Pain and Itch Assessment and Management for the Burns Patient (Adults) Type: Clinical guideline Register No: 15025 Status: Public Developed in response to: Best Practice Contributes to CQC Regulation 9,11 Consulted With Post/Committee/Group Date Dr Tom Durcan Lead Consultant for Acute Pain October 2015 Dr Patricia Richardson Consultant Anaesthetist October 2015 Dr Rebecca Martin Consultant Anaesthetist October 2015 Lynne Mustard IPMS Service Manager October 2015 Alison Felton Burns Pharmacist October 2015 Professionally Approved By Dr Peter Dziewulski Clinical Lead for the Burns Department October 2015 Version Number 1.0 Issuing Directorate Integrated Pain Management Service Ratified by: Document Ratification Group Ratified on: 7 th December 2015 Executive Management Board Sign Off Date December/January 2016 Implementation Date 22 nd December 2015 Next Review Date November 2018 Author/Contact for Information Jayne Somerset, CNS, IPMS Policy to be followed by (target staff) Distribution Method Related Trust Policies (to be read in conjunction with) Burns specific Medical & Nursing Staff Hard copies to all wards-burns Reference Folder in Metavision (EPR), & departments. Intranet & website. Staff meetings and email Policy for the Use of Medicines Observation Policy 06001 Management of Procedural Pain 06000 Use of Entonox for Procedural Pain 06007 Severe Pain Management 06043 Oral Ketamine or Midazolam in Burns patients 09072 Intranasal Diamorphine for Burns Patients 11027 Pain Assessment and Management on Wards Document Review History Version Number Brief Reason for Change or Update Reviewed by Active Date (leave this blank if it s a full review) 1.0 Jayne Somerset 22 December 2015 1
INDEX 1. Purpose 2. Background 3. Scope of practice 4. Staff and Training 5. Pain Assessment 6. Pain Management 7. Infection Control 8. Non-Compliance with this Guideline 9. Audit & Monitoring 10. References Appendix 1: Appendix 2: Appendix 3: Appendix 4: Appendix 5: Abbey Pain Score Pain and Itch assessment Score Chart Adult Acute Pain Management Protocol Procedural pain relief for burn wound inspections Itch Management Algorithm 2
1. Purpose 1.1 The guideline has been developed to assist in the pain assessment and management of patients who have suffered burns. This covers both immediate, post burn rehabilitation, and procedural burns pain assessment and management. The guideline has been developed for patients who are 18 years or older. Note there is a separate guideline for Paediatric management in this group. 2. Background 2.1 Burn injuries are very painful and the intensity of the pain can be difficult to predict from the visual appearance of the injury and the size of wound. Deep burns can be relatively painless but burns are often not of uniform depth. Fear, anxiety and pain on previous inspection of the injury can lead to worse pain than the healthcare worker may expect, and with healing, the pain will evolve, making it better, or sometimes worse. Consequently, an effective assessment of pain is necessary to guide titration of analgesia. 2.2 Healing burns can also be very itchy. The mechanism of this is not clearly defined but involves nerve pathways often associated with pain transmission. Gabapentin has been shown to be effective in the management of itch, but there is no one size fits all therapy. The antihistamines have also been shown to be of some benefit, especially in combination with Gabapentin. As with the management of pain, itch intensity must be assessed to guide therapy. 2.3 Implementation of the guidelines should have minimal impact on staff workload or cost of service but will have a significant positive effect on quality of patient care. Improvement in the quality of pain and itch management strategies will reduce patient suffering, enhance psychological well-being and functioning and may reduce the anxiety felt by patients with regard to potentially painful clinical procedures. Good quality pain management in the acute phase of burn injury may reduce the incidence of chronic pain syndromes in the later phases of recovery. 3. Scope of practice 3.1 The guideline is intended to be used to help all nursing, relevant allied health care professionals, and medical staff in the accurate assessment and management of pain and itching for patients who have suffered any degree of burn injury. Further it is aimed to guide the doctor in prescribing the most appropriate analgesia required to treat burn pain. 4. Staff and Training 4.1 Approved guidelines are accessible from the staff intranet under clinical guidelines. 4.2 In addition, the clinical guideline will be disseminated to the ward through Pain Link nurses within their ward setting. 4.3 The new guideline will be introduced to anaesthetic staff through anaesthetic meetings. 4.4 Pharmacy are involved and made aware of the new guideline. 3
