How to Increase Happiness With Your Pain Management Skills

As health professionals involved in patient care we all want to deliver high-quality care, leaving at the end of the day knowing we've done our absolute best. And hoping that we won't learn later that our actions fell short of providing the patient with the best care possible.

With regard to pain management, this puts us in a challenging position.

How do we measure how well we are doing?

While on the one hand we want patients to be comfortable after a surgical procedure, physical trauma, or with a medical condition, we are also aware of the many pitfalls of medication prescription and the risk of polypharmacy. While scrutiny of our prescribing practices is warranted, we need to assure we are not swinging to the opposite pole and avoiding critical assessment of our own ability to manage pain.

We're learning that, despite all of the improvements in pain management over the years, poorly treated acute pain continues to be a significant problem. I'll talk about all of the ramifications of poorly treated acute pain in another post but today I'm posing two questions personally to you...

How are you doing with your pain management skills?

How do you think your patients would rate you based on

your ability to manage acute pain?

The truth is, it is often quite difficult to know how effective you are, especially when there are only subjective measures as our guide. The medications and the modalities we use are not the only factors to be considered; it is also the manner in which one conveys caring and compassion, a curiosity to understand the patient experience, and how we use the tools available to us that makes pain management 'a success'. Pain management is both a science and an art, and the necessary contribution of those two factors may change with different patients.

Let's look at some measures we may use to gauge the effectiveness of our pain management (and the pitfalls of doing so). And an alternative.

Pain scores. While occasionally you will encounter patients that rate their pain low on the pain scale, this should not necessarily be the ultimate goal. Everyone probably knows this theoretically; however in a real life situation, it's more challenging than that. High pain scores are distressing to not only the patient but also to us as health care professionals. We strive to minimize suffering. However, pain is an emotional experience and filtered through the patient's previous encounters; there are different types of pain, and not all of them are amenable to treatment with medications. In one study, even when pain scores remained high, patients were more satisfied with their pain management when their providers expressed willingness to work with the patients to improve the situation. Having said that, the overall trend in the pain scores during treatment can be beneficial but should not be the sole gauge of pain management efficacy.

Time to discharge. For a given surgical procedure, there may be an expected number of days to remain in the hospital. Time is needed to manage pain well, transition to oral diet, meet functional expectations in order to discharge the patient home safely. While meeting set goals for length of stay is important, hospitals have the responsibility to assure that patients feel confident upon hospital discharge, able to manage their pain and symptoms well while becoming more mobile. Many practices boast of their patient's compliance with expected discharge dates. If a patient feels they must leave the hospital because they are not receiving the care (or pain management) they need, that is not a 'win'. While length-of-stay is an important metric, we must do our best to empower patients to feel confident they have the knowledge to manage their pain at home.

The amount of opioid tablets prescribed. I believe there is a time and a place to prescribe opioids in the acute setting and not all procedures are associated with the same expected intensity of pain. Prescribing of opioids (in select circumstances) should not be considered a failure and can be an important decision to enhance recovery and mobility. Many providers are now making collaborative decisions of ranking surgical procedures based on expected intensity of pain for the typical individual and agreeing on an acceptable number of opioid tablets to dispense... or perhaps that opioids are not warranted at all. While I applaud these initiatives and agree that in the past that some health care professionals did prescribe excessive opioid tablets, we need to assure we are considering opioid prescription when it is warranted, even for a short period of time.

Check out this article regarding guidelines for opioid-prescribing from the Journal of the American College of Surgeons.

https://pubmed.ncbi.nlm.nih.gov/30118896/

Patient satisfaction scores. This is a challenging construct to assess as there are many confounding factors. Questions on satisfaction surveys regarding pain have been directed as follows:

1 'how hard the team worked to address your pain'

2 'how many times you were asked about your pain'

3 'the medication you received for pain took your pain away'

The challenge with the first question (how hard the team worked) is that often it is difficult for a patient to understand all of the nuances of pain management. Despite the health care team working to develop and deliver an effective pain management plan, the patient may simply not be aware of the efforts that are happening behind the scenes. Nurses are often proactive in educating patients of the indications for medications and treatments delivered but this is not consistent, or easy to implement.

