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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 109-112  

Pain management policy formulation at a tertiary care teaching institute in India: A prospective observational study


1 Senior Resident, Department of OncoAnaesthesia and Palliative Medicine, Dr. B.R.A.I.R.C.H. and N.C.I., A.I.I.M.S., New Delhi, India
2 Assistant Professor, Department of OncoAnaesthesia and Palliative Medicine, Dr. B.R.A.I.R.C.H. and N.C.I., A.I.I.M.S., New Delhi, India
3 Clinical Fellow, Department of Anaesthesia and Pain, Toronto General Hospital, University of Toronto, Toronto, Canada
4 Assistant Professor, Department of Anaesthesia, Super Speciality Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India
5 Professor and Head, Department of OncoAnaesthesia and Palliative Medicine, Dr. B.R.A.I.R.C.H. and N.C.I., A.I.I.M.S., New Delhi, India

Date of Submission09-Sep-2021
Date of Decision21-Sep-2021
Date of Acceptance17-Nov-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Sushma Bhatnagar
Department of OncoAnaesthesia and Palliative Medicine, Dr. B.R.A.I.R.C.H. and N.C.I., A.I.I.M.S., Office: Room No. 242, 2nd Floor, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1769_21

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   Abstract 


Background: Access to pain management has been recognized as a fundamental human right. Inadequate pain relief hampers the quality of life and has a physiological and psychosocial impact on the patient and caregivers. Inadequate pain relief remains the leading cause of suffering in hospitalized patients worldwide. Objective: The objective of this article is to provide adequate pain relief to hospitalized patients through proper assessment, treatment, and monitoring of pain by the trained health-care workers through a sustainable and effective institutional pain management policy. Methods: The formulation of pain management policy at a tertiary care teaching institute was conducted in three phases – Phase 1: need assessment by an open-label, uncontrolled, prospective observational study over 1 month period, Phase 2: teaching, training, and awareness of health-care workers, and Phase 3: constitution of the committee at the institute level with the formation of pain resource teams. Results: An open-label, prospective observational study conducted over 1 month revealed that among 814 hospitalized patients, 108 out of 235 (46%) patients in medical and 385 out of 579 (66.5%) patients in the surgical cohort had NRS score of ≥3, implying an inadequate pain relief even at 24 h following medical or surgical intervention, respectively. Conclusion: The provision of effective and adequate pain relief to hospitalized patients requires trained health-care workers and a uniform and structured pain management policy at the institutional level. Recognition and addressal of the barriers and challenges while framing an institutional pain policy is of utmost importance.

Keywords: Hospitalized patients, pain management, pain management policy, quality of life, teaching and training


How to cite this article:
Gupta R, Singh R, Ratre BK, Roychoudhury P, Yadav HP, Bhatnagar S. Pain management policy formulation at a tertiary care teaching institute in India: A prospective observational study. Indian J Public Health 2022;66:109-12

How to cite this URL:
Gupta R, Singh R, Ratre BK, Roychoudhury P, Yadav HP, Bhatnagar S. Pain management policy formulation at a tertiary care teaching institute in India: A prospective observational study. Indian J Public Health [serial online] 2022 [cited 2022 Aug 18];66:109-12. Available from: https://www.ijph.in/text.asp?2022/66/2/109/350656




   Introduction Top


An undertreated pain in hospitalized patients remains a global phenomenon, with India being no exception to it.[1] Inadequate relief of the pain hampers the quality of life of the patient as well as of the caregivers and incurs an extra burden on the health-care resources.[2],[3] A high incidence of pain ranging from 74% to 95% in hospitalized patients has been observed in a previous study.[4] The objective of this article is to describe the phased manner through which formulation and implementation of this institutional pain management policy have undergone, and the systematic addressal of barriers that were encountered during the process.


