RESEARCH
2.5
Infrequent Assessment of Pain in Elderly Trauma Patients
ANCC Contact Hours
Sarah K. Spilman, MA ■ Lisa A. Baumhover, MS, ARNP, GCNS-BC ■ Cheryl L. Lillegraven, MSN, ARNP, ACNS-BC ■ George Lederhaas, MD ■ Sheryl M. Sahr, MD, MS, FACS ■ Lori L. Schirmer, PharmD, BCPS, BCNSP ■ Dustin L. Smoot, MD, FACS ■ James R. Swegle, MD, FACS
ABSTRACT There are inherent difficulties in assessing and managing pain in elderly trauma patients, especially those with chronic health conditions or diminished capacities for self-reporting pain. This retrospective study identifies and describes patterns of pain assessment for a trauma population of older adults (age ≥65 years). Gaps between patient assessments existed in all phases of hospitalization and did not meet hospital guidelines for frequency of assessment. In addition, assessment methods were not always appropriate for the patient population. We conclude that older patients were not assessed for pain frequently enough, and that more regular and routine pain assessments may improve patient outcomes.
Key Words Critical care, Elderly, Geriatric, Pain assessment, Trauma
A
s the American population ages, so too does the population of trauma patients presenting to hospitals and clinics after sustaining injury.1 The leading cause of injury for these patients is same- or multilevel falls, often resulting in lengthy or repeat hospitalizations and substantial medical costs.2,3 It is clear that pain results from most traumatic injuries, yet very little attention has been given to the assessment and management of pain in older trauma patients. Effectively assessing and managing pain in older adults is difficult. First, older adults are more likely to have chronic pain conditions before the traumatic injury, such as degenerative joint disease, neuropathy, nerve impingements, or osteoporotic fractures.1 They may be taking
Author Affiliations: UnityPoint Health Des Moines (Ms. Spilman, Ms. Baumhover, Ms. Lillegraven, Dr Lederhaas, Dr Sahr, Dr Smoot, and Dr Swegle), Des Moines, Iowa; and Fort Sanders Regional Medical Center (Dr Schirmer), Knoxville, Tennessee. The authors declare no conflicts of interest. Correspondence: Sarah K. Spilman, MA, Trauma Services, UnityPoint Health Des Moines, 1200 Pleasant St, Des Moines, IA 50309 (sarah. [email protected]). DOI: 10.1097/JTN.0000000000000070
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opioids or nonsteroidal anti-inflammatory drugs to control these painful conditions,4 which may lead to atypical tolerance for pain and pain medication compared with their younger counterparts.1,5 Second, health care providers may have biased or inaccurate attitudes about pain in older adults, assuming pain is just part of old age.1,6-8 On the other hand, providers know that aggressive pharmaceutical treatment of pain is difficult and potentially risky in patients with medical comorbidities or hemodynamic instability.9 Third, older adult patients may not understand the language or process of standard assessment instruments and therefore cannot or do not communicate their pain effectively to health care providers.1,6,8,10 Accurate pain assessment is a necessary step in treating pain.11 Inadequate assessment of pain refers to evaluation that occurs intermittently or infrequently, that cannot identify pain reliably and consistently, or that fails to detect change in pain intensity.10 All these failures lead to undertreatment or overmedication of pain. Self-report is the preferred method of assessing pain,1,10-11 and several assessment tools exist that use numeric scores to quantify the presence and intensity of pain. However, not all older patients are able to self-report their pain because of cognitive impairment present upon admission (dementia), confusion and delirium during the hospital stay, or sedation and mechanical ventilation. Even when patients can self-report pain, the reported score and noted fluctuations in pain scores are difficult to interpret because of the subjective nature of pain.6,11 In some circumstances, patients’ behaviors must be considered imperfect surrogate measures of pain.10-11 Behavioral scales cannot assess the severity or intensity of pain and they cannot be equated to a score on a numeric scale, but they can be used to determine the presence or absence of pain.10,12 Several assessment tools have been validated in populations of patients who are particularly difficult to evaluate, such as patients with dementia.13 Nursing guidelines state that pain should be assessed “routinely” or “frequently.”10-11,14 Guidelines also state that pain should be reassessed regularly if a patient is reporting severe pain or has received an analgesic to alleviate pain.10 Yet prior work has shown that assessments do not occur regularly for older patients. For example, Herr and WWW.JOURNALOFTRAUMANURSING.COM
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Titler15 found that 29.3% of elderly patients received no standardized assessment of pain in the emergency department (ED).
STUDY RATIONALE No work of which we are aware has described the frequency and methods of assessment used with older adult trauma patients across the course of hospitalization. The main goal of this study is to identify and describe the patterns of pain assessment for a geriatric trauma population. Specifically, we describe the frequency of pain assessment and determine whether assessments are occurring at intervals required by hospital protocols. We also describe the methods of pain assessment to ascertain whether self-report and behavioral tools are being used appropriately within this patient population.
METHODS Study Design and Patient Sample A retrospective study was performed at a Level 1 trauma center in Iowa. The hospital serves a medium-sized city, as well as rural populations in the surrounding area. The trauma service is staffed by 5 trauma surgeons who have responsibility for all adult and pediatric trauma activations in the ED, as well as consultation for trauma patients whose care is primarily managed by an affiliated service such as orthopedic surgery or neurosurgery. There is an additional population of trauma patients who suffer a traumatic injury but whose care is managed solely by affiliated services without the involvement of trauma. At our facility, for example, patients with an isolated hip fracture resulting from a same-level fall are not seen by the trauma service, but typically are admitted directly to the orthopedic service or are admitted by internal medicine with consultation to orthopedic surgery. The hospital’s trauma registry was used to identify trauma patients aged 65 years or more seen in the ED or admitted directly to the hospital during the 4-month study period (July through October 2012). Chart reviews of the electronic medical record (EMR) were conducted for data not included in the trauma registry. Two nurses and 2 pharmacy students reviewed the records for data extraction. Interrater reliability was assessed for 10% of the records, achieving an overall agreement rate of 91.2%. All patients aged 65 years or more were included in the sample; there were no exclusion criteria. Ethical approval for this study was obtained from the hospital’s Institutional Review Board. Because data were collected retrospectively, informed consent was not required.