4.5 Training and education is provided by the IPMS, both formally and informally for all clinical staff. The IPMS is available for advice and consultation via the pager system, and through the PAS referral system. 4.6 Corporate services will ensure that the guideline is uploaded to the intranet and notified to staff via Focus. 4.7 Awareness of the guideline and the cascading of information within it can be conveyed in the daily consultant anaesthetist ward rounds carried out on the Burns Unit. 5. Pain Assessment 5.1 All burns patients should have their pain and itch score assessed. Pain scores are the fifth vital sign, and should be recorded at least twice a day while the patient is in the hospital. Greater frequency of assessment is indicated if pain is uncontrolled, and when analgesic responses require regular evaluation. 5.2 Additional pain assessment is essential to determine analgesic needs for patients undergoing painful procedures such as dressings, manipulation or physiotherapy. Pain should be scored and recorded before, during and after all potentially painful procedures. 5.3 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. 5.4 Patients requiring expert support to establish objective pain assessment and management, such as vulnerable adults, non-english speaking patients, and or the cognitively impaired, must be referred to the appropriate specialty as indicated. Separate assessment tools can be used. For cognitively impaired the Abbey Scale (see Appendix 1), for non-english speaking patients Translated assessment tools can be requested. 5.5 A specific combined Pain and Itch (See Appendix 2) assessment tool is used on the Burns Unit. 6. Pain Management 6.1 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. 6.2 All staff prescribing or administering analgesia, are responsible, and accountable for understanding the actions and adverse effects of the drugs given. 6.3 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. 6.4 Non-pharmacological pain management strategies should be used in addition to pharmacological methods whenever available and appropriate. 4
6.5 Patients with complex pain issues which are unresponsive to standard analgesics may be referred to the IPMS for advice and further management. 6.6 Sources of information for analgesic doses and actions are: Pharmacy dept., IPMS, BNF (British National Formulary). 6.7 An Analgesic ladder specific to the Burns Unit has been formulated from evidence based information, hard copies can be found within the unit (See Appendix 3). 6.8 A Burns specific quick reference algorithm tool is used to manage Procedural pain specific to this group (See Appendix 4) 6.9 A specific Itch management algorithm is used within the Burns Unit (See Appendix 5). 7. Infection Control 7.1 The Trust policy for prevention of cross infection is to be adhered to for all patient contact procedures. The infection prevention practice within MEHT is for all staff to have strict hand hygiene before and after patient contact. Any equipment must be cleaned between patients unless it is a single use item which will be disposed of appropriately as per the Waste Management Policy. 7.2 Use Aseptic Non-Touch Technique (ANTT) when administering injections. 8. Non-Compliance with this Guideline 8.1 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 8.2 A Datix form should be completed and submitted to the Risk Management Department for non-compliance with this guideline. 8.3 Incidence of clinical risk or patient complaints resulting from non-compliance with this guideline are to be recorded via the central risk events database and PALS (Patient Advisory Liaison Service) if involved. 9. Audit & Monitoring 9.1 The use of this guideline will be monitored by review of any reported incidents and annual audit. 9.2 Clinical meetings for Link nurses are held three times a year. Potential audit discussion and problems can be evaluated in this meeting. 9.3 The IPMS manager and lead consultant will liaise at corporate level to put strategies in place to address issues that may arise. 5
9.4 Pharmacist involvement within the Burn s unit review individual patient prescription charts. Issues that may raise concern can be readily discussed with the patient s medical or surgical teams. 9.5 Daily patient ward rounds are carried out within the Burns Unit. Any incident that may arise can be discussed and reported to the relevant persons at that time. 10. References 1. Goutos, I, Clarke,M, Upson,C, Richardson, Pand Sudip J. Ghosh (2010) Review of therapeutic agents for burns pruritus and protocols for management in adult and paediatric patients using the GRADE classification. Indian Journal of Plastic Surgery Sep 2010, vol. 43, p. S51. 2. P. Richardson, L. Mustard (2009) The management of pain in the burns unit. Journal of the International Society for Burn Injuries Nov 2009 vol. 35, no. 7, p. 921-936 Appendix 1: Abbey Pain Score Appendix 2: Pain and Itch assessment Score Chart Appendix 3: Adult Acute Pain Management Protocol Appendix 4: Procedural pain relief for burn wound inspections Appendix 5: Itch Management Algorithm 6