Pain Assessment and Management Guidance for All Wards and Units Type: Register No: 11027 Status: Public Clinical Guideline Developed in Response to: Best Practice Contributes to CQC Outcome 4.9 Consulted With Post/Committee/Group Date Dr Alexander-Williams Pain Consultants 15/9/14 Dr Tom Durcan (Lead for Acute Pain) Lynne Mustard Pain Service Manager 15/9/14 Bharvi Patel Pain Specialist Pharmacist 15/9/14 Professionally Approved By Lead Consultant, IPMS Dr Alexander-Williams 17/9/14 Version Number 2.0 Issuing Directorate Pain Service Ratified By Document Ratification Group Ratified on 25th September 2014 Trust Board Sign Off date October 2014 Implementation Date 29th September 2014 Next Review Date September 2017 Author/Contact for Information Lynne Mustard, Clinical Nurse Specialist, Pain Management Policy to be followed by (target staff) Medical and nursing staff in contact with in patients Distribution Method Hard copies distributed to all wards and depts. Available electronically Related Trust Policies (to be read in conjunction Policy for the Use of Medicines with) Policy for the prevention of infection Policy for the protection of vulnerable adults Acute Pain Assessment and Management 3 months-16years (10045) Document review history Review No Authored/Reviewed by Review Date 1.1 28 April 2011 2.0 Jayne Somerset September 2014 1
Index 1. Purpose 2. Staff & Training 3. Scope of Practice 4. Policy 5. Analgesia 6. Infection Control 7. Non-Compliance with this Guideline 8. Audit & Monitoring 9. Communication & Implementation 10. References Appendices Appendix 1 Pain/Sedation and Nausea Measurement Tool Appendix 2 Analgesic stepladder 2
1. Purpose of Guideline 1.1 This guideline is intended to provide guidance for all medical, nursing and therapy staff in fundamental principles of ward-based pain assessment and management of noncomplex pain. 2. Staff and Training 2.1 Medical, nursing and therapy staff are expected to have an understanding of the need for regular assessment of pain and the clinical importance of treating pain promptly and safely. 2.2 The IPMS (Integrated Pain Management Service) is available for advice and consultation via the pager system, and through the PAS referral system. Information, guidelines and policy are available on the Trust intranet. 2.3 Training and education is provided by the IPMS, both formally and informally for all clinical staff. 2.4 Overall responsibility for ward-based pain management practice is that of the ward manager. It is the individuals responsibility to identify training needs and liaise with their senior to address these. 3. Scope of Practice 3.1 Every adult and child patient admitted to wards within the Trust or awaiting assessment, treatment or investigations within the emergency assessment wards has the right to pain management based on effective and regular assessment. For Children also refer to 10045 Acute Pain Assessment Management for Children 3 months -16yrs. 4. Policy 4.1 Full pain assessment must be recorded as part of the admissions procedure for every patient. This includes: pain history, existence of chronic (long term) painful conditions, acute episodes and their frequency, duration, site and severity, nature of pain, what helps/worsens the pain, and current analgesic drugs. 4.2 Pain scores are the fifth vital sign, and should be recorded at least twice a day while the patient is in the hospital. (See appendix 1). Greater frequency of assessment is indicated if pain is uncontrolled, and when analgesic responses require regular evaluation: i.e. up to hourly. 4.3 Additional pain assessment is essential to determine analgesic needs for patients undergoing painful procedures such as dressings, manipulation or physiotherapy. 4.4 Management of pain must be individually tailored according to the patient s requirements, own choices and clinical status. A holistic approach is required, addressing anxieties and queries as part of the pain management. 4.5 Patients requiring expert support to establish objective pain assessment and management, such as vulnerable adults, non-english speaking, cognitively impaired and children, must be referred to the appropriate specialty as indicated. 3