Study Variables Previous research has revealed risk factors and correlates of underassessed and undertreated pain in older 230
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adults, and several of these variables were included in the analyses. Mechanism of injury, or the external cause of injury (E-Code), was classified as fall, motor vehicle crash, or other injury. Injury diagnoses were derived from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and were categorized as skull or facial fracture (ICD-9 codes: 801-804), vertebrae fracture (805-806), rib fracture (807), pelvic fracture (808), upper limb fracture (810-819), lower limb fracture (820-829), or head injury (851-854). The categories are not mutually exclusive and patients could have multiple injuries. Discharge status was coded as alive or deceased, whereas discharge location matched the categories of the National Trauma Data Standard. The patient’s residence at home before admission included patients in a private home and did not include residence in a nursing or assisted living facility. Comorbid health conditions and complications relevant to the current study were coded as binary variables for the absence or presence of the following conditions: taking an opioid before hospitalization, reported allergy to opioids, and history of depression, respiratory distress, stroke, dementia, chronic pain (eg, arthritis), and alcoholism or substance abuse. Complications included bradycardia, receiving comfort care, change in mental status during hospitalization (eg, delirium, confusion), cardiac arrest requiring cardiopulmonary resuscitation, a medical emergency team call, administration of naloxone to reverse effects of an opioid, and alcohol or drug withdrawal. We created a composite variable for adverse events if a patient received naloxone, had a medical emergency team call, or required cardiopulmonary resuscitation; the occurrence of any one of these events could signify an overdose of opioids. Pain assessments were ascertained by reviewing the nursing flow sheets from the hospital stay. We abstracted the date and time of each documented assessment, method of assessment, and score. Several assessment methods were simultaneously available at our hospital: 0 to 10 Numeric Rating Scale,16 Nonverbal Pain Scale,17 Critical Care Pain Observation Tool,18 Behavioral Pain Scale,19 and Pain Assessment in Advanced Dementia scale.13 Nurses could also select assessment tools that were developed for pediatric patients but have been used with adult patients, including the Wong-Baker FACES scale20 and the COMFORT scale.21 We likewise noted when nurses documented pain assessments that did not correspond to any standardized scale. Documentation of “no/denies” was noted as a pain assessment, although it is not clear whether this is an assessment of the patient denying any pain (the equivalent of a 0 on the Numeric Rating Scale) or the nurse omitted an assessment because the patient was sleeping or unavailable. We also noted when nurses documented a patient’s behavior or verbalization that did not correspond Volume 21 | Number 5 | September-October 2014
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to a standardized assessment tool (eg, nurse noted “the patient is moaning”). Lastly, we noted when nurses documented that they were “unable to assess” the patient’s pain. This is an additional notation that was unclear of meaning; it could mean the patient was unavailable to be assessed (eg, sleeping, left the room for a test), or it could signify the nurse’s interpretation that the patient’s condition did not allow for assessment. We expect a very small number of patients should be truly unable to be assessed because of chemical paralysis or traumatic brain injury. Because patients are likely to have more assessments as the length of stay increases, we computed rates of assessment for the ED, the intensive care unit (ICU), and the medical/surgical floors. This was computed as the total number of assessments in each location, divided by the number of hours in the location. In addition, during data abstraction we noted the total number of gaps in pain assessment that were 12 hours or longer; the gap rate was computed as the total number of 12-hour or longer gaps, divided by the total number of hours in the hospital. This gap rate was only computed for patients with an overall length of stay exceeding 24 hours. These computed rates were compared with our hospital’s written standards for the frequency of assessment: ED pain assessment is required at least once an hour, ICU assessment at least once every 2 hours, and floor assessment at least once every 4 hours.
Statistical Procedures All analyses were performed with IBM SPSS Basic Statistics for Windows, version 20.0 (IBM Corp, 2011). Descriptive statistics were examined and reported for continuous data as medians and interquartile ranges (IQR); categorical data were reported as counts and percentages. Differences between means were assessed with analysis of variance or t tests, and correlations between variables were calculated with the Spearman coefficient (rs). All statistical tests were 2-tailed and based on a 0.05 significance level.
TABLE 1
Descriptive Characteristics of Older Trauma Patients, July to October 2012 (N = 160)
Characteristic
Total
Male, n (%)
66 (41.3)
White, n (%)
153 (95.6)
Age, yrs, median (interquartile range)
81 (73-86)
Injury severity score, median (interquartile range) Length of stay, d, median (interquartile range)
There were 587 trauma patients seen in the ED or admitted directly to the hospital during the study period, and 160 (27.3%) were older adults who met the study criteria. Descriptive characteristics of the sample are found in Table 1. The median age of patients in the study was 81 years, although the range was 65 to 99 years. The majority of patients experienced a same- or multilevel fall (83.8%), and the most common injury was a head injury (36.3%) or a lower limb fracture (25.6%). Eighty-three percent of patients resided in a private home before admission, but only 42.9% returned to home (with or without home health services) after hospitalization. Six percent of patients died. The median length of stay for all patients was 5.5 days (IQR, 4.0-8.0 days). JOURNAL OF TRAUMA NURSING
5.5 (4.0-8.0)
Type of the trauma patient, n (%) Managed or seen by trauma service
77 (48.1)
Not managed or seen by trauma service
83 (51.9)
Mechanism of injury, n (%) Fall
134 (83.8)
Motor vehicle crash
13 (8.1)
Other
13 (8.1)
Injury, n (%) Skull/facial fracture
16 (10.0)
Vertebrae fracture
24 (15.0)
Rib fracture
27 (16.9)
Pelvis fracture
11 (6.9)
Upper limb fracture
27 (16.9)
Lower limb fracture
41 (25.6)
Head injury
58 (36.3)
Hospital location, n (%) Emergency department
139 (86.9)
Intensive care unit
50 (31.3)
Acute care floor
148 (92.5)
Deceased, n (%)
RESULTS
9 (5-16)
10 (6.3)
Discharge location, n (%) Discharged home from the emergency department
5 (3.3)
Home, no assistance
35 (23.3)
Home, with home health care
25 (16.7)
Skilled nursing facility
70 (45.7)
Rehabilitation facility
7 (4.7)
Other
13 (8.1)
Residing at home before admission, n (%)
133 (83.1)
Returned home (with or without services), n (%)
57 (42.9)
Discharged to skilled nursing facility, n (%)
55 (41.4)
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As shown in Table 2, a sizeable number of patients in the sample had at least one health condition upon admission. Nearly half (48.8%) of the patients reported a history of chronic pain, and 26.9% of these patients were taking an opioid before admission. Patients also had high rates of comorbid depression (41.9%), respiratory distress (26.3%), and stroke (21.9%). More than 70% of the sample reported at least one of these 4 medical conditions. During their hospitalization, 26.3% of patients had an episode of bradycardia, 21.9% had a change in mental status, and 22.5% were converted to comfort care measures (Table 3). Thirty-two percent of the sample spent at least 1 day in the ICU (median days, 2.0; IQR, 1.0-4.0) and 10 patients (6.3%) spent time on the ventilator (median days, 2.0; IQR, 1.0-5.0). Patients not seen by the trauma service were more likely to have an orthopedic or neurosurgical operative procedure during their hospitalization, but were not more likely to have an adverse event.
