Pain is an individual experience that must be translated into quantifiable terms that clinicians can use to assess and direct medical care to safely ameliorate. Adverse consequences of acute pain increase physiologic stress, are associated with adverse cardiovascular outcomes, and limit patients’ capability to cooperate in their postoperative recovery and rehabilitation. Treatment is directed at diminishing the perception of pain while, in balance, minimizing the potential adverse consequences of effective medical care. Following a review of assessment modalities to measure therapeutic success, strategic approaches to pain management are considered.

The University of California at San Francisco-Stanford University Evidence-Based Practice Center has previously defined patient safety as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.”¹ This definition emphasized the importance of reducing harm in patients to provide safe care and have been demonstrated in current practices such as “Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk” and “Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.”¹ The World Health Organization states that in order to achieve quality of care, “health care must be safe, effective, timely, efficient, equitable, and people-centered.”²

Since 2000, safety and quality of care have been described as “indistinguishable” by the Institute of Medicine, and since this time, patient safety during delivery of health care has been gaining increasing momentum.² Evidence-based models of improved health care delivery and advancing information technology have significantly improved communication and delivery of safe and effective care among providers. One such model, the Donabedian model was developed to provide a framework for examining health services and evaluating quality in health care by drawing information about quality of care from three categories called structure, process, and outcomes.³,⁴ While this has been useful in evaluating quality of care, the model does not account for patient, economic, or social factors.³ Nonetheless, the Donabedian model has successfully been used for safety and quality of care assessment.

The field of acute pain management has seen exponential growth in advancement of treatment options for acute pain; however, pain continues to be poorly managed and quality and safety concerns still present health care providers with obstacles.

Effective pain management first begins with accurate assessment of the pain that the patient is experiencing. Only from here may a practitioner initiate strategies to alleviate the pain as well as assess the quality of the pain management. Inaccurate assessment of pain quality can lead to poor quality of pain control measures, increased risk of delirium, increased morbidity and mortality, prolonged hospital stay, and worsening patient satisfaction.

Several barriers exist to safe and effective pain management and are identified as systemrelated (lack of evidence-based and standardized pain management protocols, pain specialists, and pharmaceutical agents), staff-related (ineffective communication and lack of knowledge and skills), physician-related (lack of knowledge and false concerns about addiction and overdosing), patient-related barriers (reluctance to take analgesics, fear of side effects and addiction), and nursing-related barriers.⁵,⁶ In addition, pain in itself is complex, multidimensional, and subjective in nature often requiring multidisciplinary approach to effective management.

Health care organizations are currently required to collect and review data regarding pain assessment and management while installing protocols to minimize risk associated with treatment options allowing for continual improvement in the safety and quality of acute pain management.⁷

Nurses play a pivotal role in the assessment of pain as they maintain the closest relationship with the patient within the hospital setting. In fact, nurses may play the most fundamental key role in safety and proper assessment in the acute pain setting. Some nurse-related barriers to effective pain management have been identified as inadequate knowledge, heavy workload, lack of time, and insufficient physician orders prior to procedures.⁵,⁶,⁸

Pain is multidimensional and subjective in nature. Pain assessment is challenging because the clinician must integrate relevant aspects of psychological, sensory, social, and cultural contributions to the patients’ experiences. For nurses to comprehensively assess and implement the treatment plan, they must factor in patient reports of pain location, aggravating and alleviating factors, timing, duration, intensity, effectiveness of any previous pain treatment, and the effects of the patients’ ability to cooperate with their rehabilitation plan. Frequency of assessment of acute pain should be standardized. This can vary greatly among institutions occurring as often as several times per hour in critical care units and to as little as once per shift within medical/surgical units.⁹ It is important that timely pain reassessment be performed after each intervention to help guide treatment as some intermediate interventions may be inadequate. A uniform method of pain assessment is a foundation for quality improvement activities. An ideal program yields high sensitivity and specificity data, is automated for ease of use, and provides a useful feedback loop to the clinicians and hospital leadership. Acute pain assessment tools and programs do not translate to management of patients with chronic pain and vice versa as the source of acute pain is generally known and usually less complex to understand and manage.

