Saturday, June 3, 2006

Pain as the "5th Vital Sign" doesn't seem to help

Two recent articles in the Journal of General Internal Medicine address the effects of institution-wide pain management programs.

The first looks at the effect of implementing pain standards on pain control in a hospital.  It is a retrospective review of a single hospital's experience with implementing "pain standards" hospital-wide as part of a JCAHO compliance effort (the article's describes hospital-wide nurse and physician education measures and the introduction of nursing pain assessment, recording, and reaction standards).  They compared patients before and after and, to make a very long story short* they found no differences to speak of with regards to pain assessment, documentation, or control. 

The second looks at the policy making pain as the "5th vital sign" on pain control at a VA hospital.  This article was set in the VA's outpatient clinics and compared pain management practices (pain assessment, evaluation, and treatment)  before and after the "5th vital sign" policy began.   The authors found 1) no difference before or after, and 2) that pain management was generally of poor quality.

Neither of these studies should be a surprise, particularly in light of the recent Mt. Sinai pain management improvement project .  While it's tempting to interpret these findings as a condemnation of bureaucracy-driven quality improvement, even the Sinai study which was a well-thought out, rational, aggressive, and comprehensive effort to improve pain management hospital-wide did not demonstrate an actual improvement in pain control (as measured by patient self-reported pain levels).  (The Sinai study did show improvements in other areas such as pain assessment and opioid prescription.)  This goes to show just how difficult it is to demonstrate improvement of pain control across an institution, and why simple solutions probably don't help much.  The problem is, what if careful, data-based, "non-simple" solutions don't help much either?  I did much of my internal medicine training at a VA and while I was aware than pain was the 5th vital sign, and had a vague sense that that means someone takes it seriously, few of my attendings or peers in the clinic or wards seemed to care about it--pain control wasn't part of the culture for the most part, and that's not something that's going to change because there's a new box to fill out on a vitals sheet.  That sentence was too long, which tells me it is too late, and I should stop writing.

*And I mean very long story--this article's methods section was over two journal pages long!

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