Events During Hospitalization of Older Trauma Patients (N = 160)
Variable
Total
Bradycardia, n (%)
42 (26.3)
Received comfort care, n (%)
36 (22.5)
Change in mental status, n (%)
35 (21.9)
Cardiac arrest with cardiopulmonary resuscitation, n (%)
7 (4.4)
Medical emergency team call, n (%)
6 (3.8)
Received naloxone, n (%)
4 (2.5)
Drug or alcohol withdrawal, n (%)
3 (1.9)
Intensive care unit days, n = 51, median (interquartile range)
2.0 (1.0-4.0)
Ventilator days, n = 10, median (interquartile range)
2.0 (1.0-5.0)
Had an operative procedure, n (%)
Wide Variety of Assessment Methods Many different assessment methods were used to monitor pain in older trauma patients. The most frequently used assessment tools were numeric, which were used at least once with 90.0% of the patients. The 0 to 10 Numeric Rating Scale was used with 89.4% of patients and the Wong-Baker FACES scale was used with 14.4% of patients (Table 4). Use of a numeric tool was inversely related to the injury severity score (ISS) (rs= −0.23; P < .01) and head bleed (rs= −0.36; P < .001). It was also positively associated with the ICU rate of assessment (rs= 0.37; P < .01) and the floor rate of assessment (rs= 0.23; P < .01). Behavioral assessment methods were used with 20% of patients, including the Nonverbal Pain Scale (9.4%), the Critical Care Pain Observation Tool (7.5%), the Behavioral Pain Scale (4.4%), the Pain Assessment in Advanced Dementia scale (3.1%), and the COMFORT scale (1.3%). Use of a behavioral assessment tool was moderately cor-
TABLE 2
Comorbid Health Conditions of Older Trauma Patients (N = 160)
Variable
Total, n (%)
History of chronic pain
TABLE 3
78 (48.8)
Taking opioid before admission
21 (26.9)
Not taking opioid before admission
57 (73.1)
51 (31.9)
related with the ISS (rs= 0.29, P < .001), hospital length of stay (rs= 0.38; P < .001), and head injury (rs= 0.27; P < .001). Use of a behavioral assessment was strongly associated with a change in patient’s mental status (rs= 0.42; P < .001). Nonstandard assessment of pain was used at least once with 90% of patients. More than three quarters of patients had at least one assessment recorded as “no/denies,” which was associated with hospital length of stay
TABLE 4
Pain Assessment Methods Used With Older Trauma Patients (N = 160)
Variable
Total, n (%)
Numeric assessment tool 0-10 Numeric Rating Scale Wong-Baker FACES scale
144 (90.0) 143 (89.4) 23 (14.4)
Behavioral assessment tool
32 (20.0)
Nonverbal Pain Scale
15 (9.4)
Critical Care Pain Observation Tool
12 (7.5)
Behavioral Pain Scale
7 (4.4)
67 (41.9)
Pain Assessment in Advanced Dementia Scale
5 (3.1)
History of depression History of respiratory distress
42 (26.3)
COMFORT scale
2 (1.3)
History of stroke
35 (21.9)
History of dementia
28 (17.5)
“No/denies”
124 (77.5)
History of alcoholism or substance abuse
15 (9.4)
Patient observation or verbalization of pain
108 (67.5)
Reported allergy to opioid
14 (8.8)
Unable to assess
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Nonstandardized method
144 (90.0)
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TABLE 5
Frequency of Pain Assessments of Older Trauma Patients (N = 160) No Recorded Assessments
One or More Recorded Assessment(s)
41 (29.5)
98 (70.5)
3.03 (1.9-4.0)
4.1 (2.7-5.5)
Number of pain assessments, median (interquartile range)
N/A
2 (1-4)
Rate of assessments, median (interquartile range)
N/A
1 every 1.7 hrs (1.1-2.8)
4 (8.0)
46 (92.0)
9.6 (1.2-19.6)
37.8 (23.4-95.7)
N/A
15 (4-26)
ED assessments, n = 139, n (%) ED time, hrs, median (interquartile range)
ICU assessments, n = 50, n (%) ICU time, hrs, median (interquartile range) Number of pain assessments, median (interquartile range) Rate of assessments, median (interquartile range)
Significance F = 9.26; P = .000
F = 11.82; P = .000
N/A
1 every 3.3 hrs (2.3-5.5)
1 (0.7)
147 (99.3)
6.6 (N/A)
93.1 (61.0-150.5)
Number of pain assessments, median (interquartile range)
N/A
26 (12-36)
Rate of assessments, median (interquartile range)
N/A
1 every 4.2 hrs (3.4-5.3)
No ≥12-hr Gaps
One or More ≥12-hr Gaps
57 (39.6)
87 (60.4)
92.3 (65.1-119.7)
141.5 (92.9-217.9)
t = 4.33; P = .000
1 every 6.8 hrs (5.7-8.6)
1 every 5.9 hrs (4.8-7.5)
t = 2.86; P = .005
Acute care floor assessments, n = 148, n (%) Floor time, hrs, median (interquartile range)
Gap assessments, patients with length of stay ≥24 hrs, n = 144, n (%) Length of stay, hrs, median (interquartile range) Rate of assessments, median (interquartile range)
F = 29.37; P = .000
Significance
Abbreviations: ED, emergency department; ICU, intensive care unit; N/A, not available.
(rs= 0.42; P < .001) and discharge to a skilled nursing facility (rs= 0.26; P < .001). It was also moderately correlated with patients who had a comorbid diagnosis of a stroke (rs= 0.21; P < .01) or depression (rs= 0.17; P < .05). Three quarters of patients had documentation of pain in the format of a patient observation or verbalization noted by the nurse. This methodology was strongly associated with hospital length of stay (rs= 0.50; P < .001), but moderately correlated with discharge to a skilled nursing facility (rs= 0.17; P < .05), leg fracture injury (rs= 0.19; P < .05), and history of comorbid diagnosis of depression (rs= 0.26; P < .001). Lastly, 35.0% of patients had at least one notation of “unable to assess.” This assessment was positively correlated with leg fracture injury (rs= 0.32; P < .001) and a change in mental status (rs= 0.28; P < .001), and was negatively correlated with discharge to home (rs= −0.22; P < .01).
Infrequent Assessments In all phases of hospitalization, older trauma patients did not receive pain assessments in intervals that met hospital JOURNAL OF TRAUMA NURSING
standards (Table 5). In the ED, 29.5% had no recorded pain assessments, even though the median length of stay in the ED was 3.03 hours (IQR, 1.9-4.0). For patients who received at least one pain assessment in the ED, the assessment occurred approximately once every 1.7 hours (IQR, 1.1-2.8), which is more infrequently than the hospital’s ED protocol of at least once every hour. The rate of ED assessments grew more infrequent as patient age increased (rs= −0.36; P < .001) and for patients with a preexisting condition of dementia (rs= −0.32; P < .001). The rate of assessment in the ED was more frequent for patients who were discharged to home (rs= 0.22; P < .05). Of the 50 patients who spent time in the ICU, 4 patients (8.0%) had no recorded pain assessment, but all 4 patients died in the ICU after a relatively short stay (9.6 hours, IQR: 1.2-19.6). For the other 46 patients, the frequency of assessment was once every 3.3 hours (IQR, 2.3-5.5), which is more infrequent than the hospital’s ICU protocol of once every 2 hours. Length of stay in the ICU was strongly correlated with the ISS (rs= 0.45; P < .001) and head injury (rs= 0.38; P < .001). Being a patient WWW.JOURNALOFTRAUMANURSING.COM
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managed or seen by the trauma service was moderately correlated with an increased rate of pain assessment in the ICU (rs= 0.35; P < .05). The majority of patients (92.5%) spent some time on a medical/surgical floor; only 1 patient received no documented pain assessment. The other patients were assessed at a frequency of once every 4.2 hours (IQR, 3.4-5.3), which is comparable to the hospital’s standard for assessments on the floor. An infrequent rate of assessment was positively correlated with patients being male (rs= 0.18; P < .05), age (rs= 0.20; P < .05), and a preexisting history of dementia (rs= 0.22; P < .01), but negatively correlated with discharge to a skilled nursing facility (rs= −0.25; P < .01). Of the patients who stayed in the hospital for at least 24 hours (n = 144), 60.4% experienced at least one 12hour or longer gap in pain assessment. These patients had a significantly longer length of stay than patients who did not experience an assessment gap (t = 4.33; P < .001), but their overall median rate of assessments was more frequent (t = 2.86; P < .01). Male patients were more likely to have a 12-hour or longer assessment gap (rs= 0.29; P < .001), as were patients with a skull or facial fracture (rs= 0.18; P < .05), vertebrae fracture (rs= 0.20; P < .05), or head bleed (rs= 0.18; P < .05). The assessment gap was also positively correlated with the ISS (rs= 0.22; P < .01), hospital length of stay (rs= 0.33; P < .001), and a change in mental status (rs= 0.22; P < .05).
DISCUSSION A basic tenet of pain management is that pain must be assessed adequately and consistently. Although an examination of the frequency of pain assessment may seem simplistic, this analysis provides a first look at one set of barriers that exist in providing superior care to older trauma patients. Pain has been linked to many negative patient outcomes, such as the increased likelihood of delirium, the inability to obtain restful sleep, and decreases in mobility.11,13 Undertreated pain can delay recovery and lengthen the patient stay, as well as affect options for patient discharge if the patient is not able to return home. In short, a lack of adequate pain assessment indicates a lack of pain evaluation, which can paradoxically lead to both undertreated and overmedicated pain. During the course of their stay, 21.9% of patients experienced a change in mental status. This is likely underreported because at the time of this study our hospital did not utilize a tool to screen for cognitive impairment or delirium, so this data was ascertained by physician and nursing documentation of patient confusion and delirium. A change in mental status was positively correlated with the use of a behavioral assessment tool, which is appropriate. It was also correlated with the notation “unable to assess” and the occurrence of a 12-hour or longer gap 234
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in assessment, which suggests that pain assessment may have been suboptimal before or after a patient experienced a change in mental status. Several factors correlated with the patient’s discharge location. Although 83.1% lived at home before the injury, only 42.9% of patients returned home after the trauma and 41.4% were discharged to a skilled nursing facility. Although we are limited by the correlational nature of our data, there are significant associations between discharge to the skilled nursing facility and nonstandard methods of pain assessment (eg, “no/denies,” documentation of patient verbalization or observation). This implies that perhaps poor pain assessment may delay return to home or may increase the likelihood that patients will need skilled care after discharge. Another finding that emerged from this data is that nurses in our facility have too many assessment tools from which to choose. The EMR allows the choice of 11 assessment tools, not all of which are appropriate for older patients. This leads to confusion as to which tool is appropriate in each setting, as well as difficulty communicating pain assessments clearly between providers. It seems that nurses do not always use the appropriate tools in the correct populations and often use nonstandard forms of documentation to compensate. It will benefit patients at our hospital if protocols are revised to limit the choice of pain assessment tools and to increase nurse training for the selected methodologies. Finally, study findings suggest that pain is not assessed in consistent and frequent intervals during the course of hospitalization. Assessment gaps were longer than those prescribed by hospital protocols, especially in the most acute phases of hospitalization. There also were significant numbers of older adult patients who never received a single pain assessment. If we consider the nonstandard assessment methods described earlier as inadequate assessment, 90% of patients had at least one substandard assessment. Moreover, 40% of older patients received no assessment-– standard or otherwise-–in the ED. These findings point out several areas in need of improvement for our hospital.
Limitations This study has several limitations. The first limitation is that we could only ascertain pain assessments that were documented in the EMR. We suspect that bedside providers are assessing pain more frequently than the documentation demonstrates, even if they are not using standard instruments, but not every assessment makes it in the EMR. We included nursing notes from the free-text portion of the flow sheet as a way to remedy this limitation. Second, standardized tools for pain assessment in use at our facility do not presently distinguish between pain at rest and pain with movement,22 and we could not differentiate between the two in the nursing documentation. This is a Volume 21 | Number 5 | September-October 2014
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fundamental distinction that should be made, as it potentially impedes or affects patient mobility and pain treatment. Third, as mentioned previously, our hospital did not routinely use a standard screening tool for delirium at the time of this study. The Confusion Assessment Method23-24 is now available in our EMR and nurses are being trained in its use. Physicians are also receiving instruction for how to interpret and respond to an abnormal Confusion Assessment Method score. Fourth, there are 2 notations of pain assessment for which the meaning is unclear–-“no/denies” and “unable to assess.” Upon presentation of these study results at our hospital, supervisors began to query nurses about their interpretations of these 2 notations and hope to standardize the meanings, or even remove them as options, given feedback from staff. Fifth, the data are correlational in nature and their interpretation is therefore limited. Care of a trauma patient is extremely complex and multifaceted, which is not adequately captured in correlational data. We can, however, see patterns emerge that warrant further analyses and attention.
CONCLUSION Assessment and management of pain in older trauma patients is extremely difficult, making this a topic of importance for the nurses and physicians who care for these patients. Nurses are the frontline workers who are the first to notice and assess pain, but the entire medical team must be involved to effectively treat and manage pain in the elderly population. Study results point to the need at our facility, and probably other facilities, as well, to educate nurses on the most appropriate pain assessment tools for elderly patients and the importance of reassessment and documentation of pain. All patients, not just older adults, will benefit from more frequent and higher quality pain assessment.
Acknowledgments The authors thank Alicia Atwell, Beth Cady, Darla Eastman, Sherry Olson, Sarah Pandullo, and Masoud Yousif for their contributions to the research.
REFERENCES 1. Cavalieri TA. Managing pain in geriatric patients. J Am Osteopath Assoc. 2007;107:ES10-ES16. 2. Banks SE, Lewis MC. Trauma in the elderly: considerations for anesthetic management. Anesthesiol Clin. 2013;31:127-139. 3. Calland JF, Ingraham AM, Niels M, et al. Evaluation and management of geriatric trauma: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma. 2012;73:S345-350.
