Measurement of Pain as the Fifth Vital Sign. Dr Stephen Gilbert Scottish National Lead Clinician For Chronic Pain

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1 Measurement of Pain as the Fifth Vital Sign Dr Stephen Gilbert Scottish National Lead Clinician For Chronic Pain

2 Disclosure Statement of Financial Interest I, Stephen Gilbert, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3 Measurement A method of determining quantity, capacity, or dimension. Several systems of measurement exist, each one comprising units whose amounts have been arbitrarily set and agreed upon by specific groups. but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind. "If you can not measure it, you can not improve it." Lord Kelvin

4 How? What? Why? What next? Discussion

5 Pain Measurement Physical response to stimulus Dol developed to quantify pain threshold," just noticeable difference & maximum tolerated. Questionnaire too many to count Self Report Visual Analogue, verbal & numerical rating, dolotest

6 physical

7 physical

8 physical

9 physical

10 physical

11 AMYGDALA INSULA PARIETAL CORTEX ANTERIOR CINGULATE CAUD ATE NUCLEUS CEREBELLUM

12 Questionnaires McGill BPI Oswestry Low back pain scoring Low back pain rating Pain & Distress Scale Illness behaviour Questionnaire Pain Perception Profile Bio-behavioural pain profile TSK DAPOS Becks POMS Pain Catastrophising SF36 EQ5D Roland Morris WOMAC Etc... HADS

13 Self report

14 DOLOTEST Pain Problems with light physical activities Problems with more strenuous physical activities Problems doing your job Reduced energy and strength Low spirit Reduced social life Problems sleeping

15 IMMPACT Pain Numerical or verbal scale + analgesic use Physical functioning MPI or BPI Emotional Beck or Profile of Mood Global Impression of Change Symptoms & adverse events free text Patient disposition what happened? Dworkin et al IMMPACT recommendations Pain 113 (2005) 9-19

16 The 5 th Vital Sign Introduced by APS 1996 Taken up in California VA, 1999 Worldwide campaign Declaration of Montreal purpose to raise awareness Assessing & treating pain is just as important as checking vital signs

17 Objectives: The overall objective of this policy is to prevent pain and suffering Provide a system-wide standard of care for pain management that will reduce suffering from preventable pain. Assure that pain assessment is performed in a consistent manner. Assure that pain treatment is prompt and appropriate. Include patients and families as active participants in pain management. Provide for continual monitoring and improvement in outcomes of pain treatment. Provide for an interdisciplinary, multi-modal approach to pain management. Assure that clinicians practicing in the VHA healthcare system are adequately prepared to assess and manage pain effectively.

18 How bad is your pain? Q. "I don't really have pain, but I do have aching; is that pain?" A. People experience physical discomfort that they may label as something other than pain. This may include aching, pulling, tightness.. rate this aching experience on the pain scale. This will help us in making an assessment.

19 The Backlash Why pain cannot be a vital sign Hornstein - Misinterpretation of the Fifth Vital Sign Kozol - Arch Surg. 2007;142(5): Vila H et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Vila -Anesth Analg. 2005;101: Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign Lucas - J Am Coll Surg 2007;205: Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management Mularski - J Gen Intern Med June; 21(6):

20 How can we counter negative publicity?

22 Understanding

23 Understanding Believing

24 Understanding Believing Explaining

25 Understanding Believing Explaining Knowing our limits

26 Understanding Believing Explaining Knowing our limits Sharing decisions

27 Understanding Believing Explaining Knowing our limits Sharing decisions Using common sense

28 Thankyou questions??

Measure #131 (NQF 0420): Pain Assessment and Follow-Up National Quality Strategy Domain: Community/Population Health*

Measure #131 (NQF 0420): Pain Assessment and Follow-Up National Quality Strategy Domain: Community/Population Health* *Please note that PQRS 131 is incorrectly listed under the Communication and Care Coordination