Pain.
Easy to feel but hard to describe, isn’t it?
Sharp, dull, aching, throbbing, excruciating. Like a Vise-Grip clamped on my back, a marching band playing in my head, a two-ton truck-tire tread on my leg.
Variations on the poetry of descriptions of pain are heard every day in emergency rooms and doctors’ offices. But the trouble with pain is that assessing it relies on a patient’s self-reporting. It can’t be taken like a temperature, heard in a stethoscope or verified by an X-ray. It’s invisible, subjective, sometimes fleeting, sometimes unrelenting.
And it’s the No. 1 reason people seek medical attention, as well as the leading complaint that goes unresolved.
Come Jan. 1, you’ll hear a lot more about pain. Hospitals will be looking for ways to assess, record and treat it more aggressively, as advocacy groups launch a national campaign to make this “hidden epidemic” a health care priority.
“In general, health care professionals, policy-makers and the public don’t consider pain a critical health issue,” said Jim Guest, executive director of the American Pain Foundation, an advocacy and information group.
Guest and 1,200 others were in Atlanta recently at the annual scientific meeting of the American Pain Society, a professional organization of researchers, physicians and other health care providers.
“The crime is that treatments and therapies to manage most pain are available, yet most pain goes untreated, undertreated or improperly treated,” Guest said.
That should begin to change next year, when 20,000 hospitals, health care networks, long-term and assisted-living facilities, behavioral health centers and other health services under the Joint Commission on Accreditation of Healthcare Organizations are mandated to make pain assessment a priority. Pain will become, in essence, the fifth medical “vital sign,” tracked and charted along with temperature, pulse, blood pressure and respiration.
Under the new standards, patients will be asked about pain and the intensity of the pain-sometimes by rating it on a simple 0 to 10 scale. Doctors and nurses will be expected to treat the pain and continue to assess treatment during and after hospitalization.
Anxiety, depression, sleep disturbances, loss of work and increasing pressure on vital organs are some of the results of not treating pain, as well as higher health care costs when patients return again and again seeking relief or change doctors repeatedly.
But despite such numbers, medical schools haven’t emphasized pain management, and hospitals and doctors in general have a dismal track record of recognizing and adequately treating it.
“Medicalizing the pain issue has been the push the last few years,” said Dr. Knox Todd, associate professor and vice chairman of Emory University School of Medicine’s Department of Emergency Medicine. “We do an inadequate job of taking care of pain.”
Overall, studies have shown that almost half of patients seeking relief at emergency rooms for painful ailments — sprains, fractures, broken ribs, abdominal pain, headaches, back strains — leave in moderate to severe pain.
And the outcome seems to be worse for minorities, said Todd, who has been involved in research comparing pain relief in African-Americans and Hispanics to whites.
In two separate studies that looked at pain medication given to people with broken legs and arms in Los Angeles and Atlanta emergency rooms, whites were treated for pain about 75 percent of the time, while African-Americans and Hispanics received pain medication 55 percent of the time.
“We could not explain that difference,” Todd said. “It couldn’t be explained with socioeconomic differences, language or severity of pain.
“And our ability to assess pain didn’t have anything to do with it,” Todd said. “It had to do with the decision by the physician to treat it. It raises the unpleasant possibility that it has to do with a bias against treating pain in minorities.”
The fear of abuse of narcotics is one reason doctors may withhold pain drugs or prescribe a non-addictive but less effective medication.
But the overwhelming reason pain is poorly treated, patient advocacy groups say, is failure to assess its presence and severity.
Two Grady Health System employees may have come up with a solution to that situation, in a software program called docuCare that’s used in a hand-held personal computer.
Dr. James Eckman and Allan Platt, who work in Grady’s Sickle Cell Center, have been working for years on a better way to assess sickle cell disease patients’ frequent episodes of pain.
The standard approach was to ask patients to pick a number from 0 (no pain) to 10 (worst pain of my life) to describe their pain at the moment. But the numbers seemed to just get scrawled onto charts and never reviewed to reveal the bigger picture of the effectiveness of treatment over time, Platt said.
His patented software program, being marketed by Triad Technologies of Lawrenceville, Ga., adds a few more questions, such as those about mood or behavioral changes influenced by pain.
The questions take no more than one minute, and answers are quickly punched into the computer.
The program also includes gathering of other standard information, such as intake of fluids and the patient’s weight.
“It’s a matter of just taking a little plastic pencil and touching a dot on a tiny screen,” said Sara Singley, an orthopedic nurse at West Georgia Health System, a 276-bed hospital in LaGrange, Ga., where the software program is being tested.
In 20 years in the nursing profession, Singley said, she has seen at least five charting systems come and go, none of which eliminated endless paperwork and stacks of patient records. “I’ve figured this has saved me one to two hours per shift, time I can be spending with my patients doing the little things for them and getting to know them better.”
Patients don’t seem to mind answering the additional questions about their pain, Singley said, and the system provides a running record that doctors can quickly review. The bedside assessment is repeated over the course of a person’s emergency room visit or hospitalization, downloaded into a main computer and then printed out in graph form. Colored-coded charts, each clearly showing the pattern of the five vital signs, become the paper record in a patient’s folder.
“It’s much easier to read and much more organized,” Singley said.
Several Georgia hospital systems are looking at the docuCare system, but so far none has purchased it. The system would cost a 400-bed facility about $100,000, said Jeffrey Dunbar, Triad’s president and chief executive officer.
“That may sound like a lot, but based on the experience at LaGrange, we’ve figured it would mean a savings of $400,000 to $500,000 a year when the time that’s being added back to the nursing staff is tallied up,” Dunbar said.
The new standards will not affect all hospitals, nursing homes and other facilities–only those accredited by the JCAHO, which accredits 80 percent of the nation’s hospitals that control 98 percent of the hospital beds.
“Undertreating pain has been and still is bad medicine, and is often based on unfounded fear, ignorance or miscommunication by health care professionals and patients, said June L. Dahl, professor of pharmacology at the University of Wisconsin Medical School and president of the American Alliance of Cancer Pain Initiatives. “Hopefully, the new standards will begin to change this.”
NEW RULES ON PAIN
Under rules of the Joint Commission on Accred-itation of Healthcare Organizations that take effect Jan. 1, hospitals and other health-care facilities must:
– Recognize the right of patients to have proper assessment and management of pain.
– Identify pain in patients during initial assessment and continue ongoing, periodic reassessments.
– Educate patients and families about pain management.
Contacts:
– American Pain Society: www.ampainsoc.org, 847-375-4715 or write 4700 W. Lake Ave, Glenview, IL 60025.
– American Pain Foundation: www. painfoundation.org, 888-615-7246 or write 11 S. Calvert St., Suite 2700, Baltimore, MD 21202.
– Joint Commission on Accreditation of Healthcare Organ-izations: www.jcaho.org, complaint hot line 800-994-6610, or write to 1 Renaissance Blvd., Oakbrook Terrace, IL 60181.