4. Turk DC, Wilson HD, Cahana A. Treatment of chronic noncancer pain. Lancet. 2011;377:2226-2235. 5. McLiesh P, Mungall D, Wiechula R. Are we providing the best possible pain management for our elderly patients in the acutecare setting? Int J Evid Based Healthc. 2009;7:173-180. 6. Badura AS, Grohmann JM. Psychological issues in pain perception and treatment in the elderly. Anns Longterm Care. 2002;10:29-34. 7. Gagliese L, Melzack R. Chronic pain in elderly people. Pain. 1997;70:3-14. 8. Puntillo K. Managing pain, delirium and sedation. Crit Care Nurs. 2007:8-15. 9. Lucas CE, Vlahos AL, Ledgerwood AM. Kindness kills: the negative impact of pain as the fifth vital sign. J Am Coll Surg. 2007;205:101-107. 10. Herr K. Pain in the older adult: an imperative across all health care settings. Pain Manag Nurs. 2010;11:S1-S10. 11. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306. 12. Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287-294. 13. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4:9-15. 14. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In:Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Heathcare Research and Quality; 2008. 15. Herr K, Titler M. Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends. J Emerg Nurs. 2009;35:312-320. 16. McCaffery M, Beebe A, et al. Pain: Clinical Manual for Nursing Practice. St Louis, MO: Mosby’s Inc; 1989. 17. Odhner M, Wegman D, Freeland N, Steinmetz A, Ingersoll GL. Assessing pain control in nonverbal critically ill adults. Dimens Crit Care Nurs. 2004;22:260-267. 18. Gélinas C, Fillion L, Puntillo KA, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006;15:420-427. 19. Payen J-F, Bru O, Bosson J-L, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258-2263. 20. Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P. Wong’s Essentials of Pediatric Nursing. 6th ed. St Louis: Mosby’s Inc; 2001:1301. 21. Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992;17:95-109. 22. Srikandarajah S, Gilron I. Systematic review of movementevoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain. 2011;152:1734-1739. 23. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29:1370-1379. 24. Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R. Clarifying confusion: the confusion assessment method. Ann Intern Med. 1990;113:941-948.
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2.5
Infrequent Assessment of Pain in Elderly Trauma Patients
ANCC Contact Hours
Sarah K. Spilman, MA ■ Lisa A. Baumhover, MS, ARNP, GCNS-BC ■ Cheryl L. Lillegraven, MSN, ARNP, ACNS-BC ■ George Lederhaas, MD ■ Sheryl M. Sahr, MD, MS, FACS ■ Lori L. Schirmer, PharmD, BCPS, BCNSP ■ Dustin L. Smoot, MD, FACS ■ James R. Swegle, MD, FACS
ABSTRACT There are inherent difficulties in assessing and managing pain in elderly trauma patients, especially those with chronic health conditions or diminished capacities for self-reporting pain. This retrospective study identifies and describes patterns of pain assessment for a trauma population of older adults (age ≥65 years). Gaps between patient assessments existed in all phases of hospitalization and did not meet hospital guidelines for frequency of assessment. In addition, assessment methods were not always appropriate for the patient population. We conclude that older patients were not assessed for pain frequently enough, and that more regular and routine pain assessments may improve patient outcomes.
Key Words Critical care, Elderly, Geriatric, Pain assessment, Trauma
A
s the American population ages, so too does the population of trauma patients presenting to hospitals and clinics after sustaining injury.1 The leading cause of injury for these patients is same- or multilevel falls, often resulting in lengthy or repeat hospitalizations and substantial medical costs.2,3 It is clear that pain results from most traumatic injuries, yet very little attention has been given to the assessment and management of pain in older trauma patients. Effectively assessing and managing pain in older adults is difficult. First, older adults are more likely to have chronic pain conditions before the traumatic injury, such as degenerative joint disease, neuropathy, nerve impingements, or osteoporotic fractures.1 They may be taking
Author Affiliations: UnityPoint Health Des Moines (Ms. Spilman, Ms. Baumhover, Ms. Lillegraven, Dr Lederhaas, Dr Sahr, Dr Smoot, and Dr Swegle), Des Moines, Iowa; and Fort Sanders Regional Medical Center (Dr Schirmer), Knoxville, Tennessee. The authors declare no conflicts of interest. Correspondence: Sarah K. Spilman, MA, Trauma Services, UnityPoint Health Des Moines, 1200 Pleasant St, Des Moines, IA 50309 (sarah. [email protected]). DOI: 10.1097/JTN.0000000000000070
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opioids or nonsteroidal anti-inflammatory drugs to control these painful conditions,4 which may lead to atypical tolerance for pain and pain medication compared with their younger counterparts.1,5 Second, health care providers may have biased or inaccurate attitudes about pain in older adults, assuming pain is just part of old age.1,6-8 On the other hand, providers know that aggressive pharmaceutical treatment of pain is difficult and potentially risky in patients with medical comorbidities or hemodynamic instability.9 Third, older adult patients may not understand the language or process of standard assessment instruments and therefore cannot or do not communicate their pain effectively to health care providers.1,6,8,10 Accurate pain assessment is a necessary step in treating pain.11 Inadequate assessment of pain refers to evaluation that occurs intermittently or infrequently, that cannot identify pain reliably and consistently, or that fails to detect change in pain intensity.10 All these failures lead to undertreatment or overmedication of pain. Self-report is the preferred method of assessing pain,1,10-11 and several assessment tools exist that use numeric scores to quantify the presence and intensity of pain. However, not all older patients are able to self-report their pain because of cognitive impairment present upon admission (dementia), confusion and delirium during the hospital stay, or sedation and mechanical ventilation. Even when patients can self-report pain, the reported score and noted fluctuations in pain scores are difficult to interpret because of the subjective nature of pain.6,11 In some circumstances, patients’ behaviors must be considered imperfect surrogate measures of pain.10-11 Behavioral scales cannot assess the severity or intensity of pain and they cannot be equated to a score on a numeric scale, but they can be used to determine the presence or absence of pain.10,12 Several assessment tools have been validated in populations of patients who are particularly difficult to evaluate, such as patients with dementia.13 Nursing guidelines state that pain should be assessed “routinely” or “frequently.”10-11,14 Guidelines also state that pain should be reassessed regularly if a patient is reporting severe pain or has received an analgesic to alleviate pain.10 Yet prior work has shown that assessments do not occur regularly for older patients. For example, Herr and WWW.JOURNALOFTRAUMANURSING.COM
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Titler15 found that 29.3% of elderly patients received no standardized assessment of pain in the emergency department (ED).
STUDY RATIONALE No work of which we are aware has described the frequency and methods of assessment used with older adult trauma patients across the course of hospitalization. The main goal of this study is to identify and describe the patterns of pain assessment for a geriatric trauma population. Specifically, we describe the frequency of pain assessment and determine whether assessments are occurring at intervals required by hospital protocols. We also describe the methods of pain assessment to ascertain whether self-report and behavioral tools are being used appropriately within this patient population.
METHODS Study Design and Patient Sample A retrospective study was performed at a Level 1 trauma center in Iowa. The hospital serves a medium-sized city, as well as rural populations in the surrounding area. The trauma service is staffed by 5 trauma surgeons who have responsibility for all adult and pediatric trauma activations in the ED, as well as consultation for trauma patients whose care is primarily managed by an affiliated service such as orthopedic surgery or neurosurgery. There is an additional population of trauma patients who suffer a traumatic injury but whose care is managed solely by affiliated services without the involvement of trauma. At our facility, for example, patients with an isolated hip fracture resulting from a same-level fall are not seen by the trauma service, but typically are admitted directly to the orthopedic service or are admitted by internal medicine with consultation to orthopedic surgery. The hospital’s trauma registry was used to identify trauma patients aged 65 years or more seen in the ED or admitted directly to the hospital during the 4-month study period (July through October 2012). Chart reviews of the electronic medical record (EMR) were conducted for data not included in the trauma registry. Two nurses and 2 pharmacy students reviewed the records for data extraction. Interrater reliability was assessed for 10% of the records, achieving an overall agreement rate of 91.2%. All patients aged 65 years or more were included in the sample; there were no exclusion criteria. Ethical approval for this study was obtained from the hospital’s Institutional Review Board. Because data were collected retrospectively, informed consent was not required.