   Materials and Methods Top


Permission to initiate the project was obtained from the Institute Ethics Committee of the institute. A team of clinicians and nursing staff who had a special interest in pain management and believed that a uniform and structured pain management policy is required for providing holistic care to the patients took part in this project. Meetings were held regularly to assess and reassess the outcomes so that the policy could be framed, keeping in mind the perspectives of health-care workers, patients, and their caregivers. The project was completed in three phases, first, need assessment by exploring the magnitude of the problem (prevalence of inadequately controlled pain in hospitalized patients); second, teaching, training, and creating awareness among health-care workers regarding the importance of adequate relief of pain in hospitalized patients to decrease their suffering; and third, being the constitution of a committee at the institute level along with the formation of pain resource teams.

Phase 1: Need assessment by exploring the magnitude of the problem of inadequate pain relief in hospitalized patients

An open-label, prospective observational study was conducted to assess the magnitude of inadequate pain relief among hospitalized patients over 1 month. Inclusion criteria were all the adult patients with age ≥18 years admitted to the medical or surgical wards of the institute hospital irrespective of the diagnosis. The exclusion criteria were the patients ≤18 years of age and patients unable to communicate due to any physical or mental disability. After collecting baseline demographic, clinical, and baseline vital data, pain intensity was recorded on the 11-point Numerical Rating Scale (NRS) ranging from 0 to 10 by a trained nurse upon admission to the hospital ward. The 11-point NRS scale represents “0” as no pain and “10” as the worst possible pain ever. After admission, NRS was recorded and documented at a regular interval. An average NRS score was also calculated for 24h after the admission or any intervention.


   Results Top


Data obtained from a total of 814 patients were analyzed to determine the magnitude of inadequate pain relief among hospitalized patients. The majority of patients (23.3%) were in the age group of 18–29 years. Males and females were 492 (60.52%) and 322 (39.48%), respectively. The majority of our patients had attended high school (22.08%), but 134 patients (16.46%) were illiterate with no formal educational background. Out of 814 patients, 235 patients (28.86%) belonged to the medical cohort and 579 (71.13%) to the surgical cohort. [Table 1] highlights the number of patients in the medical cohort with pain scores <3 and >3 at the time of admission to the ward, 24-h postadmission, and an average NRS during 24 h since admission. [Table 2] highlights the number of patients in the surgical cohort with pain scores <3 and >3 at the time of admission to the ward, 24-h postsurgery, and an average NRS during 24 h postsurgery. Patients with pain scores >7 on the NRS scale were also noted, as highlighted in [Figure 1]. Hence, 108 out of 235 (46%) patients in medical and 385 out of 579 (66.5%) patients had NRS score of ≥3, even at 24 h after the medical or surgical intervention, respectively.{Figure 1}
Table 1: Pain scores of patients in the medical cohort

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Table 2: Pain scores of patients in the surgical cohort

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Phase 2: Teaching, training, and awareness of health-care workers

Aside from initial training for nursing personnel on the need of considering pain as the fifth vital sign and assessing intensity on the NRS scale, a focus was placed on correct documentation with other vital indicators. They were also taught about the safe use of opioid and nonopioid analgesics during the second phase of the training. The resident doctors of the institute were first sensitized about the importance of pain assessment and adequate treatment of the pain to alleviate the suffering of the patients. A comprehensive training about methods to assess pain in a different set of patients, use of various pain measurement scales, safe and rational use of opioids and nonopioid analgesics, and indication for referral of a patient to a specialist pain physician or an interventionist was given. For creating awareness, posters emphasizing our motto “Say No to Pain” were printed and circulated. Vital charts of the institute were modified with the incorporation of the pain as the “Fifth Vital sign” [Figure 2]. Also, pain as a fifth vital sign was incorporated in the hospital information system (HIS), thus making it mandatory for the entry of pain scores of all the admitted patients.
Figure 2: Incorporation of the pain as the “Fifth Vital sign” in the vital chart of a case file.