Asking the patient about pain scores is an important aspect of identification and treatment but this activity cannot stand alone. The purpose of asking the pain score is ultimately that we can act on their response if the score is outside a particular range (ideally their realistic comfort goal). A recent study demonstrated that some providers did not consistently ask pain scores when visiting patients.

The third question ('medication you received took your pain away') is just an inappropriate question. We administer a medication because we hope to decrease discomfort but it would be unrealistic to think the goal should be complete elimination of pain. This question may have been removed from recent surveys but this is a good concept to discuss and you will encounter it frequently on the wards.

My recommendation --> I do ask patients if they feel the medication regimen is working for them. By that I mean that they are increasingly able to meet the mobility goals of the primary team, that they are able to rest some, improve their eating, work with physical therapy. Despite some discomfort, patients should be reassured that they will need to work to begin healing and some discomfort is normal. Complete elimination of pain should never be the expectation and these should be set with the patient prior to a surgical procedure whenever possible. You can stress that you will do your absolute best to safely and effectively minimize your patient's discomfort.

Feedback from your institution about your pain management skills. Your performance regarding use of evidence-based pain management strategies may not come in a formal manner. Often one needs to seek this out by speaking with the individuals that spend most time at the bedside, nursing personnel. Nurses will often have a very good idea which practitioners are more responsive to pain management concerns and those who are the most proactive. Make sure you check with them on a regular basis especially if your patient is having difficulty with pain. Just this action in itself can greatly change a challenging scenario into a beneficial one, particularly if you also revisit with the patient later in the day to follow up on a change you have made in the regimen.

Gauging Our Efficacy - Summary

Pain scores - Higher pain scores do not necessarily signal inappropriate or ineffective care. Instead of the actual number, the trend in the pain scores with treatment and the ability to improve mobility and reconditioning is more important. Also try to determine if there are other factors associated with higher pain scores such as sleeplessness, anxiety, mood concerns, being away from home, social concerns.

Time to discharge - while minimizing side effects and improving pain management contributes to appropriate length of stay, one must make strides to empower the patient to effectively manage their pain and symptoms at home. This includes making the patient actively aware of their pain management regimen while in the hospital and making adequate plans for transition to home.

Opioid tablets - while opioid prescriptions should be well-intentioned and ideally standardized to the intensity of the surgical procedure or medical condition, it may be unrealistic to consider a non-opioid approach for every situation.

Patient satisfaction scores - these scores are by nature subjective and are difficult to interpret. Alternatively, our institution has developed an electronically-derived list of patients whose pain scores are above a certain threshold, for example two or more pain scores greater than 6 (on the 0 - 10 Numeric Rating Scale) in a 24 hour period. One can determine if their patient is on this list and, if so, can make increased effort to verbally check in with them about their pain management experience. This may in itself set you apart from other providers and improve your therapeutic relationship with the patient.

- inform the patient of all medications and treatments used for pain; be specific and

encourage questions

- make an effort every time you see the patient to ask for and document their pain

score; find ways to reassure the patient of their progress and be flexible to make

changes as needed

- ask the patient if the medication regimen is working for them; reset expectations,

reassure, commend them for improved mobility and meeting mobility goals

Seek Feedback - check in with the nurses, your chief residents, your attending physicians about your pain management skills. Being proactive about this feedback demonstrates your intention to provide optimal care.

An Alternative.

Rather than relying heavily on patient satisfaction surveys, I believe we need to approach acute pain management in a systematic manner. Similar to the aviation industry, we could begin to gauge our efficacy with development of a pain management plan by beginning with a checklist of sorts. This is not a prescriptive approach per se but would prompt us to consider all aspects of pain that we may not have been aware of.

The basic components of this checklist would look like this:

- plan based on expected pain intensity

- appropriate expectations

- first-line agents

- non-pharmacologic agents

- adjunctive treatments

- are opioids appropriate?

- considerations for breakthrough pain

- how to reassess pain

If you are interested in this practical tool to be used at the bedside, check out my PreEmpt Pain app on this site.

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Do you have tips on how you gauge your efficacy with pain management?

Does your institution have a formal mechanism to measure this and communicate with you?

How do you seek feedback from others? Share your experiences with this community in the comments below or in the Forum.