A thorough, comprehensive pain history must be obtained and shared among team members who share patient care responsibilities for the patient experiencing acute pain. A thorough history of previous treatment plans, pharmacologic and nonpharmacologic modalities, and their effectiveness will help guide future treatment. The provider must understand the physical and psychosocial ramifications of the patients’ acute pain experience, the patients’ attitude towards opioid, anxiolytic, or other pain pharmaceutical agent used, the patients’ coping response for the acute pain, and history of current psychological disorders. Finally, it is important that the clinician understand the patient and family’s beliefs, knowledge of, and expectations regarding previous, current, and future treatment plans.⁹

The current gold standard for pain assessment remains direct patient feedback regardless of vital signs such as respiratory rate, blood pressure, and heart rate. Commonly used pain assessments for acute pain management include the Visual Analog Scale (VAS), Numeric Pain
Rating Scale (NPRS), Verbal Rating Scale (VRS), Faces Pain Scale Revised (FPS-R), Wong-Baker FACES scale, McGill Pain Questionnaire, and the Assessment in Advanced Dementia (PAIN-AD) scale and are discussed below (See Table 51.1).

The VAS is very similar to the NPRS as a measure of acute and chronic pain in which patients will select a measurement between a line drawn between 1 and 10 cm. A mark made at zero represents “no pain,” while a mark made at 10 represents the “worst pain.” The strength of this assessment is the ability to track pain measurements overtime similar to the NPRS. The VAS has shown to be the most common test utilized for rating endometriosisrelated pain including dysmenorrhea, dyspareunia, and nonmenstrual chronic pelvic pain.¹⁰ It has also demonstrated clinical importance in assessing skin graft site-related pain.¹⁰ In addition, the Adamchic et al. VAS has also been used to assess loudness and annoyance of acute and chronic tinnitus.¹¹

The NPRS is a commonly used pain scale and consists of a numeric version of the VAS. The NPRS is a subjective assessment in which the patient selects verbally or in writing a value of pain that he or she has experienced within the last 24 hours on a horizontal line showing an eleven-point scale from no pain at all (Score of 0) to the worst pain imaginable (Score of 10). The test is used for adults and children 10 years or older. Advantages include quick testing (<3 minutes to complete and score) and ability to be given verbally and in writing and that it can be used without translation between languages. Studies have shown that the NPRS has been found to be an accurate and reliable method of rating acute pain with high sensitivity in which data can be analyzed statistically.¹²,¹³ It must be noted, however, that this method may only reliably rate pain intensity and does not take into account previous pain experiences or variations in pain intensity over time. In fact, the test may only average pain intensity experienced over the course of 24 hours.¹²,¹³ With the use of the NPRS over the course of days to weeks, one can track a patient’s progression in pain over time between health care providers allowing for better diagnoses and treatment and improving communication between providers.

The VRS presents different adjectives to the patient to choose which best fits the pain intensity that the patient is currently experiencing. The adjectives are used to describe different levels of pain intensity in order from “no pain at all” to “extremely intense pain.”¹⁴ The benefit to
having adjectives describe levels of pain intensity is thought to help patients and clinicians understand the nature of the acute or chronic pain in hopes of leading to a more effective treatment.

And while significantly different from VAS and NPRS, several studies have shown close correlation with these as well as other assessments of pain.¹⁵,¹⁶ In addition, the VRS presents descriptors of pain intensity that are easy to interpret and can give researchers more information regarding the complex nature of the pain experienced by the patient. Although adjectives used can range anywhere from 4 to 15 descriptors and the list must be completely read prior to giving an answer, participants have shown to be compliant. The VRS has been found to be a reliable assessment of pain in cognitively intact and cognitively impaired geriatric population.¹⁷

Advantages to the VRS include quickness to administer and ease of interpretation. This assessment may be disadvantageous in that interpretation of the adjectives may be influenced by age, sex, education, and other psychological factors present within the patient prior to the assessment. In addition, patients with mental health history or poor vocabulary may lead to inaccurate pain assessment necessitating the use of demographic and clinical factors to adjust scores. Finally, the VRS has a limited number of adjectives that may not be sufficient for certain populations and, unlike the NPRS, may not be easily translatable across languages requiring adjustment.

Also known as the McGill Pain Index, the McGill Pain Questionnaire was developed in 1971 as a pain questionnaire that gives the provider a more explicit description of their pain as it consists of 78 words description of pain within 20 sections.²² By doing this, the patients are able to give the provider a thorough description of their pain quality and intensity and attempt to answer the following questions²²: