Managing the pain of hospitalized patients is a fundamental ethical responsibility of hospitalists, enshrined as a core competency by SHM and, according to the Joint Commission on Healthcare Accreditation Organizations (JCAHO), a right for hospitalized patients.
Following last month’s exploration of IV pain medications (“Perfect Pain Control,” p. 40), this month we begin a three-part series on pain management issues in the hospital setting, based on interviews with working hospitalists and other pain experts.
Part one (below) provides a context for pain management and emphasizes assessment as the cornerstone of pain control. Next month, we will explore common dilemmas and difficult cases in pain management that can take hospitalists out of their comfort zone, along with the myths and realities of hot button topics such as addiction. The following month, we will chart the continuum of pain management modalities used in the hospital and discuss how working hospitalists can best utilize them for patients with special needs.
—Steven Pantilat, MD, hospitalist and palliative care physician, UCSF Medical Center
Listen to Your Patient’s Pain
Assessment and follow-up remain key to managing hospitalized patients’ pain. Stephen J. Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and consultant on the medical center’s palliative care service, remembers a hospitalized patient whose pain problem was not what it seemed—although a more careful assessment showed the way to a solution. A woman in her early 80s who resided in a long-term-care facility was admitted to the hospital with out-of-control back pain and mild dementia. House staff fitted her with a patient-controlled analgesia (PCA) pump to treat her pain, with instructions to press the control button whenever she experienced pain. Dr. Bekanich got a call 48 hours later because the patient was still voicing significant pain complaints, despite the PCA.
“I found that her pain scores were taken by the nurses every four hours, which is not often enough when pain is out of control,” he says. “I also looked at a printout of the PCA history, which indicated that she had only pressed the button 10 or 12 times in 48 hours. You would have expected a lot more attempts, given her reports of pain.”
Dr. Bekanich showed the patient the PCA button and asked her, “ ‘What’s this?’ She replied, ‘I can’t see it. I don’t have my glasses here in the hospital.’ When I put it in her hand, she said, ‘This is what I use to call the nurse.’ ”
A small tag on the PCA handle indicated that the patient should push for pain, but the patient was unable to read it. Once Dr. Bekanich understood her functional limitations, he wrote a new order for continuous infusion of an opioid analgesic, which brought the pain under control.
This case illustrates several principles of effective pain management. First is the importance of assessing the various factors that influence pain and the physician’s need to look more deeply if the pain doesn’t respond to initial measures. “That should be a warning flag to ask, ‘OK, what am I missing?’ ” Also, for moderate to severe pain, a component of around-the-clock dosing or continuous infusion to bring the pain under control is just as important as having the availability of a PRN analgesic for responding to breakthrough pain, such as starting the patient on a PCA.