5. Analgesia 5.1 Analgesic prescriptions and administration must be evidence-based, and multi-modal, taking into consideration variability in individual responses, and contra-indications or cautions for certain clinical conditions. (See Appendix 2 for simple analgesic stepladder) 5.2 All staff prescribing or administering analgesia are responsible, and accountable for understanding the actions and adverse effects of the drugs given. 5.3 Analgesic drugs prescribed for Trust patients are provided from formulary in accordance with the Medicines Management Policy and Controlled drugs Policy 08083. 5.4 Analgesic needs must be evaluated regularly, as clinically indicated, and tailored accordingly. Escalation or reduction of dosage, change or cessation of drugs must be based on clinically sound evaluation. 5.5 TTAs ( To Take Away ) must be provided according to patient need, and further management advice stated clearly in the GP discharge letter. 5.6 Patient with complex pain issues which are unresponsive to standard analgesics may be referred to the IPMS for advice and further management. 5.7 Sources of information for analgesic doses and actions are: Pharmacy dept., IPMS, BNF (British National Formulary). 6. Infection Control 6.1 Staff coming into patient contact during assessment and administration of treatment and analgesics must conform to Trust infection prevention standards and guidance, by adhering to hand-washing standards between contacts. 7. Non-Compliance with this Guideline 7.1 Failure to provide regular assessment and effective pain management is a breach of patient rights, and has clinical and non-clinical repercussions: Patient satisfaction and well-being is compromised Accountability and professional responsibility is breached Clinical risk is increased, due to multi-systemic influence of pain Delayed discharge from hospital decreases Trust efficiency and increases risk of hospital-inquired infection 7.2 A risk event form should be completed and submitted to the Risk Management Department for non-compliance with this guideline. 8. Audit & Monitoring 8.1 Yearly audit of compliance to regular pain assessments on wards is carried out by the IPMS. 8.2 Incidence of clinical risk or patient complaints resulting from non-compliance of this guideline is recorded via the central risk events database and PALS if involved and a quarterly review of incidence of breaches will be undertaken by the IPMS based on these data, to identify trends, learn from reports and establish necessary actions. 4
8.3 The IPMS manager and lead consultant will liaise at corporate level to put strategies in place to address issues. 9.0 Communication and Implementation 9.1 Corporate services will ensure that the guideline is uploaded to the intranet and the website and notified to staff via Focus. 9.3 All link nurses will be informed of updated guidelines at regular meetings for them to disseminate to their areas/wards. 9.4 Medical staff will be informed of revised guidelines via senior medical staff within the IPMS at audit meetings and twice yearly teaching sessions for all FY1 and FY2 doctors. 10. References Dougherty L, Lister S (eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 6th ed. 2004, Blackwell Oxford (pub) Myths and misconceptions about opiates McCaffrey M, Pasero C (eds). In: Pain, Clinical Manual, 2nd ed. 1999, Mosby London (pub) DoH Essence of Care. Benchmarks for Prevention and Management of Pain. October 2010 Chronic pain Policy Coalition 2007: A new pain manifesto: Pain the 5th vital sign. Australian and New Zealand College of Anaesthetists and Chronic Pain Coalition ANZA 2005. Nurses knowledge of pain. Journal of Clinical Nursing;16:6,1012-1020; 2008 Older people are less likely to report pain: Hall-Lloyd and Larson 2006 Services for patients with pain. Clinical Standards advisory Group (CSAG) DoH 2000 Acute Pain Services: British Pain Society 2000 Code of Conduct: NMC Professional accountability: GMC 5
Appendix 1 Pain/Sedation and Nausea Measurement Tool This tool can be used for all patients requiring analgesia. Movement = eg patient attempts to touch the opposite side of the bed or deep breathe. All patients should be asked about pain at least bd (twice daily), regardless of analgesia prescription/intake. Pain Score Score 0 (none) No pain at rest, no pain on movement Score 1 (mild) No pain at rest, mild pain on movement Score 2 (moderate) Intermittent pain at rest, moderate pain on movement Score 3 (severe)* Continuous pain at rest, severe pain on movement * Call doctor or pain team Sedation Score Score 0 (none) Awake and fully responsive Score 1 (mild) Occasionally drowsy, easy to rouse Score 2 (moderate) Frequently drowsy, easy to rouse Score 3 (severe)* Somnolent, difficult to rouse * Call doctor or anaesthetist Nausea Score Score 0 Score 1 Score 2 Score 3 No nausea Nausea Vomiting Refuses treatment 6
Appendix 2 Analgesic stepladder SEVERE PAIN (Score 3) Epidural analgesia or morphine PCA or SC/IM protocol or oramorph/oxycodone plus NSAID plus paracetamol 1g QDS regularly MODERATE PAIN (Score 2) Low dose morphine or tramadol 400mg in 24hrs plus NSAID plus paracetamol 1g x 6hrly regularly MILD PAIN (Score 1) paracetamol max 4g-day NSAID * It is advisable not to give codeine or tramadol with other opiate based products. Avoid tramadol in epileptics; caution in patients receiving drugs that reduce seizure threshold. * NSAIDs should not be prescribed for more than 5 days in the first instance: caution in the elderly. Do not prescribe NSAIDs in the presence of renal impairment, dehydration, heart failure, active bleeding or a history of peptic ulceration. 7