Study Variables Previous research has revealed risk factors and correlates of underassessed and undertreated pain in older 230
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adults, and several of these variables were included in the analyses. Mechanism of injury, or the external cause of injury (E-Code), was classified as fall, motor vehicle crash, or other injury. Injury diagnoses were derived from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and were categorized as skull or facial fracture (ICD-9 codes: 801-804), vertebrae fracture (805-806), rib fracture (807), pelvic fracture (808), upper limb fracture (810-819), lower limb fracture (820-829), or head injury (851-854). The categories are not mutually exclusive and patients could have multiple injuries. Discharge status was coded as alive or deceased, whereas discharge location matched the categories of the National Trauma Data Standard. The patient’s residence at home before admission included patients in a private home and did not include residence in a nursing or assisted living facility. Comorbid health conditions and complications relevant to the current study were coded as binary variables for the absence or presence of the following conditions: taking an opioid before hospitalization, reported allergy to opioids, and history of depression, respiratory distress, stroke, dementia, chronic pain (eg, arthritis), and alcoholism or substance abuse. Complications included bradycardia, receiving comfort care, change in mental status during hospitalization (eg, delirium, confusion), cardiac arrest requiring cardiopulmonary resuscitation, a medical emergency team call, administration of naloxone to reverse effects of an opioid, and alcohol or drug withdrawal. We created a composite variable for adverse events if a patient received naloxone, had a medical emergency team call, or required cardiopulmonary resuscitation; the occurrence of any one of these events could signify an overdose of opioids. Pain assessments were ascertained by reviewing the nursing flow sheets from the hospital stay. We abstracted the date and time of each documented assessment, method of assessment, and score. Several assessment methods were simultaneously available at our hospital: 0 to 10 Numeric Rating Scale,16 Nonverbal Pain Scale,17 Critical Care Pain Observation Tool,18 Behavioral Pain Scale,19 and Pain Assessment in Advanced Dementia scale.13 Nurses could also select assessment tools that were developed for pediatric patients but have been used with adult patients, including the Wong-Baker FACES scale20 and the COMFORT scale.21 We likewise noted when nurses documented pain assessments that did not correspond to any standardized scale. Documentation of “no/denies” was noted as a pain assessment, although it is not clear whether this is an assessment of the patient denying any pain (the equivalent of a 0 on the Numeric Rating Scale) or the nurse omitted an assessment because the patient was sleeping or unavailable. We also noted when nurses documented a patient’s behavior or verbalization that did not correspond Volume 21 | Number 5 | September-October 2014
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to a standardized assessment tool (eg, nurse noted “the patient is moaning”). Lastly, we noted when nurses documented that they were “unable to assess” the patient’s pain. This is an additional notation that was unclear of meaning; it could mean the patient was unavailable to be assessed (eg, sleeping, left the room for a test), or it could signify the nurse’s interpretation that the patient’s condition did not allow for assessment. We expect a very small number of patients should be truly unable to be assessed because of chemical paralysis or traumatic brain injury. Because patients are likely to have more assessments as the length of stay increases, we computed rates of assessment for the ED, the intensive care unit (ICU), and the medical/surgical floors. This was computed as the total number of assessments in each location, divided by the number of hours in the location. In addition, during data abstraction we noted the total number of gaps in pain assessment that were 12 hours or longer; the gap rate was computed as the total number of 12-hour or longer gaps, divided by the total number of hours in the hospital. This gap rate was only computed for patients with an overall length of stay exceeding 24 hours. These computed rates were compared with our hospital’s written standards for the frequency of assessment: ED pain assessment is required at least once an hour, ICU assessment at least once every 2 hours, and floor assessment at least once every 4 hours.
Statistical Procedures All analyses were performed with IBM SPSS Basic Statistics for Windows, version 20.0 (IBM Corp, 2011). Descriptive statistics were examined and reported for continuous data as medians and interquartile ranges (IQR); categorical data were reported as counts and percentages. Differences between means were assessed with analysis of variance or t tests, and correlations between variables were calculated with the Spearman coefficient (rs). All statistical tests were 2-tailed and based on a 0.05 significance level.
TABLE 1
Descriptive Characteristics of Older Trauma Patients, July to October 2012 (N = 160)
Characteristic
Total
Male, n (%)
66 (41.3)
White, n (%)
153 (95.6)
Age, yrs, median (interquartile range)
81 (73-86)
Injury severity score, median (interquartile range) Length of stay, d, median (interquartile range)
There were 587 trauma patients seen in the ED or admitted directly to the hospital during the study period, and 160 (27.3%) were older adults who met the study criteria. Descriptive characteristics of the sample are found in Table 1. The median age of patients in the study was 81 years, although the range was 65 to 99 years. The majority of patients experienced a same- or multilevel fall (83.8%), and the most common injury was a head injury (36.3%) or a lower limb fracture (25.6%). Eighty-three percent of patients resided in a private home before admission, but only 42.9% returned to home (with or without home health services) after hospitalization. Six percent of patients died. The median length of stay for all patients was 5.5 days (IQR, 4.0-8.0 days). JOURNAL OF TRAUMA NURSING
5.5 (4.0-8.0)
Type of the trauma patient, n (%) Managed or seen by trauma service
77 (48.1)
Not managed or seen by trauma service
83 (51.9)
Mechanism of injury, n (%) Fall
134 (83.8)
Motor vehicle crash
13 (8.1)
Other
13 (8.1)
Injury, n (%) Skull/facial fracture
16 (10.0)
Vertebrae fracture
24 (15.0)
Rib fracture
27 (16.9)
Pelvis fracture
11 (6.9)
Upper limb fracture
27 (16.9)
Lower limb fracture
41 (25.6)
Head injury
58 (36.3)
Hospital location, n (%) Emergency department
139 (86.9)
Intensive care unit
50 (31.3)
Acute care floor
148 (92.5)
Deceased, n (%)
RESULTS
9 (5-16)
10 (6.3)
Discharge location, n (%) Discharged home from the emergency department
5 (3.3)
Home, no assistance
35 (23.3)
Home, with home health care
25 (16.7)
Skilled nursing facility
70 (45.7)
Rehabilitation facility
7 (4.7)
Other
13 (8.1)
Residing at home before admission, n (%)
133 (83.1)
Returned home (with or without services), n (%)
57 (42.9)
Discharged to skilled nursing facility, n (%)
55 (41.4)
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As shown in Table 2, a sizeable number of patients in the sample had at least one health condition upon admission. Nearly half (48.8%) of the patients reported a history of chronic pain, and 26.9% of these patients were taking an opioid before admission. Patients also had high rates of comorbid depression (41.9%), respiratory distress (26.3%), and stroke (21.9%). More than 70% of the sample reported at least one of these 4 medical conditions. During their hospitalization, 26.3% of patients had an episode of bradycardia, 21.9% had a change in mental status, and 22.5% were converted to comfort care measures (Table 3). Thirty-two percent of the sample spent at least 1 day in the ICU (median days, 2.0; IQR, 1.0-4.0) and 10 patients (6.3%) spent time on the ventilator (median days, 2.0; IQR, 1.0-5.0). Patients not seen by the trauma service were more likely to have an orthopedic or neurosurgical operative procedure during their hospitalization, but were not more likely to have an adverse event.