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Phase 3: Constitution of the committee at the institute level along with the formation of pain resource teams

In the third phase, a central committee was formed at the institute level with stakeholders from various disciplinary backgrounds to make them aware of the aim, scopes, procedure of implementation, and outcomes expected of the institutional pain policy. At the individual centers within the institute, teams were formed comprising of primary clinicians, trained nurse specialists, and pain resource teams and defined their roles. The role of nurses was to elicit information regarding pain, inform the physician in charge if NRS >3, administer prescribed medications, watch for side effects, and continuously reassess the pain at a regular interval. The role of the primary clinician was to respond promptly to reports of pain from the nursing team, assess the pain, prescribe medications to manage it, and refer the case to a specialist pain physician if the pain is difficult to manage. The role of the pain resource team was also well defined. They had to create awareness regarding the importance of pain relief, organize sessions for the education of the concerned personnel, and prepare and disseminate assessment and management protocols. They have to respond to difficult pain situations, be available for consultation after the treating primary unit has attempted its best with the available resources, and follow patients who have been prescribed strong opioids. An algorithm was formulated to seek help in case of inadequate pain relief in any patient at any ward of the hospital [Algorithm 1].



Barriers and challenges faced during implementation of the pain policy

The major obstacles that we observed while propagating the importance of pain management were the lack of organized, structured training courses in basic pain management and standard guidelines.[5] The proper assessment of the pain by clinicians from different specialty backgrounds sometimes becomes difficult due to lack of adequate training.[6] Physicians are also wary of using opioids for managing pain because of fear of misuse, addiction, and lack of awareness about government rules and regulations about opioid usage.[7],[8] Another important challenge was that the field of pain management being a gray zone because of the need for a multidisciplinary approach, thus the formation of a specialized pain resource team was imperative. Furthermore, the major challenge encountered to bring this noble project to the fore was the humongous scale on which it was planned to be launched with different strata of patients to cater to, as well as to persuade clinicians from the different disciplinary backgrounds and the nurses about the importance of uniformly implementing it. Removing their apprehensions about the safety of drugs, especially opioids, was a difficult task, but to our pleasant surprise, the feedback from the management, clinicians, and the nursing staff was phenomenal and encouraging.


   Discussion Top


”The Declaration of Montreal” in 2011 by the International Association for the Study of Pain states that the access to pain management must be recognized throughout the world as a fundamental human right.[9] The Global Burden of Disease survey has described the pain as the fifth highest contributor to the total number of disability-adjusted life years.[10] Through this project, we have taken the initiative to bring to the fore importance of addressing the pain concerns of hospitalized patients and managing them properly in the hospital itself. The results of our observation that quantified the prevalence of the problem revealed that the percentages of patients complaining of moderate-to-severe pain in both medical and surgical cohort even after 24 h of medical and surgical management were quite high (45.9% and 66.5% in medical and surgical cohort, respectively). This observation was an eye-opener that had further motivated us by providing evidence of the burden of inadequate pain relief in more than 50% of the patients admitted to the hospital and also gave an impetus to formulate the pain management policy for the institute. The primary reason for a high incidence of patients suffering in pain is the organizational barriers, fear of opioid use by the health-care providers, lack of basic education and training in pain management at the undergraduate curriculum level, and lack of service evaluation at regular intervals. There is a huge disparity in the use of opioids around the globe, with developing nations accounting for only 7% of global usage.[11] Tackling the problem of pain in the hospitals should not just be an institutional priority but become an important topic to be addressed at the national level also. At the same time, it is imperative to have a robust digital data collection of the patients suffering in pain in the hospitals. This can be made possible by the integration of pain as the fifth vital sign in the HIS, as has been done in our institute to enable clinicians to have regular pain audits. The purpose of this pain management policy was to reaffirm the institutional commitment to provide adequate pain relief to all its hospitalized patients. To effectively implement and frame this policy, a SWOT analysis was done. S – strength was a strong commitment, able leadership, and a unifying will to make patients happy and pain-free with the help of a multidisciplinary team involving doctors, nurses, physiotherapists, psychologists, and pharmacists; W – weakness was the presence of multiple pain clinics with no uniform guidelines and protocols of managing pain; O – opportunity was the huge lacunae in management of pain and demand from patient's side for providing good pain relief; and T – threat was that treating pain as a fifth vital sign would convert the policy into a drug epidemic.

