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.

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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).

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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

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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

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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.

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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 of dementia, sensory impairment, an increased risk of adverse drug reactions and incidence of polypharmacy.

II. Plan of Care: 1. The assessment of pain does not stop upon completion of the screening/admission process. Patients who have pain will have their pain managed based on an individualized plan of care. This plan will be an interdisciplinary approach and will include: a) Input from the patient and/or their designee(s). . b) The patient’s pain intensity goal. c) The pharmacologic/non-pharmacologic interventions appropriate to the patient’s condition and age, such as positioning, physical therapy, cold/heat applications, behavioral therapies, diversional activities, relaxation and imagery techniques, etc. d) Patient and/ or their designee(s). education. e) Follow up: • Acute care setting: plan of care and follow up care will be documented on the discharge plan. • Ambulatory Care Setting: Plan of Care and any indicated follow up care will be documented in the medical record. 2. The Plan of Care should be revised as indicated by the patient’s condition and response to treatment.

3. Once pain is assessed, it will be classified for treatment purposes as follows: On pain scales from zero to 10- (zero indicating no pain) • Mild: Pain level 1 to 3 • Moderate: Pain level 4 to 6 • Severe: Pain level 7 to 10 4. Anticipated pain: Patients who need to be treated for pain at a zero pain level before participating in potentially pain provoking activities such as prior to a dressing change, procedure, or PT/Rehab should have a specific order to support the treatment for anticipated pain.

III. Reassessment 1. At the appropriate interval, the Health Care Provider will reassess the patient’s response to interventions based on the patient’s condition and treatment plan. 2. Assess pain relief from pharmacological and nonpharmacological interventions; monitor the efficacy of the interventions. a. Acute Care Setting i. PO analgesia: one half to one hour. ii. Subcutaneous and Intramuscular routes: one half hour. iii. Intravenous analgesia: fifteen minutes.

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iv. Patient - controlled analgesia (PCA), continuous IV drip and / or epidural opioid infusions: as ordered by prescriber or as required by policy. v. PCA or epidural analgesia: fifteen minutes to one half-hour if changes are made in rate. vi. All non-pharmacological interventions: one half-hour to one hour afterward. b. Ambulatory Care Setting: Reassessment will be individualized and completed based on the health care provider’s plan of care. Patient and / or their designee(s) will receive education related to the plan of care and instructed as to appropriate follow up.

3. If pain management is not adequate, revise the plan in collaboration with the patient/family member, health care prescriber and nursing staff.

IV. Patient Education: 1. Explain that pain can be managed and/or relieved, the importance of reporting pain and the benefits of pain control. 2. Explain the importance of preventing rather than chasing pain in effective pain management. Teach patients and /or patient designees to report pain as soon as it is experienced. 3. Describe to the patient and /or patient’s designee atypical manifestations of pain such as: a) Changes in function and gait. b) Withdrawn or agitated behavior. c) Increased confusion. 4. Teach patients and /or patient designees to use a pain scale at home. Once the appropriate tool has been determined, continue to use that particular scale. 5. Allay common fears/misconceptions regarding opioid use, such as addiction and respiratory depression. 6. Explain common side effects of analgesics (constipation, sedation, and nausea). 7. Teach non-pharmacological interventions and inform patient and /or patient designee that these interventions complement the treatment plan. 8. Patients and /or patient’s designee will also be educated regarding: a) Their rights to have their pain recognized and managed as part of treatment. b) Their role and participation in the overall treatment plan and management of their pain, including identifying cultural, spiritual, or personal beliefs, which should be taken into consideration in formulating an individualized pain management plan. c) Other education as identified by assessment and reassessment process. 9. Employ teach back strategies to facilitate understanding and participation. 10. Education and demonstration of understanding will be documented in the Medical record.

V. Follow up care 1. When treated at an acute care facility, the discharge process provides for continuing care based on the patient’s assessed needs at discharge. When evaluated and/or treated at an ambulatory facility, follow up plans and instructions are generated as necessary.

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2. The Pain Management Plan will be communicated to the next care provider, when applicable (e.g., patient, family, skilled nursing facility, home care, etc.). 3. This plan will identify the patient’s pain level, the patient’s goal of treatment, the scale utilized, location of pain, pharmacological interventions including last dose given and non-pharmacological strategies. 4. The plan will be documented in discharge summary or appropriate portion of medical record so that it may be accessed by providers as necessary.

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Appendix A

Pain Measurement Scales

1. Neonatal Infant Pain Scale (NIPS) Neonate born greater than or equal to 37 weeks gestation: 0 through 28 days of life (≤28 days of life) Neonate born less than 37 weeks gestation: corrected gestational age up to 45 weeks (<45 weeks corrected gestation) NEONATAL INFANT PAIN SCALE (NIPS) A score greater than 3 indicates pain. FACIAL EXPRESSIONS 0 – Relaxed Muscles: Restful face, neutral expression 1 – Grimace: Tight facial muscles; furrowed brow, chin, jaw, (negative facial expression – nose, mouth, and brow CRY 0 – No cry: Quiet, not crying 1 – Whimper: Mild moaning, intermittent 2 – Vigorous cry: Loud scream, rising, shrill, continuous (Note: silent cry may be scored if baby is intubated as evidenced by mouth and facial movements

BREATHING PATTERNS 0 – Relaxed: Usual pattern for this infant 1 – Change in Breathing: In drawing, irregular, faster than usual; gagging; breath holding ARMS 0 – Relaxed/Restrained: No muscular rigidity; occasional random movements of the arms 1 – Flexed/extended: Tense, straight arms; rigid and/or rapid extension, flexion LEGS 0 – Relaxed/Restrained: No muscular rigidity; occasional random leg movement 1 – Flexed/extended: Tense, straight legs; rigid and/or rapid extension, flexion STATE OF AROUSAL 0– Sleeping/Awake: Quiet, peaceful sleeping or alert random leg movement 1 – Fussy: Alert, restless, and thrashing

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2. Face, Legs, Activity, Cry, Consolability (FLACC)- Pediatrics less than 3 years of age / Patients unable to communicate

FLACC SCALE (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY) Patients less than 3 years of age or patients unable to communicate. SCALE 0 1 2 No particular expression or Facial muscles tense Frequent to constant frown, FACE smile. Facial muscles grimacing, frowning, clenched jaw, quivering chin relaxed withdrawn LEGS Normal position, quiet, Occasional restlessness, Frequent to restlessness, (Restlessness) relaxed shifting positions kicking, legs drawn up ACTIVITY Normal muscle tone, Squirming, tense, flexion of Rigid tone, (Muscle Tone) lying quietly, relaxed fingers and toes arched, jerking CRY No cry (awake or asleep) Moans or Whimpers; Frequent or continuous grunts (Vocalization) No abnormal sounds Occasional Complaint moans, whimpers, or cries Reassured by touching, Difficult to comfort/console CONSOLA- Content; Relaxed talking to, hugging, by touching, talking to, BILITY rocking. Distractible hugging, or rocking

3. Wong-Baker Faces Pain Rating Scale- Pediatrics 3 years of age and over WONG-BAKER FACES Pain Rating Scale

Using the pain rating scale is helpful for patients to communicate how much pain they are feeling.

Instructions: − Explain to the patient that each face is for a person who feels happy because he/she has no pain (hurt) or sad because he/she has some pain, or a lot of pain.

Face 0 is very happy because he/she doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts even more. Face 6 hurts even more Face 8 hurts a whole lot more. Face 10 hurts as much as you can imagine, although you do not have to be crying to be feeling this bad. Ask the patient to choose the face that best describes how he/she is feeling

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4. NUMERIC-Pain Rating Scale: Visual analog Scale 1-10 • Pediatrics over 6 years of age who understand concepts of rank & order: Numeric Pain Rating Scale

• Adults: a. Numeric Pain Rating Scale for those who understand concepts of rank & order. b. Consider the options of the FLACC SCALE (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY) or Wong-Baker Pain Rating Scale for a difficulty of expressing a numeric value for pain assessment. c. Advanced Dementia use the Pain Assessment in Advanced Dementia (PAINAD)

Pain Assessment in Advanced Dementia (PAINAD) BREATHING NEGATIVE FACIAL BODY CONSOLABILITY VOCALIZATION EXPRESSION LANGUAG E 0 Normal None Smiling, or Relaxed No need to console inexpressive 1 Occasional Occasional moan or Sad, frightened, Tense, Distracted or reassured labored groan. Negative frown Distressed by voice or touch. breathing. Short quality speech. pacing. period of Fidgeting Hyperventilation

2 Noisy, labored Calling out, loud Facial Rigid. Fists Unable to console, breathing. Long moaning, groaning, grimacing clenched. distract or reassure. period of crying Knees pulled hyperventilation. up. Pulling/ Cheyne –Stokes pushing respirations. away. Striking out. ** Add ratings of each of the 5 categories and obtain the TOTAL SCORE *(Warden, V., Hurley, A., & Volicer, L. (2003).

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