Original Articles Pain Prevalence Study in a Large Canadian Teaching Hospital yyy Jason Sawyer, RN, ACNP,* Lynn Haslam, RN, ACNP,* Sara Robinson, RN, ACNP,† Pat Daines, RN, MN, CHPCN(C),* and Kalli Stilos, RN, MScN, CHPCN(C)*

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From the *Sunnybrook Health Sciences Center and the †Holland Orthopaedic & Arthritic Centre, Toronto, Canada. Address correspondence to Jason Sawyer, Acute Care Nurse Practitioner, Acute Pain Service, Department of Anesthesia, Sunnybrook Hospital, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. E-mail: [email protected]. 1524-9042/$34.00 © 2008 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2008.02.001

ABSTRACT:

Despite the continued evolution of pain management techniques and an increased awareness of the importance of effective pain management, pain continues to be poorly managed. Following an earlier organization-wide pain collaborative, nursing leaders representing acute and palliative pain services together conducted a pain prevalence study. The purpose of this cross-sectional study was to evaluate the prevalence of pain and the level of interference that pain has on patient activities at a large teaching hospital. Two valid pain measurement tools, the short form of the Brief Pain Inventory (SF-BPI) and the short form of the McGill Pain Questionnaire (SF-MPQ), were chosen to be self-administered. The study revealed a pain prevalence of 71% in a mix of 114 medical and surgical adult inpatients. The SF-BPI results indicated that 31.5% of patients reported pain of moderate to severe intensity and that 11.4% of patients reported pain of severe intensity. The Nursing Advisory Council has committed to supporting an annual prevalence study as part of a corporate goal to monitor pain management across the institution. Forthcoming research will focus on including cognitively impaired patients and conducting thorough chart audits of all patients enrolled in the study. This project provided an opportunity for advanced practice nurses who share a common interest in pain, to collaborate in seeking improvements in pain management for hospitalized patients. © 2008 by the American Society for Pain Management Nursing Patients both expect high quality health care and assume that it exists (Green, Graham, et al., 2004). Pain management has been identified as a quality of care indicator for nursing (American Nursing Association, 1996) and a hospital accountability indicator (Ontario Joint Policy & Planning Committee, 2006). Studies have demonstrated that pain is the most common reason people visit the emergency room (Walsh, 1993) and a common reason for accessing general and specialty physicians (Bope, et al., 2004). Unrelieved acute pain can result in negative physiologic and psychologic effects (Carr & Goudas, 1999) and has been identified as a primary factor in the development of chronic postsurgical pain (Kehlet, Jensen, & Woolf, 2006; Perkins & Kehlet, 2000; Shipton, 2005). Pain Management Nursing, Vol 9, No 3 (September), 2008: pp 104-112

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In North America, attempts have been made to raise awareness about pain management, and to integrate it into patient care. In 1992 the Agency for Healthcare Policy and Research published acute pain management guidelines (Acute Pain Management Guidelines Panel, 1992), and in 1999 the Joint Commission introduced pain management standards into the accreditation standards of health care institutions (Joint Commission 1999). In 2003 the U.S. Congress passed the National Pain Care Policy Act, which established a White House Conference on Pain Care. Congress identified 2000-2010 as the decade of pain research (American Pain Society, 2000). In 2001, the Canadian Pain Society published their “patient pain manifesto,” a bill of rights for patients regarding pain management (Canadian Pain Society, 2001), and in 2003 pain management was integrated into the accreditation standards for hospitals (Canadian Council on Health Services, 2003). An OvidMedline and Cinahl online search on June 20, 2007, combining the title keywords “pain” and “practice guidelines” revealed 60 unique practice guidelines. Despite these initiatives, and the availability of information on managing pain, similarly designed prevalence studies completed several years apart indicate that patients’ pain is no better managed now than it was in the mid-1990s (Apfelbaum, Chen, Mehta, & Gan, 2003; Warfield & Kahn, 1995). In 2003, our hospital-wide pain collaborative won a National Best Practice Award for improvements in pain management. Despite this collaborative, our institution currently performs below the provincial average and a full standard deviation below the top performer in a patient satisfaction survey. The survey asks questions about all aspects of care received at our institution; however, the specific question that received low scores was: “Do you think that the hospital staff did everything they could to help control your pain?” (National Research Council & Picker, 2006). In response to these results, nursing leaders from the acute pain service and palliative care consultation team decided to perform a pain prevalence study, using validated and reliable tools to try to understand the prevalence and experience of patients’ pain. The objectives of this cross-sectional study were to assess the prevalence of pain and to what degree pain was interfering in patients’ activities at a large teaching hospital in Toronto, Ontario, Canada. The investigators hypothesized that pain (acute, chronic, postoperative, etc.) was not well managed.

