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ViewsRegular Pain Assessment Scores in Infants: Help or Hindrance?
By Annie Rohan
In 2001, the Joint Commission (JC) implemented standards in the United States for regular reassessment of pain to improve its detection and management in patients (1). The
implementation of this guideline has been carried out most commonly by nurses using scaled pain assessment scoring at the time of vital sign assessment. Despite broad consumption of nursing resources to meet the JC requirement for patient pain assessment and reassessment documentation, little research has evaluated the JC standard for improved pain management. In particular, the utility of regular pain reassessment scores to improve pain management in nonverbal and preverbal patients had not been validated.
New research suggests that pain reassessment scores achieved with regular vital sign processes may not be quality indicators of the pain experience in infants cared for in the Neonatal Intensive Care Unit (NICU) (2). In a recent cross sectional study, over 800 pain assessment scores from 196 ventilated, premature infants in two tertiary care NICU centers were examined. During the study epochs, there were 836 documented painful procedures (primarily skin breaking procedures, such as heel sticks and intravenous attempts) of which 90 percent were not associated with analgesic or sucrose therapy. In addition, 23 percent of the scores were obtained from infants experiencing a painful conditions (such as need for a chest tube or postoperative status). Of the 804 pain scores evaluated, only 2 percent were elevated (n=24). In addition, 95 percent of patient days had no elevated pain scores.
This research demonstrates that in certain populations, pain assessment scores achieved using regular reassessment processes (e.g: with vital signs, when the patient is generally at rest) are poorly correlated with exposure to pain associated procedures or painful conditions. It is possible that serial low pain scores in this population may even be impeding the incorporation of analgesics into the patient’s plan of care. Providers who review pain score records may feel confident in having evaluated the patient’s pain experience without fully understanding the patient’s painful exposures.
There is an ongoing need to explore alternate methods for evaluating pain in nonverbal and preverbal patients, as well as managing the cumulative pain experience in these patients. For example, in addition to pain reassessment scores, documentation of the number of individual skin breaking events (including procedures and attempts at procedures) may be collected and reviewed alongside pain reassessment scores.
The use of multidimensional pain scales requires documentation on numerous points for nurses who carry out pain assessment processes. Documentation of six or seven pain assessment points in the electronic medical record has significant cumulative impact on nursing resources.
It may not be practical to require nursing documentation on this many points at regular intervals throughout the day. Nursing resources that are currently expended on regular pain reassessment processes need to be carefully considered in light of the clinical yield for these Expenditures.
References
(1) Joint Commission on Accreditation of Healthcare Organizations. Comprehensive
Accreditation Manual for Hospitals. Assessment of Patients. Vol Standard PE. 1: 42001.
(2) Rohan, AJ (2014) The Utility of Pain Scores Obtained During “Regular Reassessment
Process” in Premature Infants in the NICU. Journal of Perinatology (online ahead of print, April 10, 2014).
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Regular Pain Assessment Scores in Infants: Help or Hindrance?
By Nurse Advisor Magazine (Official)
There is an ongoing need to explore alternate methods for evaluating pain in nonverbal and preverbal patients, as well as managing the cumulative pain experience in these patients.
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