Pain - We do not do a great job with it.
It is subjective, laced with emotions, culture, and biology. There is no lab test, x-ray, or scan to prove its existence or intensity. It is what the patient states it is. It is the most common reason for physician visits. It is under-assessed, under-documented, and under-treated. It is coming to the forefront that we must do a better job with pain.
1993 - In the Monastery
We were all sitting around at a monastery outside of Boston, at the New England Regional Genetic Group consensus conference on sickle cell pain management. James Eckman, MD, and I had been invited from Atlanta, because we designed and operated the world's first and only 24-hour pain management center for sickle cell patients. Our goal was to write a consensus document on the assessment and management of sickle cell pain for the medical community. The group consisted of pain experts from around the US and the state of the art in pain assessment was reviewed. Working emergent care for 10 years gave me the appreciation that a pain assessment tool needed to be quick, simple and a part of the work routine, or it wouldn't be used. Being a closet engineer and a gizmo aficionado, the idea of a palm-sized, touch screen computer, that allowed the patient or caregiver to see and enter pain information was birthed.
Pain in Four Dimensions
The whole of the idea was to capture four dimensions of pain: intensity, mood, relief, and one additional that the Memorial Pain Card did not capture, side effects. These are all dimensions that we, as clinicians, can do something about. The patient or caregiver would have a 0 to 10 visual scale to quickly mark and the computer would time and date stamp the reading and store the number. The idea included asking the patient to rank the importance of each dimension at that moment in time, on a scale ranked from 1 to 4. The palm computer would compute a weighted score from 0 to 10 from a mathematical formula combining the numerical scores and their weights. This data would be transferred to a desktop PC database for tracking and graphical reports.
MPS Multidimensional Pain Score - a computed combination of the weighted scores as one number from 0 - 10 for global tracking of the pain episode.
XXXXXX1996 - Hewlett Packard Omnigo made the Pain Plan Go
The only palmtop computer at the time in 1993 was the Apple Newton, but the skill to program the device was lacking in the local brain trust. The idea went on the shelf for 3 years. In 1996, the multidimensional pain system was programmed to work on Hewlett Packard Omnigo handheld touch screen computer. Vital signs and the multidimensional pain assessment were entered by touch screen using a programming tool named IZL by Ferras Technology. A prototype was now available to demonstrate. The system and programming was documented and submitted to Emory University's department of Technology Transfer. Jeff Dunbar, the director of Emory University's telemedicine project reviewed the idea. The initial discussion was that a clinical trial was needed to validate the new method of pain data collection before approaching companies for funding. The research protocol took two years to write, rewrite, and pass through various committees.
1998 HP Dumps the Omnigo, Hello Palm
The sales of the Omnigo just wasn't enough to keep it supported, so Plan A sunk and Plan B arose: Using a database programming tool by Pendragon Software, the multidimensional pain score and vital signs were reworked to display on a Palm Pilot. Visual analog scales appear on the palm screen and touching the screen captures the level from 0 to 10. About this time the Human Investigation Review Board had approved our research proposal to test the pain score. The study design was to compare the multidimensional pain score or MPS, with standard pain and mood questionnaires in fifty sickle cell patients with acute pain crisis. The standards included the McGill Pain Questionnaire, Hamilton and BSI mood scales, a Visual Analog Scale and a patient satisfaction survey.
Show Me the Money
We had the study design, and the approval, now we needed funding to pay for the data collection and statistical analysis. E-mail was sent to Jeff Dunbar at Emory who had sent us on our way to get data and who had promised to help gather some funding at Emory to jump-start the study. The day the e-mail was sent was the day after Jeff had left Emory to start his own company, Triad Technologies, to develop new medical products to improve patient care. Jeff, agreed to sponsor the research and the project began.
1999 MPS data shows Promise
The pain data was recorded and analyzed on 50 sickle cell patients with acute pain crisis. The new calculated MPS showed good correlation to the sensory portion of the McGill Pain questionnaire. There was no relationship with the psychological scales of depression. The majority of patients ranked all four dimensions of pain as most important. The next step was to test the MPS in other types of pain such as post operative, cancer and trauma pain. Another protocol was designed and sent through the research approval process to gather pain data on 200 patients in multiple pain settings including cancer, post operative, and trauma. This data has been collected and is undergoing statistical analysis.
Meanwhile JCAHO Pain Standards are published
After reading the new JCAHO pain documentation standards for hospitals, long-term care facilities, outpatient clinics and home health agencies, the light bulbs went off. The pain documentation on the palm, without the new MPS, captured 90% of what the JCAHO required for documentation. Collecting the four dimensions of pain: intensity, mood, relief, and side effects on the palm at the bedside would help ease the documentation burden of the nursing world who will be asked to meet the new standards. Jeff Dunbar's wife Sandy, and his daughter, who are both RNs, reviewed the standards and our existing program. The ability to document the seven aspects of pain, the location, other associated symptoms, character, aggravating -alleviating factors: timing, environment, severity and pain goals were added to the palm using drop down menus for rapid entry. The ability to record and track multiple pain sites on one patient was added. A cognitively impaired patient pain scale was added to allow assessment of non-communicative patients. A database programmer with Oracle, VB, and web based programming skills began to design a back-end application that would run on a single PC, a network, and on the web.