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METHODS Study Design This study is a cross-sectional prevalence study of hospitalized patients’ pain experience. Data collection occurred on a single day in November 2006 during National Pain Awareness Week. Setting The study occurred in a hospital that has more than 600 beds, with established acute, palliative, and chronic pain teams. The concept of a pain prevalence study was introduced in September 2006. An initial meeting of the five internal pain management nurse experts (three acute pain nurse practitioners and two palliative care clinical nurse specialists) was convened and it was agreed to move forward with the initiative. Physician leaders from the acute, chronic, and palliative care teams at the institution were given notice of our intent, and all agreed that it was an important initiative. An expedited Research Ethics Board review was prepared and submitted on September 15, 2006, and approval was granted on November 1, 2006. Concurrently, the local nursing advisory council and patient care managers (PCMs) were introduced to the concept of the study at a monthly meeting and by e-mail. No objections were voiced, and concerns about potential workload increases for staff nurses were addressed. The investigators intended to meet with unit educators about the study, both as a professional courtesy and to enquire about their willingness to help with the study. Unfortunately, their next monthly meeting was after the intended study date. PCMs were asked to discreetly approach their respective educators about assisting with the study and to contact any of the investigators with any questions. It was agreed that the study would happen on Thursday, November 9, 2006. The PCMs were kept informed of progress via e-mail, and a forum for questions and concerns was available. To avoid any attention bias from the staff nurses, the managers were instructed to not inform their staff of the study. On the day of the study, envelopes containing the surveys were delivered to all units by the investigators. To minimize selection bias, the investigators worked with the nursing team leader to identify all patients meeting the inclusion criteria. A single member of the nursing team was identified on each unit to approach patients about participating in the study. On morning rounds, before 9 a.m., all eligible patients were approached and were informed about the study. A script prepared by the investigators was used to minimize recruitment bias. Patients interested in participating were given the consent forms and surveys at noon and were instructed to

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complete the survey by 3 p.m. the same day. That would ensure that the same nurse distributing the surveys would be able to pick them up before change of shift (3:30 p.m. on some units). Contact information for the primary investigator was available on the consent form.

Barcott, & Rossi, 1992; Melzack, 1987). It has also been used for the clinical evaluation of pain (McDonald & Weiskopf, 2001; Wilkie, Savedra, Holzemer, Tesler, & Paul, 1990). Zalon (1999) reported that these tools measure different aspects of the pain experience and should not be used as substitutes for one another.

Participants The PCMs provided data on the number of beds on their respective units. It was agreed that all units with potentially eligible patients would participate. The investigators were hoping to collect additional data (demographics, analgesics prescribed, analgesics administered) and asked for units to volunteer. The PCMs were also asked to volunteer their units and manpower to help collect the additional data. Two of 22 units volunteered. Criteria for inclusion in the study included the ability to read and write English, signed informed consent, and hospital admission ⬎24 hours. Having a ⬎24-hour admission requirement was important because it would provide sufficient opportunity for a pain management plan to be ordered and allow for pharmacy input and, if requested, consultation from the acute pain service, chronic pain service, or palliative care consult team. Exclusion criteria included inability to read and write English, refusing or not comprehending informed consent, admission ⬍24 hours, and patients admitted to ICUs, step-down units, and psychiatric units. Owing to limited resources, demographic data (including surgical procedure, past medical history, etc.) could not be collected.

