Acute pain management: Implications of scientific evidence for nursing practice in the postoperative context

Unrelieved acute pain remains prevalent in hospitalized patients despite advances in pain management. A decade after the Australian National Health and Medical Research Council called for improved pain management practices by health professionals, it released clinical guidelines to provide clinicians with current scientific evidence to augment their clinical decision-making. This paper examines the implications of national guidelines on nursing practice and highlights the inadequacies of current implementation policies. Pain management guidelines have failed to decrease patients' postoperative pain because organizations and researchers have ignored the impact of contextual influences on clinicians' decision-making. It is recommended that for successful implementation of national guidelines to occur at the local level of practice, organizations must assist clinicians to identify local influences on their decision-making, to address the issues specific to their own work environment and to evaluate any changes in practice.

Effectiveness of pain management in hospital in the home programs

Alternative health care delivery models such as HITH facilitate the care of patients requiring acute treatments in their own homes. There are over 570 Diagnostic Related Groups managed in HITH programs and many of these are known to have associated physical pain. The impact of the home environment on patients’ experience of pain or how pain is managed is poorly understood. The purpose of this presentation is to
present the background and preliminary findings of a study that aims to increase our understanding of the issues related to providing optimal pain management for acute care patients who are transferred to Hospital in the Home. This knowledge will enable the development of effective practice guidelines to improve patient outcomes. More specifically, the aims are:
• To identify whether patients are transferred to HITH in pain or develop
   significant pain while in the program
• To identify the frequency and intensity of pain experienced by patients in 3      HITH programs.
• To describe patients’ experience of pain in the home environment.
• To investigate whether patients receive adequate pain relief once                      transferred to HITH.
• To explore the strategies patients use to manage pain at home.

The study will be carried out over 12 months in three HITH units in Victoria: Box Hill Hospital, Alfred Hospital and Epworth Hospital. The design is a descriptive survey of patients’ experience of pain and pain management using a modified version of The American Pain Society’s Patient Outcome Questionnaire. 360 consecutive surgical patients transferred to HITH care in the three participating programs will be interviewed by telephone between 48 and 72 hours of admission to the program.

The findings of this study will identify issues in providing optimum pain management for patients receiving acute care in non-traditional treatment environments.

Knowledge transfer and utilization: implications for home healthcare pain management

Implementation of research evidence into clinical practice is a complex and dynamic process that has become the subject of investigation in the field of "translation science" or "knowledge utilization." Research shows how individuals, units, and organizations all influence the rate and extent of adoption of research evidence. Environmental factors also play an important role in this process. This article summarizes key lessons from translation science and examines the implications for the organization and delivery of home healthcare. The implementation of pain management guidelines is used as an example.

Pain beliefs and pain management of oncology patients

Cancer pain is estimated to occur in 30% to 70% of patients with early-stage cancer and 60% to 95% with advanced cancer. Current research shows that cancer pain continues to be undertreated despite the availability of analgesics and established guidelines to maximize their effectiveness. The purpose of this study was to describe oncology patients' pain experience during an episode of hospitalization with particular emphasis on exploring the relationship between oncology patients' beliefs about pain and the treatment they received. Consecutive patients (n = 126) were interviewed 48 hours after admission to an urban and a regional hospital in Australia; 47.6% of patients had experienced moderate to severe pain in the previous 24 hours but had only received 40.4% of available analgesic. Patients held varying beliefs about pain and pain treatments in particular, 41% held strong beliefs about the potential for addiction to narcotics. Patients who held this belief reported higher current pain, worst pain intensity, and higher average pain intensity in the previous 24 hours. Effective pain management in the inpatient oncology setting continues to be an important clinical issue, and patients do not receive all available pain treatment. There may be an important association between patients' beliefs about pain and pain management and the pain management they receive.

The impact of patient sex on paramedic pain management in the prehospital setting

Objective: The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting.
Methods: This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, χ2 test, and logistic regression.
Results: Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84).
Conclusion: Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.

Effectiveness of pain management in hospital in the home programs

Objectives: The objective of the study was to examine patients’ experiences of pain in Hospital in the Home (HITH) programs and
identify the issues related to providing optimal pain management for acute care patients in the home environment.
Methods: A descriptive survey of patients’ experience of pain and pain management in 3 HITH programs in metropolitan Melbourne,
Australia (n=359). Data were collected by telephone interview using a modified version of The American Pain Society’s Patient Outcome Questionnaire. Patients were interviewed 48 to 72 hours after admission to the HITH program. Consecutive, adult, acute care patients were invited to participate in the study. Patients who had previously participated or had communication difficulties unable to be overcome with the assistance of an interpreter were excluded.
Results: Sixty-nine percent of patients interviewed experienced pain at home and 86% of these patients had experienced pain in the 24 hours before the interview. Over half (56%) of the patients had experienced moderate-to-severe worst pain in the previous 24 hours and 33% reported moderate-to-severe pain as their average pain experience. Two hundred thirty-two (93.2%) of the 250 patients who experienced pain had pain in hospital before being transferred to HITH. Of these patients, 52.2% (n=132) were prescribed analgesics to take home with them; the remaining 118 patients experiencing pain were not prescribed analgesics and either sourced analgesics once home (n=81, 68.1%) or did not take any analgesics (n=38, 31.9%).
Discussion: Treatment of pain at home was suboptimal with patients experiencing moderate-to-severe pain and discomfort during the treatment phase of their illness. Lack of appropriate discharge planning strategies meant that patients went home without adequate analgesia and use of non prescribed pain medication was common. The number of patients transferred home without analgesics indicates a worrying under recognition of the need for analgesia in this care context and poses a risk to patient safety that is no less significant because patients are at home.

A prospective analysis of pain experience, beliefs and attitudes, and pain management in a cohort of Danish surgical patients.

Background: 

Patient participation in quality pain management during an acute care admission

The objective of the study was to explore patient participation in the context of pain management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease. This is a single-institution study, with a case-study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including preadmission and predischarge patient interviews (n=98), naturalistic observations (n=48), and focus group interviews (n=2).

Observation of pain assessment and management- the complexities of clinical practice

• Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions.

• This observational study sought to investigate nurse–patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings.

• Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions.

• Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients.

• These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.