Making Pain the Fifth Vital Sign
Thinking about the nursing work flow, it made sense to add entry forms on the palm that encompass the majority of information collected at the bedside, usually on scraps of paper and written in the patient's chart after making rounds. To add pain assessment to the vital sign documentation would facilitate its collection. Vital signs were added to the palm as a form. The vital signs form included: pulse, respirations, blood pressure, temperature, pulse oximitry, appearance, and a question documenting the presence of pain. This meets the JCAHO standards of asking about the presence of pain during routine rounds. If pain is present then a full assessment can be entered. A form for daily weight, intake, and output by site, therapy ordered and given, and patient satisfaction were all added to the palm and tracked on the desktop application. The palm allows automatic time and date stamping of all entry at the bedside. It also allows for full signature capture making the note complete.
Back at the Nursing Station
The entire software system that operates the PC database and the palm collection is docucare. It has had the design input of several frontline caregivers including nurses, ward secretaries, clinic assistants, physician assistants, nurse practitioners, and physicians. The system is designed to run on a single or networked PC running Windows NT, 98 or 2000, with palm connected organizers. The station PC maintains a list of all active patients on the nursing unit. Each technician or nurse making patient rounds would take a palm with the active patient list sorted by room number and document at the bedside. Each staff member could do their assigned documentation; return to the station PC and hot sync the data to the docucare database. The database sorts the information by patient, and summary reports are generated for viewing on screen or printout for the paper chart. The entire pain history can be graphed with the four dimensions allowing real time adjustments in therapy. Vital signs are graphed and in table four. Intake and output is totaled by shift and by 24 hours by site and total body fluid balance. Therapy given is a medication administration record with time, name, dose, and administration method. Patient satisfaction can be tallied by patient, by unit and by the entire institution with the click of a button. Outcome analysis comparing treatments with pain outcomes can be monitored by disease type, by unit or for the institution.
XXXXXXInto the Hospital
Nurses, using it as a documentation tool, have tested the docucare system in two acute care hospitals. Feedback from the nursing staff about report formats, drop down menus, and suggestions to improve the information flow have been incorporated into the current software. The nursing staff became comfortable with the palm entry after an inservice session and practice with a take home video. The estimated charting time saved using the palm entry method was between one to two hours per nurse per ten-hour shift. With this return of time to nursing staff, the return on investment can be realized quickly and the business model for using palms for data entry at the bedside is clear. It is exciting to see nurses excited about technology that saves them documentation time. One nurse said she had seen computer systems come and go but this one really worked.
A Complete Inpatient and Outpatient Solution
Triad Technologies is designing a pain assessment centralized database that is accessible to patients, institutions, and health care providers. This database will allow patient entry of pain assessment values from the Internet, from a touch-tone phone using IVR technology, and from palm based PC's. Patients can enter pain data from home, and pain history reports may be generated for their use and/or transmitted to their health care provider. For those with chronic pain, the variable "Pain relief" would be replaced with "Functionality." This would be a measure of how the patient can function at work, home, or in activities of daily living. When certain parameters exceed predefined thresholds, fax, e-mail, phone or pager can notify the caregiver. This allows the caregiver to respond to the patient's needs in a timely manner. The pain data warehouse would ensure patient privacy and security. Composite pain data can be used to look at pain therapy outcomes, disease management, and payment negotiations with third party payers. Hospital wards, long-term care facilities, emergency rooms, and home health care providers can use the program to obtain patient pain assessment scores at the point of contact. These values would be downloaded to PC's in the nursing stations and composite pain history reports would be generated.
The Future
The palm pain measurement system is a patient - clinician communication tool. Pain can be quantified and objectively tracked in four dimensions over time and documented with interventions given. Outcome analysis will reveal optimum pain treatments for different disease states with the least amount of side effects. It is our hope that this method will make the pain level given by the patient believable, so proper treatment is administered. It allows clinicians to document the reason for prescribing pain therapy with out the fear of regulatory agencies descending upon them.
Web Resources
The JCAHO pain standards
The American PainSociety
Agency for Health Care Policy and Research for pain guidelines
The Sickle Cell information Center - Based in Atlanta, GA with two online guidebooks.
Docucare - The development of the new pain assessment method to meet JCAHO standards.
My Cool Clip - A Palm clip and lanyard to wear the palm around your neck or in your pocket clipped to a belt. Prevents fatal falls.
XXXXXXAllan Platt, PA-C is Program Coordinator, and Physician Assistant at the Georgia Comprehensive Sickle Cell Center, Grady Health System, in Atlanta, Georgia. He has been in this position from 1984 until present. He has a BS in Health Systems Engineering from the Georgia Institute of Technology and a BSMS from the Emory University School of Medicine Physician Assistant program. He is responsible for the day-to-day operation of the world's first and only 24-hour comprehensive sickle cell clinic and web designer of The Sickle Cell Information Center. He can also be reached at (404) 616-5994.
Allan is a Clinical Instructor in the Department of Family and Preventive Medicine,Physician Assistant Program, Emory University School of Medicine since 1979. He is the course director for teaching patient communications skills and the medical history to first year Physician Assistant students. He founded the company: Patient Communications Unlimited with physician - author Neil Shulman, MD author of the book and movie DocHollywood. You can find products and books at Patient Communications.
Allan is a consultant with Triad Technologies and Co-developer of docuCare information system, he is co-inventor of the MPS - Multidimensional Pain Score and a consultant in pain assessment and pain management.