Data Analysis Once data were collected, they were entered into a Microsoft Access database. Scoring sheets were randomly checked for quality assurance purposes. Statistical analysis was performed with Microsoft Excel 2003 and verified by a biostatistician using SAS Version 9.1 (SAS Institute, Cary, NC). Frequencies, ranges, means, and standard deviations were used to describe the sample.

Instruments The short form of the Brief Pain Inventory (SF-BPI) and the short form of the McGill Pain Questionnaire (SF-MPQ) were chosen as the prevalence tools. Both tools are validated and can be self-administered. The SF-BPI, originally developed as a general use pain assessment tool (Daut, Cleeland, & Flanery, 1983), has predictive validity in a number of patient populations (Keller et al., 2004; Mendoza, Mayne, Rublee, & Cleeland, 2006; Mendoza et al., 2004; Tan, Jensen, Thornby, & Shanti, 2004; Tittle, McMillan, & Hagan, 2003), and has been used for clinical and research purposes (Cleeland & Ryan, 1994). It is a 9-item survey that examines both pain and interference measures. The SF-MPQ (Melzack, 1987) consists of 15 descriptors (11 sensory, 4 affective) rated on a 4-point intensity scale. It also includes a Present Pain Intensity index and a Visual Analog Scale. Concurrent validity with the long-form MPQ (Dudgeon, Raubertas, Rosenthal, 1993; Melzack, 1975) has been demonstrated. Predictive validity has also been established in a number of patient populations (Fortin, Schwartz-

Sample The sample consisted of 72 surgical and 42 medical patients. The surgical patients were recruited from units that provide care to a variety of cancer and noncancer patients that had undergone colorectal, hepatobiliary, orthopedic, urology, gynecologic, cardiovascular, and trauma procedures. The 42 medical patients were on palliative, medical, and long-term units.

RESULTS The pain prevalence of the 114 respondents at our institution at the time of the survey was 71% (n ⫽ 81). See Figure 1 for patient flow through study. Results from the BPI indicated that 31.5% of patients reported pain of moderate-severe intensity (⬎4/10) and 11.4% reported severe pain intensity (⬎7/10) at the time of the survey. When asked to rate their pain at its worst in the last 24 hours, 76.3% reported pain ⬎4/10 and 47.3% reported pain ⬎7/10. When asked to report on the least pain intensity they had experienced in the last 24 hours, 26.3% reported moderate-severe pain, and 7% reported a least pain score of ⬎7/10. Patients reporting average pain ⬎4/10 were 58.7%, and ⬎7/10 14%. Many of the medical and surgical patients reported that pain severely interfered with their mood (19% and 24%, respectively) walking ability (33% and 43%), relationships (19% and 20%), sleep (30% and 38%), and enjoyment of life (31% and 42%). The most commonly reported measure of the SF-MPQ is the Pain Rating Index Total (PRIT), which is based on the rank value of each of the 15 descriptors used, and the mean intensity rating of each descriptor. Each descriptor ranks with a value from 0 to 3, with 0 as none, 1 mild, 2 moderate, and 3 severe. The PRIT is obtained by summing up the points from all descrip-

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TABLE 1. Brief Pain Inventory and McGill Questionnaire Results for 42 Medical Patients

Brief Pain Inventory Throughout our lives most of us have had pain from time to time Please rate your pain at its worst in the last 24 hours Please rate your pain at the least in the last 24 hours Please rate your pain on average Please rate your pain right now % relief from medications Pain interferes in: General activity Mood Walking ability Normal work Relationships Sleep Enjoyment of life McGill Pain Questionnaire Sensory PRI Affective PRI Total PRI (0-45 max score) VAS PPI

% Complete

Mean Score

90.4

66.6 (Y)

Range

SD

% ≥7/10

95

4.85

0-10

3.61

37.5

92.8 92.8 92.8 88 (4 NA)

2.03 3.36 2.23 61.67

0-10 0-10 0-10 0-100

2.90 3.09 3.07 35.6

10.2 17.9 15.3

85.7 (3 NA) 83.3 (3 NA) 83.3 (4 NA) 80.9 (6 NA) 85.7 (3 NA) 85.7 (3 NA) 90.4 (3 NA)