Events During Hospitalization of Older Trauma Patients (N = 160)
Variable
Total
Bradycardia, n (%)
42 (26.3)
Received comfort care, n (%)
36 (22.5)
Change in mental status, n (%)
35 (21.9)
Cardiac arrest with cardiopulmonary resuscitation, n (%)
7 (4.4)
Medical emergency team call, n (%)
6 (3.8)
Received naloxone, n (%)
4 (2.5)
Drug or alcohol withdrawal, n (%)
3 (1.9)
Intensive care unit days, n = 51, median (interquartile range)
2.0 (1.0-4.0)
Ventilator days, n = 10, median (interquartile range)
2.0 (1.0-5.0)
Had an operative procedure, n (%)
Wide Variety of Assessment Methods Many different assessment methods were used to monitor pain in older trauma patients. The most frequently used assessment tools were numeric, which were used at least once with 90.0% of the patients. The 0 to 10 Numeric Rating Scale was used with 89.4% of patients and the Wong-Baker FACES scale was used with 14.4% of patients (Table 4). Use of a numeric tool was inversely related to the injury severity score (ISS) (rs= −0.23; P < .01) and head bleed (rs= −0.36; P < .001). It was also positively associated with the ICU rate of assessment (rs= 0.37; P < .01) and the floor rate of assessment (rs= 0.23; P < .01). Behavioral assessment methods were used with 20% of patients, including the Nonverbal Pain Scale (9.4%), the Critical Care Pain Observation Tool (7.5%), the Behavioral Pain Scale (4.4%), the Pain Assessment in Advanced Dementia scale (3.1%), and the COMFORT scale (1.3%). Use of a behavioral assessment tool was moderately cor-
TABLE 2
Comorbid Health Conditions of Older Trauma Patients (N = 160)
Variable
Total, n (%)
History of chronic pain
TABLE 3
78 (48.8)
Taking opioid before admission
21 (26.9)
Not taking opioid before admission
57 (73.1)
51 (31.9)
related with the ISS (rs= 0.29, P < .001), hospital length of stay (rs= 0.38; P < .001), and head injury (rs= 0.27; P < .001). Use of a behavioral assessment was strongly associated with a change in patient’s mental status (rs= 0.42; P < .001). Nonstandard assessment of pain was used at least once with 90% of patients. More than three quarters of patients had at least one assessment recorded as “no/denies,” which was associated with hospital length of stay
TABLE 4
Pain Assessment Methods Used With Older Trauma Patients (N = 160)
Variable
Total, n (%)
Numeric assessment tool 0-10 Numeric Rating Scale Wong-Baker FACES scale
144 (90.0) 143 (89.4) 23 (14.4)
Behavioral assessment tool
32 (20.0)
Nonverbal Pain Scale
15 (9.4)
Critical Care Pain Observation Tool
12 (7.5)
Behavioral Pain Scale
7 (4.4)
67 (41.9)
Pain Assessment in Advanced Dementia Scale
5 (3.1)
History of depression History of respiratory distress
42 (26.3)
COMFORT scale
2 (1.3)
History of stroke
35 (21.9)
History of dementia
28 (17.5)
“No/denies”
124 (77.5)
History of alcoholism or substance abuse
15 (9.4)
Patient observation or verbalization of pain
108 (67.5)
Reported allergy to opioid
14 (8.8)
Unable to assess
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Nonstandardized method
144 (90.0)
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TABLE 5
Frequency of Pain Assessments of Older Trauma Patients (N = 160) No Recorded Assessments
One or More Recorded Assessment(s)
41 (29.5)
98 (70.5)
3.03 (1.9-4.0)
4.1 (2.7-5.5)
Number of pain assessments, median (interquartile range)
N/A
2 (1-4)
Rate of assessments, median (interquartile range)
N/A
1 every 1.7 hrs (1.1-2.8)
4 (8.0)
46 (92.0)
9.6 (1.2-19.6)
37.8 (23.4-95.7)
N/A
15 (4-26)
ED assessments, n = 139, n (%) ED time, hrs, median (interquartile range)
ICU assessments, n = 50, n (%) ICU time, hrs, median (interquartile range) Number of pain assessments, median (interquartile range) Rate of assessments, median (interquartile range)
Significance F = 9.26; P = .000
F = 11.82; P = .000
N/A
1 every 3.3 hrs (2.3-5.5)
1 (0.7)
147 (99.3)
6.6 (N/A)
93.1 (61.0-150.5)
Number of pain assessments, median (interquartile range)
N/A
26 (12-36)
Rate of assessments, median (interquartile range)
N/A
1 every 4.2 hrs (3.4-5.3)
No ≥12-hr Gaps
One or More ≥12-hr Gaps
57 (39.6)
87 (60.4)
92.3 (65.1-119.7)
141.5 (92.9-217.9)
t = 4.33; P = .000
1 every 6.8 hrs (5.7-8.6)
1 every 5.9 hrs (4.8-7.5)
t = 2.86; P = .005
Acute care floor assessments, n = 148, n (%) Floor time, hrs, median (interquartile range)
Gap assessments, patients with length of stay ≥24 hrs, n = 144, n (%) Length of stay, hrs, median (interquartile range) Rate of assessments, median (interquartile range)
F = 29.37; P = .000
Significance
Abbreviations: ED, emergency department; ICU, intensive care unit; N/A, not available.
(rs= 0.42; P < .001) and discharge to a skilled nursing facility (rs= 0.26; P < .001). It was also moderately correlated with patients who had a comorbid diagnosis of a stroke (rs= 0.21; P < .01) or depression (rs= 0.17; P < .05). Three quarters of patients had documentation of pain in the format of a patient observation or verbalization noted by the nurse. This methodology was strongly associated with hospital length of stay (rs= 0.50; P < .001), but moderately correlated with discharge to a skilled nursing facility (rs= 0.17; P < .05), leg fracture injury (rs= 0.19; P < .05), and history of comorbid diagnosis of depression (rs= 0.26; P < .001). Lastly, 35.0% of patients had at least one notation of “unable to assess.” This assessment was positively correlated with leg fracture injury (rs= 0.32; P < .001) and a change in mental status (rs= 0.28; P < .001), and was negatively correlated with discharge to home (rs= −0.22; P < .01).
