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Pain Management Assessment and Reassessment North Shore-LIJ Health System is now Northwell Health System Patient Care Services POLICY TITLE: CLINICAL POLICY AND PROCEDURE Pain Management: Assessment and MANUAL Reassessment POLICY #: PCS.1603 CATEGORY SECTION: System Approval Date: 10/20/16 Effective Date: NEW Site Implementation Date: 12/2/16 Last Reviewed/Revised: NEW Prepared by: Notations: System Nursing Policy and Procedure This policy was created by incorporating the Committee Northwell Health’s Geriatric Guidelines for Pain Management into the Northwell Health’s Pain Management : Assessment and Reassessment Policy dated 11/10 that can be found on the Intranet. GENERAL STATEMENT of PURPOSE To establish a standard for routine assessment, reassessment and documentation of pain as appropriate to the patient’s condition and treatment regimen. POLICY 1. Patients are screened and assessed for pain based upon clinical presentation, services sought, and in accordance with the care, treatment, and services provided. Facility personnel use methods to assess pain that are consistent with the patient’s age, condition, and ability to understand. 2. If the patient reports pain to a health care worker other than a licensed health care provider, the health care worker will escalate the report of pain to a licensed health care provider for assessment. 3. Pain assessment performed by health care providers will address individual, cultural, spiritual, and language differences. Pain measurement scales are available in various languages and, if necessary, access to a medical interpreter will be provided to assist in the evaluation of the patient’s pain. 4. The patient’s self-report of pain is considered the “gold standard.” For those patients who are unable to communicate the health care provider will assess pain by using the appropriate pain Measurement Scale. Assessment, intervention and reassessment of pain identified during an episode of care will be documented in the appropriate section(s) of the medical record. Page 1 of 11 PCS.1603 10/20/2016 a. In-patient units: Patients will have their pain screened, assessed and documented upon presentation to the facility and thereafter, with a minimum of once in each 12 hour period or more frequently based on the health provider’s physical assessment, prescriber order or patient condition. b. Behavioral Health facilities and units: Patients are screened upon admission for the absence or presence of pain. Patients positive for chronic pain conditions are assessed every 12 hours. Patients positive for acute pain, or who develop acute pain during their hospital or outpatient admission are assessed at onset, within 1 hour post-pain intervention, and as needed. c. Ambulatory Care Settings: Patients are screened for presence or absence of pain during any new patient visit, annual exam, and/or when the patient or patient’s designee reports pain. Non-licensed health care workers will escalate any complaint of pain to a licensed health care provider at the time of visit for further assessment. If indicated, patient will be referred to an appropriate provider for pain management. SCOPE This policy applies to all members of the Northwell Health workforce including but not limited to: employees, medical staff, volunteers, students, physician office staff, and other persons performing work for or at Northwell Health; faculty and students of the Hofstra Northwell School of Medicine conducting research on behalf of the School of Medicine on or at any Northwell Health facility; and the faculty and students of the Hofstra Northwell School of Graduate Nursing & Physician Assistant Studies. DEFINITIONS 1. Health Care Provider: includes but is not limited to the following: Registered Nurse (RN), Clinical Nurse Specialist, Physician, Certified Nurse Midwife, Nurse Practitioner, Physical Therapist, Occupational Therapist, Respiratory Therapist, Physician’s Assistant. 2. Patient’s designee: Whoever patient designates to be part of care plan and/or conversations, e.g. family member, significant other, support person, representative, or other. 