3.45 3.06 4.19 4.18 2.27 3.33 3.74

0-10 0-10 0-10 0-10 0-10 0-10 0-10

3.74 3.52 4.16 4.38 3.39 3.79 4.1

27.2 18.8 33.3 35.7 18.8 30.3 31.4

71 71

8.67 2.87 11.54 38.48 1.26

0-26 0-12 0-99 0-5

7.5 3.34 10.36 33.43 1.35

6.31

0-10

2.48

54.9

98.6 (1 NA) 97.2 (1 NA) 98.6 (1 NA) 95.8 (3 NA)

2.7 4.2 3.14 68.98

0-9 1-8 0-9 0-100

2.38 1.9 2.49 25.05

7 12.6 10

100 (6 NA) 100 (1 NA) 98.6 (11 NA) 91.6 (23 NA) 95.8 (4 NA) 100 (1 NA) 94.4 (9 NA)

5.61 3.92 5.58 6.77 3.08 4.59 5.29

0-10 0-10 0-10 0-10 0-10 0-10 0-10

3.32 3.31 3.51 3.79 3.22 3.48 3.75

43.9 23.9 43.3 69.7 20.3 38 42.3

97.2 97.2

10.96 3.77 14.73 40.18 1.76

0-30 0-12

4.37 3.72 7.25 32.33 1.2

73.8 85.7 (1 NA)

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Brief Pain Inventory and McGill Questionnaire Results for 72 Surgical Patients Brief Pain Inventory Throughout our lives most of us have had pain from time to time Please rate your pain at its worst in the last 24 hours Please rate your pain at the least in the last 24 hours Please rate your pain on average Please rate your pain right now % relief from medications Pain interferes in: General activity Mood Walking ability Normal work Relationships Sleep Enjoyment of life McGill Pain Questionnaire Sensory PRI Affective PRI Total PRI (0-45 max score) VAS PPI

100 98.6

91.6 100

87.5 (Y)

0-97 0-5

24.2

NA ⫽ not applicable; PPI ⫽ present pain intensity; PRI ⫽ pain ratings index; VAS ⫽ visual analog scale. Reprinted with permission from the Pain Research Group, MD Anderson.

tors, to a maximum of 45. The mean PRIT in our surgical population was 14.73 (SD 10.63; Table 1). Earlier research has demonstrated a mean score of 11

in the postsurgical pain patient (Melzack, 1987), with a similar SD of 9.65. It is interesting to note that our highest ranked descriptors in the postsurgical patients

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TABLE 2. Comparison of Postsurgical Pain Word Descriptors Between Current Study and 1987 Study by Melzack

Aching Tiring/Exhausting Tender Heavy Sharp Throbbing Shooting Stabbing Sickening Punishing/Cruel Cramping Fearful Splitting Gnawing Hot/Burning

Melzack, 1987

Current Study

Postsurgical Pain

Postsurgical Group

Mean Intensity (Preintervention)

Mean Intensity (Postintervention)

Mean Intensity

2.3 2.4 2.4 2.5 2.1 2.1 2.2 2.1 2.4 2.1 1.9 2.4 2 2 2.5

1.8 2 2.2 1.8 1.6 1.4 1.4 1.7 2 1.6 1.6 2.5 1.6 1.7 1.6

1.62 1.56 1.36 1.33 1.32 1.17 1.12 1.08 1.05 1 0.84 0.8 0.79 0.75 0.74

Sorted by mean intensity in the current prevalence study, compared with data from Melzack, 1987. Shaded areas are the five terms in each column rated with the highest mean intensity. Reprinted with permission from Ronald Melzack.

are similar to three of the top ranking descriptors in Melzack’s 1987 study (tiring-exhausting, tender, heavy; Table 2). The mean PRIT score that emerged from administration of the SF-MPQ in our medical patients was 11.54 (SD 10.37). No data in this population could be found for comparison.

