were unobtainable in 26% of patients because of severe illness or confusion. Of the remaining patients, 5% refused to take part and 15% were missed as a result of prolonged absence from the ward. Some patients did not answer all of the questions; therefore, the sample group for each question only includes those who responded. The number of patients who reported having pain during the previous 24 h was 887. The distribution of reported pain was similar for surgical, medical, and orthopaedic wards (Fig. 1) with about 60% of patients reporting pain in the previous 24 h. Seventeen per cent of these recorded pain scores of 6 or more and there was little difference between general surgical and medical wards. Patients on all ward groups reported unbearable pain, although this was less common on the orthopaedic wards (5%), than on medical or surgical wards (12.5 and 10.5%, respectively).

View larger version:

In this page

In a new window Download as PowerPoint Slide Fig 1 Percentage of patients in pain according to ward type, showing severity of pain experienced. Of the patients reporting unbearable pain, 19% stated that their pain was not assessed frequently enough (of whom 11% said it was never assessed). Fourteen per cent of patients with unbearable pain felt they were not offered painkillers frequently enough, and in 15% the analgesics given did not help.

When patients with a pain score of 6 or over were categorized by consultant specialty there was little difference between the prevalence of pain in general medicine, care of the elderly or general surgery (Fig. 2).

View larger version:

In this page

In a new window Download as PowerPoint Slide Fig 2 Percentage of patients with a pain score of 6 or more, as a proportion of all patients reporting pain within each consultant specialty.

When asked to prioritize one aspect of pain control, which could be improved, the medical patients varied in their responses (16% overall pain control, 29% fewer side effects, 39% more information, 16% more involvement). Previous SectionNext Section Discussion In The Royal Devon and Exeter Hospital, as in most others, the acute pain team has been set up primarily to manage surgical patients. Although this study only included approximately half the eligible patients, this study shows that pain can occur in any hospital in patients, not just those on surgical wards. Of the 43% of patients experiencing pain on medical wards, 12% reported unbearable pain and over 20% of elderly care and general medical patients reported pain scores greater than or equal to 6. The first stage in trying to improve pain control is to recognize and quantify the problem. Hopefully this study has achieved these aims and improvements can now be introduced. Interestingly, improved overall pain control was only the top priority for 16% of the medical patients in pain, with 39% wanting more information, and 29% wanting fewer side effects. The provision of information and treatment of side effects is relatively easy and are two of the core skills provided by the acute pain team. This suggests their involvement on the medical wards could provide easy but effective improvements in the pain management of medical patients. Other measures such as increasing staff and patient awareness of the importance of assessing and reporting pain, education of nursing and medical staff, and specific guidelines for analgesic prescribing (including treatment of side effects) may help reduce the number of patients reporting unbearable or severe pain. Such guidelines may be very different from those issued to surgical teams and may include specific strategies for medical and elderly care patients.

Reaction: According to this journal, pain is very common to the medical ward. In order to control the pain first stage in trying to improve pain control is to recognize and quantify the problem. This suggests their involvement on the medical wards could provide easy but effective improvements in the pain management of medical patients. Other measures such as increasing staff and patient awareness of the importance of assessing and reporting pain, education of nursing and medical staff, and specific guidelines for analgesic prescribing (including treatment of side effects) may help reduce the number of patients reporting unbearable or severe pain.

Theory: Melzack and Walls Gate control theory. This theory explains about a pain modulating system in which a neural gate present in the spinal cord can open and close thereby modulating the perception of pain. It also explains that pain can manage or control by doing different exercise like deep breathing exercise and taking medicines like paracetamol analgesic to reduce pain.