3. Pain: is the unpleasant sensory and emotional experience associated with actual or potential tissue damage, or an experience described in terms of such damage. Pain is characterized by several quantifiable features, including intensity, time, course, quality, impact and personal meaning. “Pain is whatever the patient says it is, existing whenever the experiencing person says it does” (McCaffery and Pasero, 2011). Page 2 of 11 PCS.1603 10/20/2016 a. Acute pain: is characterized by sudden onset and short duration. The pathology and cause is often obvious (e.g. surgery). b. Chronic pain: “Pain that has lasted 3 months or longer, is ongoing on a daily basis, is due to non-life threatening causes, has not responded to currently available treatment methods, and may continue for the remainder of the patient’s life” (McCaffery and Beebe,1994). c. Nociceptive pain: is derived from stimulation of the pain receptors. Nociceptive pain is often due to inflammatory, musculoskeletal, or ischemic disorders. d. Neuropathic pain: results from a pathological process of the peripheral or central nervous system. Examples include post herpetic neuralgia, phantom limb pain, and trigeminal neuralgia. e. Mixed or Unspecified pain: caused by a mixed (both nociceptive and neuropathic) or unspecified cause of pain. f. Psychologically Mediated pain: caused by psychological factors that have a major role in onset, severity, exacerbation, or maintenance of pain. PROCEDURE AND GUIDELINES Refer to Attachment A - Pain Management: Assessment and Reassessment CLINICAL REFERENCES/PROFESSIONAL SOCIETY GUIDELINES 1. AHCPR (Agency for Healthcare Policy and Research) (1992). Acute Pain Management: Operative or Medical Procedures and Trauma 2. AHCPR (1994) Clinical Practice Guideline Cancer Pain Management 3. Feldt, K.S. (2000). Checklist of Nonverbal Pain Indicators. Pain Management Nursing, 1 (1), 13-21. 4. Horgas, A. (2003). Try This: Assessing Pain in Persons with Dementia. In Boltz, M (ed.), Try This Series: Best Practices in Nursing Care to Older Adults from the Hartford Institute for Geriatric Nursing, 1(2). New York, New York: The John A. Hartford Foundation Institute for Geriatric Nursing. 5. McCaffery, M., Pasero, C., (2011). Pain Assessment and Pharmacologic Management ELSEVIER Mosby 6. Urden, L. D., Stacy, K. M., Lough, M. E. (1996). Priorities in Critical Care Nursing, 2nd edition. Mosby, Inc. 7. Warden, V., Hurley, A., & Volicer, L. (2003). Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4(1), 9 – 15. REFERENCES to REGULATIONS and/or OTHER RELATED POLICIES The Joint Commission Hospital Accreditation Standards 2013 PC.01.02.07 The Hospital assesses and manages the patient’s pain. EP 1, 2, 3, 4 ATTACHMENTS Attachment A - Pain Management: Assessment and Reassessment Appendix A – Pain Measurement Scales Page 3 of 11 PCS.1603 10/20/2016 FORMS N/A APPROVAL: System Clinical P & P Committee 9/30/16 (e-vote) System PICG/Clinical Operations Committee 10/20/16 Standardized Versioning History: *=Clinical Policy Committee Approval; ** =PICG/Clinical Operations Committee Approval Page 4 of 11 PCS.1603 10/20/2016 Attachment A – “Pain Management: Assessment and Reassessment” I. Assessment: 1. When the presence of pain is identified, an appropriate assessment will be performed by a licensed health care provider. 2. Such assessment can include, but is not limited to the following: Location, intensity (quantity), description (quality) timing (onset/duration), precipitating/alleviating factors. Use appropriate pain scale (See Appendix A) Pain Assessment Scale Guide: • Neonate: Use Neonatal Infant Pain Scale (NIPS) o Neonate born greater than or equal to 37 weeks gestation: 0 through 28 days of life (≤28 days of life) o Neonate born less than 37 weeks gestation: corrected gestational age up to 45 weeks (<45 weeks corrected gestation) • 46 days to 3 Years: Use Face, Legs, Activity, Cry, Consolability (FLACC) scale. • Pediatrics less than 3 years of age / Patients unable to communicate: Use Face, Legs, Activity, Cry, Consolability (FLACC) scale. • Pediatrics 3 years of age and over: Use Wong-Baker Faces Pain Rating Scale. • Pediatrics over 6 years of age who understand concepts of rank & order: Use Numeric Pain Rating Scale. • Adult: Use Numeric Pain Rating Scale. Consider options of FLACC or Wong-Baker for adults with difficulty expressing numeric values for pain assessment. • Geriatric: Use Numeric Pain Rating Scale, Wong-Baker Faces Pain Rating Scale, Pain Assessment in Advanced Dementia (PAINAD). 3. Patients will be queried as to the personal acceptable level of pain. 4. Special Considerations: a. Substance Abuse Persistent (chronic pain) and/or past or present history of substance abuse: Treating medically ill patients who are experiencing chronic pain with past or present substance-abuse problems is complex and challenging. Clinicians should note the following: 1. Substance abuse can magnify chronic pain due to alterations in pain perceptions. 2. Patients with substance abuse problems may be identified in primary care or ambulatory settings. Page 5 of 11 PCS.1603 10/20/2016 3. Consider functional/behavioral status, including ability to perform ADL, work and or normal social interaction. b. Pain management in the Elderly Achieving adequate pain management in the elderly can be complicated by the presence of co morbid conditions, particularly the high prevalence
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