DISCUSSION Over several decades pain prevalence studies have been reported in the literature. True comparisons are difficult, owing to variances in methods and reporting structure. Nonetheless, some unsettling similarities are apparent. Eleven studies assessing pain prevalence of inpatient medical and/or surgical patients were reviewed. In these studies (Table 3), pain prevalence either at the time of interview (44%-91%) or in the last 24 hours (56%-78.6%) was similar to our prevalence of 71%. In these 11 studies, 17%-88.5% of patients reported pain of moderate-severe intensity during admission, compared with 31.5% in the present study. For patients reporting severe, horrible, and/or excruciating pain, the incidence was 32%-58% in the literature, at various times during their hospital admission, compared with our 11.7%. Despite our low response rate, our results reflect those found in the 11 studies we reviewed, which

were published globally over several decades. Given the vast armamentarium of analgesic options available from the traditional acetaminophen, NSAIDS, and opioids (American Medical Association, 2005) to epidural analgesia (Richman & Wu, 2005) and peripheral nerve block techniques (Karaca, Hadzic, et al., 2000), it could be inferred that pain should be better controlled in 2007 than in previous decades, but the results of the present study suggest otherwise. Historically, minimal time is spent on formal education for physicians and nurses in the field of pain management (Billings & Block, 1997; Bonica 1985; Green, Wheeler, et al., 2001), with recent evidence suggesting that this has not changed (Lasch et al., 2002). Evidence suggests that practicing nurses (Brown, Bowman, & Eason, 1999; Lebovits et al., 1997) and physicians (Lebovits et al, 1997) also have knowledge deficits regarding accepted pain management practices, and beliefs that could contribute to suboptimal pain management. Our institution also has well established acute and chronic pain services, providing regional and neuraxial techniques, and a palliative care team. Both the acute pain service and the palliative care team have advanced practice nurses. Unfortunately we were unable to gather sufficient evidence that delineates the prevalence scores of patients followed by

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TABLE 3. Comparison of Pain Prevalence Study Results over the Last 30 Years

Year

Author

No. of Patients Pain Prevalence Recruited Type of Patient Data

1973 Data from Marks & Sachar

37

Medical

1983 Data from Sriwatanakul, Weis, et al.

81

Surgical

1987 Data from Donovan, Dillon, et al.

353

1987 Data from Donovan & Dillon

69

Medical/surgical 43.3% at interview Oncology

50% at interview

1998 Data from Yates, Dewar, et al.

205

Medical/surgical 78.6% in last 24 h

2001 Data from Trentin, et al.

761

Medical/surgical 44% at interview

4,121

998

Medical/surgical/ 43.1% at rehab interview, 56.6% in last 24 h Medical surgical 55% at interview

1,594

Medical/surgical 60% in last 24 h

561

Medical surgical 50% at interview, 63% in last 24 h Medical/surgical 91% at interview

2002 Data from Costantini, Viterbori, et al. 2002 Data from Salomon, TchernyLessenot, et al. 2004 Data from Dix, Sandhar, et al. 2005 Data from Strohbuecker, Mayer, et al. 2005 Data from Visentin, Zanolin, et al. 2008 Data from Sawyer et al.

3,931 114

Medical/surgical 71% at time of survey

pain services and those that are not. It is hoped that future studies will be able to answer that question. The plan to administer a pain survey during National Pain Awareness Week to patients across all programs at a large university-affiliated hospital presented both challenges and opportunities for investigators. Limited planning and preparation time (2 months from concept to completion) meant that the ability to use all available forums and structures for communication within the organization and enlisting support for the project from senior management were compromised.

