Objective clinical pain assessment by independent service identifies significant gaps in pain assessment and control.

Akella Chendrasekhar

Volume : VIII, Issue : V, May - 2019

Objective clinical pain assessment by independent service identifies significant gaps in pain assessment and control.

Akella Chendrasekhar

Abstract :

Pain is highly subjective. Standardized measurements are necessary to ensure adequate analgesia. Our objective was to examine whether an independent objective clinical assessment differs from existing provider documented assessment of pain levels.

We performed a retrospective analysis of randomly selected patients admitted to the trauma service at our Urban level I Trauma Ctr. (448 bed), over the course of 2 months. During this time period an independent team headed by the trauma medical director (AC) performed pain assessments on these patients using an objective numeric scale, (with 0 being no pain and 10 being the worst possible pain) within 1 hour of scheduled assessment by the primary care givers be they ED, Nursing or Physician. Medical records were reviewed for type of injury, objective pain level as documented on nursing, physician, and emergency department (ED) notes, objective pain level as documented by the independent team, and analgesic treatment.

A total of 101 patients were included. Types of injury included fall (n= 38), fall with fracture (n=21), motor vehicle collision (n=19), fracture (n=12), assault (n=8), and miscellaneous (n=3). The mean overall pain level as documented by the independent team was 4.35 � 0.76; 36 patients reported no pain, 7 patients reported mild pain (level 1–3), 17 patients reported moderate pain (level 4–6), 30 patients reported severe pain (level 7–9), and 11 patients reported experiencing the worst possible pain (level 10). Pain assessment documentation was missing in 36.6 % of emergency department notes (n=37), 31.1 % of nursing notes (n=32) and 64.4% of physician notes (n=65). Mean pain level varied by ED (5.37 � 0.85), nursing (1.98 � 0.67) and physician (2.94 � 0.96) notes. Analgesic treatment was composed of morphine (n=23), Oxycodone/acetaminophen (n=10), Ibuprofen (n=10), acetaminophen (n=9), acetaminophen/codeine (n=2), ketorolac (n=3), or any combination thereof (n=41). Three patients did not receive analgesic medication.

The assessment of pain level was absent in over 30 % of all clinical documentation, with physicians being the worst offenders. Despite receiving pain medication 57.4% of patients reported experiencing moderate to excruciating pain on an objective assessment. Further prospective research is necessary to examine the utility of these findings on a large scale basis. The utilization of independent objective clinical assessment is valuable to ensure appropriate pain management in trauma patients.