Infrequent Assessments In all phases of hospitalization, older trauma patients did not receive pain assessments in intervals that met hospital JOURNAL OF TRAUMA NURSING
standards (Table 5). In the ED, 29.5% had no recorded pain assessments, even though the median length of stay in the ED was 3.03 hours (IQR, 1.9-4.0). For patients who received at least one pain assessment in the ED, the assessment occurred approximately once every 1.7 hours (IQR, 1.1-2.8), which is more infrequently than the hospital’s ED protocol of at least once every hour. The rate of ED assessments grew more infrequent as patient age increased (rs= −0.36; P < .001) and for patients with a preexisting condition of dementia (rs= −0.32; P < .001). The rate of assessment in the ED was more frequent for patients who were discharged to home (rs= 0.22; P < .05). Of the 50 patients who spent time in the ICU, 4 patients (8.0%) had no recorded pain assessment, but all 4 patients died in the ICU after a relatively short stay (9.6 hours, IQR: 1.2-19.6). For the other 46 patients, the frequency of assessment was once every 3.3 hours (IQR, 2.3-5.5), which is more infrequent than the hospital’s ICU protocol of once every 2 hours. Length of stay in the ICU was strongly correlated with the ISS (rs= 0.45; P < .001) and head injury (rs= 0.38; P < .001). Being a patient WWW.JOURNALOFTRAUMANURSING.COM
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managed or seen by the trauma service was moderately correlated with an increased rate of pain assessment in the ICU (rs= 0.35; P < .05). The majority of patients (92.5%) spent some time on a medical/surgical floor; only 1 patient received no documented pain assessment. The other patients were assessed at a frequency of once every 4.2 hours (IQR, 3.4-5.3), which is comparable to the hospital’s standard for assessments on the floor. An infrequent rate of assessment was positively correlated with patients being male (rs= 0.18; P < .05), age (rs= 0.20; P < .05), and a preexisting history of dementia (rs= 0.22; P < .01), but negatively correlated with discharge to a skilled nursing facility (rs= −0.25; P < .01). Of the patients who stayed in the hospital for at least 24 hours (n = 144), 60.4% experienced at least one 12hour or longer gap in pain assessment. These patients had a significantly longer length of stay than patients who did not experience an assessment gap (t = 4.33; P < .001), but their overall median rate of assessments was more frequent (t = 2.86; P < .01). Male patients were more likely to have a 12-hour or longer assessment gap (rs= 0.29; P < .001), as were patients with a skull or facial fracture (rs= 0.18; P < .05), vertebrae fracture (rs= 0.20; P < .05), or head bleed (rs= 0.18; P < .05). The assessment gap was also positively correlated with the ISS (rs= 0.22; P < .01), hospital length of stay (rs= 0.33; P < .001), and a change in mental status (rs= 0.22; P < .05).
DISCUSSION A basic tenet of pain management is that pain must be assessed adequately and consistently. Although an examination of the frequency of pain assessment may seem simplistic, this analysis provides a first look at one set of barriers that exist in providing superior care to older trauma patients. Pain has been linked to many negative patient outcomes, such as the increased likelihood of delirium, the inability to obtain restful sleep, and decreases in mobility.11,13 Undertreated pain can delay recovery and lengthen the patient stay, as well as affect options for patient discharge if the patient is not able to return home. In short, a lack of adequate pain assessment indicates a lack of pain evaluation, which can paradoxically lead to both undertreated and overmedicated pain. During the course of their stay, 21.9% of patients experienced a change in mental status. This is likely underreported because at the time of this study our hospital did not utilize a tool to screen for cognitive impairment or delirium, so this data was ascertained by physician and nursing documentation of patient confusion and delirium. A change in mental status was positively correlated with the use of a behavioral assessment tool, which is appropriate. It was also correlated with the notation “unable to assess” and the occurrence of a 12-hour or longer gap 234
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in assessment, which suggests that pain assessment may have been suboptimal before or after a patient experienced a change in mental status. Several factors correlated with the patient’s discharge location. Although 83.1% lived at home before the injury, only 42.9% of patients returned home after the trauma and 41.4% were discharged to a skilled nursing facility. Although we are limited by the correlational nature of our data, there are significant associations between discharge to the skilled nursing facility and nonstandard methods of pain assessment (eg, “no/denies,” documentation of patient verbalization or observation). This implies that perhaps poor pain assessment may delay return to home or may increase the likelihood that patients will need skilled care after discharge. Another finding that emerged from this data is that nurses in our facility have too many assessment tools from which to choose. The EMR allows the choice of 11 assessment tools, not all of which are appropriate for older patients. This leads to confusion as to which tool is appropriate in each setting, as well as difficulty communicating pain assessments clearly between providers. It seems that nurses do not always use the appropriate tools in the correct populations and often use nonstandard forms of documentation to compensate. It will benefit patients at our hospital if protocols are revised to limit the choice of pain assessment tools and to increase nurse training for the selected methodologies. Finally, study findings suggest that pain is not assessed in consistent and frequent intervals during the course of hospitalization. Assessment gaps were longer than those prescribed by hospital protocols, especially in the most acute phases of hospitalization. There also were significant numbers of older adult patients who never received a single pain assessment. If we consider the nonstandard assessment methods described earlier as inadequate assessment, 90% of patients had at least one substandard assessment. Moreover, 40% of older patients received no assessment-– standard or otherwise-–in the ED. These findings point out several areas in need of improvement for our hospital.
Limitations This study has several limitations. The first limitation is that we could only ascertain pain assessments that were documented in the EMR. We suspect that bedside providers are assessing pain more frequently than the documentation demonstrates, even if they are not using standard instruments, but not every assessment makes it in the EMR. We included nursing notes from the free-text portion of the flow sheet as a way to remedy this limitation. Second, standardized tools for pain assessment in use at our facility do not presently distinguish between pain at rest and pain with movement,22 and we could not differentiate between the two in the nursing documentation. This is a Volume 21 | Number 5 | September-October 2014
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fundamental distinction that should be made, as it potentially impedes or affects patient mobility and pain treatment. Third, as mentioned previously, our hospital did not routinely use a standard screening tool for delirium at the time of this study. The Confusion Assessment Method23-24 is now available in our EMR and nurses are being trained in its use. Physicians are also receiving instruction for how to interpret and respond to an abnormal Confusion Assessment Method score. Fourth, there are 2 notations of pain assessment for which the meaning is unclear–-“no/denies” and “unable to assess.” Upon presentation of these study results at our hospital, supervisors began to query nurses about their interpretations of these 2 notations and hope to standardize the meanings, or even remove them as options, given feedback from staff. Fifth, the data are correlational in nature and their interpretation is therefore limited. Care of a trauma patient is extremely complex and multifaceted, which is not adequately captured in correlational data. We can, however, see patterns emerge that warrant further analyses and attention.
CONCLUSION Assessment and management of pain in older trauma patients is extremely difficult, making this a topic of importance for the nurses and physicians who care for these patients. Nurses are the frontline workers who are the first to notice and assess pain, but the entire medical team must be involved to effectively treat and manage pain in the elderly population. Study results point to the need at our facility, and probably other facilities, as well, to educate nurses on the most appropriate pain assessment tools for elderly patients and the importance of reassessment and documentation of pain. All patients, not just older adults, will benefit from more frequent and higher quality pain assessment.
Acknowledgments The authors thank Alicia Atwell, Beth Cady, Darla Eastman, Sherry Olson, Sarah Pandullo, and Masoud Yousif for their contributions to the research.
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