Pain Severity Data 73% moderate-severe distress from pain over last 48 h 32% with severe distress from pain 41% with at least moderate pain as the minimal level in last 72 h 58% experienced horrible or excruciating on this admission 51% horrible/excruciating this admission 33.5% reported pain severity as distressing, horrible, or excruciating Mean pain intensity of all patients was 4.9/10 11.7% experienced severe pain at interview, 29.6% experienced severe in last 24 h 25% experienced severe pain in last 24 h 17% with moderate/severe pain in last 24 h 58% moderate/severe pain in last 24 h, 36% severe pain in last 24 h 70% moderate/severe pain at interview, 46.6% severe pain at interview 31.5% reported moderate/severe pain at interview, 11.4% reported severe pain at interview, 76.3% reported moderate/ severe pain in last 24 h, 47.3% reported severe pain in last 24 h, 7% reported severe pain as the least intensity in last 24 h

Interest from nursing management was easily achieved, because the organization had participated in a corporate-driven pain collaborative initiative several years earlier and a culture of continuous quality improvement was strongly supported by senior management. It should be acknowledged that the investigators chose to do the study on a short time line, so that it could be completed during National Pain Awareness Week. Overall, the study was deemed a success, despite the low response rate (41%), because there was no prior prevalence data available and there were

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695 Total Potential Beds

122 patients on cognitive deficit units deemed ineligible

573 Potential Patients Beds

277 patients met inclusion criteria

114 consented to participate in study 41.1% Response Rate* *not all patients completed every question. See results

FIG. 1.

Reasons for not consenting Refusal (no reason) No Pain Too much pain Discharged prior to 12:00 Too tired

y Flow of participants through the study.

limited resources available to assist with completing the study.

LIMITATIONS Several limitations must be acknowledged. Despite verbal support from the organization’s nursing advisory council, and frequent dialogue between managers and investigators, communication gaps did occur. This translated to additional obstacles for the investigators to overcome on the day of the survey. The PCMs had indicated that they would communicate the study concept to their educators. On the day of the survey, the investigators found that this communication had not occurred. The investigators were disappointed that only two of the 22 patient units offered to assist with additional data collection (i.e., patient demographics, analgesic use, history of chronic pain, etc.). It was therefore decided to not collect those data at all, because it would not be representative of the total population for which data were collected. This obviously affects the ability to describe the attributes of the population studied. It must be stressed that the 2-month window from study conception to completion was a factor in the lack of support. To preserve the integrity of the study, knowledge of this hospital-wide initiative was not shared with staff nurses. Both during and after the study, some staff were offended by this and indicated that they felt they had no vested interest in ensuring its success. Others felt that if they were informed they would have altered their workload to ensure they helped patients that needed additional support. Another limitation experienced during implementation of the study related to the tools. The assessment

tools used required that patients participating be able to read and write English. In our setting, a large tertiary hospital in a multicultural city, this requirement narrowed the population for recruitment. Because patients were expected to complete the questionnaires independently, some that may have had visual or motor problems were also unable to participate. Although patients in the long-term care area of the hospital were approached to participate, many were unable to, owing to a cognitive impairment. Questionnaires were not completed or were incomplete for a variety of reasons. Some patients reported that they didn’t have pain so they didn’t fill out the questionnaire, some had too much pain and thought there was no purpose to filling it out, and others were too tired, forgot, or declined with no reason. Some patients were missed owing to early discharge. Owing to the barriers outlined, it is not surprising that our response rate was only 41%.

NEXT STEPS Because most patients in the long-term care facility suffered from a cognitive impairment, the team plans to include this population by using a validated tool specific to this population, such as the Doloplus-2. After presenting preliminary results to the nursing advisory council in February 2007, there was a commitment made to ensure that next year there would be a dedicated person on each unit to ensure a higher survey completion rate. For future prevalence studies, the investigators plan to include a chart analysis of all the patients enrolled, to include diagnosis, gender, age, date of admission, number of days after a surgical procedure, type of analgesic used, frequency of analgesic, and whether a referral was made to a pain

Pain Prevalence 2006

consultation service such as the palliative care, chronic pain, or acute pain service. This additional information may provide further insight into local barriers to pain management. The project provided an opportunity for advanced practice nurses from palliative care and the acute pain service with a common interest in pain to build on collaboration and connect professionally in a

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joint effort toward a common goal that will continue to flourish and improve in the years to come.

Acknowledgements The authors are grateful for all the statistical support and guidance provided by Alex Kiss, biostatistician, from the Institute for Clinical Evaluative Sciences.

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