Study Suggests Pain Screening Implementation for Veterans Falls Short
Despite the fact that pain is a frequent reason for seeking medical attention, it is often not assessed in ways consistent with current practice recommendations, thus hindering successful pain management. To improve pain screening, the American Pain Society first coined the term “Pain as the 5th Vital Sign” to promote routine pain assessment, and VA has required routine pain screening nationally since 2003, although many VA facilities adopted the 5th vital sign earlier. VA’s mandated outpatient pain screening uses a 0-10 numeric rating scale (NRS), and in VA outpatient practice, vital signs are routinely obtained by nurses or other nursing support staff. This cross-sectional cohort study included surveys of Veteran outpatients (N=465) and nursing staff (N=94) who screened for pain during normal vital sign intake. Data were supplemented by chart review. Investigators compared patient pain levels documented by the nursing staff with those reported by Veterans during the study survey.
Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain using the NRS. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point (67.1%). When differences did occur, the nursing staff under-estimated patient pain in 25% of the cases, and overestimated patient pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate patient pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status). The authors suggest that efforts to improve pain assessment will require multiple interventions targeted to patient, nursing staff, and environmental factors.
Shugarman L, Goebel J, Lanto A, Asch S, Sherbourne C, Lee M, Rubenstein L, Wen L, Meredith L, and Lorenz K. Nursing staff, patient, and environmental factors associated with accurate pain assessment. Journal of Pain and Symptom Management August 6, 2010;e-pub ahead of print.
This study was funded by HSR&D (IIR 03-150), and Dr. Lorenz was supported by an HSR&D Career Development Award. Drs. Lanto, Asch, Lee, Rubenstein, and Lorenz are part of HSR&D’s Center for the Study of Healthcare Provider Behavior in Sepulveda, CA.