The further plan is to conduct regular audits in the wards about the effectiveness of policy implementation by a team of supervising clinicians and nurses. It is proposed to have case discussions on patients with difficult to manage pain by a multidisciplinary team and formulation of specific protocols for such cases. The outcomes that are expected after a successful implementation of the pain management policy are adequate pain relief with subsequent reduction in the suffering of the patients. At the same point of time, we would want that institutes all over the country to take a leaf out of the successful implementation of our policy and try to formulate similar policies for their hospitals.


   Conclusion Top


Access to adequate pain relief is a fundamental human right. The inclusion of pain as the fifth vital sign should not be considered as a threat to create drug epidemics. For effective and adequate pain management in any hospital setting, equitable access to high-quality pain services must be made available; a multidisciplinary team approach should be followed along with effective training of all the medical and paramedical professionals where the emphasis needs to be given on bio-psychosocial concept of the pain. Moreover, conducting regular pain audits could help us to leap forward in our ultimate goal to alleviate the suffering of patients by offering adequate pain relief.

Acknowledgement

We would like to acknowledge and thank Professor Randeep Guleria, Director, AIIMS, New Delhi for providing constant support and guidance throughout our journey of implementation of the Pain Management Policy. We would also like to thank all the Pain Management Policy committee members- Prof. Rajeshwari Subramanium (Head of the Department, Anaesthesiology, Pain Medicine & Critical Care), Prof. Anant Mohan( Head of the Department, Pulmonary Medicine & Sleep Disorders), Prof. S.V.S. Deo (Head of the Department, Surgical Oncology), Prof. Nitish Naik (Department of Cardiology) Prof. Girija Prasad Rath (Department of Neuroanaesthesia & Neurocritical Care), Prof. Maneesh Singhal ( Department of Plastic Surgery), Prof. Shah Alam Khan (Department of Orthopedics), Prof. A. Shariff (Department of Computer Facility), Dr Angel Rajan Singh & Dr. Sheetal Singh ( Department of Hospital Administration), Sister Kamlesh Chandelia (Chief Nursing Officer) and faculty members from the Department of Oncoanaesthesia and Palliative Medicine at Dr. B.R.A.I.R.C.H., A.I.I.M.S., New Delhi, Prof. Seema Mishra, Dr. Rakesh Garg, Dr. Nishkarsh Gupta, Dr. Sachidanand Jee Bharati, and Dr. Vinod Kumar who were a constant source of encouragement in our endeavor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Bruster S, Jarman B, Bosanquet N, Weston D, Erens R, Delbanco TL. National survey of hospital patients. BMJ 1994;309:1542-6.  Back to cited text no. 1
    
2.
Becker N, Thomsen AB, Olsen AK, Sjøgren P, Bech P, Eriksen J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain 1997;73:393-400.  Back to cited text no. 2
    
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Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised international association for the study of pain definition of pain: Concepts, challenges, and compromises. Pain 2020;161:1976-82.  Back to cited text no. 3
    
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A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 1995;274:1591-8.  Back to cited text no. 4
    
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ACHEON Working Group; Kim YC, Ahn JS, Calimag MM, Chao TC, Ho KY, et al. Current practices in cancer pain management in Asia: A survey of patients and physicians across 10 countries. Cancer Med 2015;4:1196-204.  Back to cited text no. 5
    
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Fink R. Pain assessment: The cornerstone to optimal pain management. Proc (Bayl Univ Med Cent) 2000;13:236-9.  Back to cited text no. 6
    
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Kwon JH. Overcoming barriers in cancer pain management. J Clin Oncol 2014;32:1727-33.  Back to cited text no. 7
    
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Yanjun S, Changli W, Ling W, Woo JC, Sabrina K, Chang L, et al. A survey on physician knowledge and attitudes towards clinical use of morphine for cancer pain treatment in China. Support Care Cancer 2010;18:1455-60.  Back to cited text no. 8
    
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International Pain Summit of The International Association for The Study of Pain. Declaration of Montréal: Declaration that access to pain management is a fundamental human right. J Pain Palliat Care Pharmacother 2011;25:29-31.  Back to cited text no. 9
    
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Available from: http://www.healthdata.org/sites/default/files/files/policy_report/2019/GBD_2017_Booklet.pdf. [Last accessed on 2021 Sep 06].  Back to cited text no. 10
    
11.


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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