Quality Pain Management in the Hospital Setting

Background and aims: Pain management is an important factor in quality health care. Reviewing the literature shows that quality pain management (QPM) is vaguely defined and that pain is still prevalent and severe in many hospitalized patients, despite efforts to improve quality in the past decades. The aims of the study were to explore, define, and assess QPM in the hospital setting. This project is based on three studies, reported in four papers (I-IV). Material and methods: In the first study (Paper I) Morse’s method of concept evaluation was used to analyze the literature to identify the structural aspects of QPM, and to put forward a definition of the concept. In the second study (Paper II), a descriptive, cross-sectional design was used to evaluate the psychometric properties of the American Pain Society Questionnaire (APS-POQ-R), purport to measure patient outcomes in relation to pain management. In the third study a descriptive point-prevalence design was used to assess QPM from the patient’s perspective (Paper III), and explore the pain management processes in a university hospital (Paper IV). APS-POQ-R, Icelandic version (APS-POQ-R-I), was used to collect data from patients, but clinical and medication data were collected from medical records and the hospital-data warehouse, by checklists made by the researchers. A modified version of the Pain Management Index (PMI) was used to measure the adequacy of the pain treatment in paper IV. For the second and third studies the sample consisted of patients, 18 years and older, who had been hospitalized for at least 24 hours, understood Icelandic, and were able to participate in the study. For the second study the patients had to have experienced pain (defined as ≥ 1 on 0-10 scale) in the past 24 hours. For the third study all patients could participate, regardless of pain. The studies were conducted in 23 inpatient wards on surgical and medical services in Landspítali, The National University Hospital of Iceland. Results: In line with the Donabedian health care quality model, QPM constitutes the structure, process, and outcomes of care, embedded in safe, equitable, patient-centered efficient, effective, and timely services. The APS-POQ-R-I was found to be feasible, and to have acceptable psychometric properties. The questionnaire has four components that explained 64% of the variance, each with Cronbach’s α ≥ .70. Assessing patient outcomes (N=308), showed that the prevalence of pain in the hospital was 83% in the past 24 hours, and 35% of the patients had experienced severe pain (≥7 on a scale of 0-10). Pain interference was generally low, but a third of the patients experienced moderate to severe interference (≥5 on a scale of 0-10) with activities and sleep. Patient satisfaction was related to less time spent in severe pain, lower pain severity, and better pain relief. Reported participation in decision making was associated with better pain relief, and less time in severe pain, p<.01. Assessment of pain management processes (N=282) revealed that 85% of patients were prescribed analgesics, most often around the clock, and for 60% of patients the prescribed treatment was multimodal. A third of the sample reported using non-pharmacological methods to treat their pain, but such methods were rarely recommended by nurses or physicians. Pain assessment was documented for 57% of the sample, and use of pain severity scales was noted in 27% of documented assessments. Analgesic prescriptions were adequate in 78%, but administered treatment was adequate in 64%, measured with a modified pain management index. Documented use of severity scales was associated with higher odds of patients receiving adequate treatment, (OR 3.44; 95% CI 1.38-8.60). Conclusions: QPM is a multidimensional concept that can be operationalized, but needs further refinements. The APS-POQ-R-I was found to be a valid and reliable instrument to measure QPM outcomes in Icelandic hospitals. The study showed that pain management processes were equitable, and in many ways in line with recommendations in guidelines and pain management standards. However, many patients did not receive adequate analgesics to match their pain severity, and documented pain assessment was relatively unstructured. Patient outcomes in relation to pain showed that pain was both prevalent and severe. Patient satisfaction and participation in decision making were related to better outcomes. Clinicians need to use standardized scales to measure the severity of pain and use available treatment options to meet patients’ needs. Providing patient centered care, such as including patients in decision making regarding their pain treatment, should be promoted to improve QPM in the hospital setting. Structural aspects, like policies, procedures, and consulting services, might support pain management practices. Future studies need to explore the relationship between structure, process, and outcomes of care