Effect of implementing pain management standards

Historical undertreatment of pain among inpatients has resulted in a national requirement for pain practice standards.

We hypothesized that adoption/promulgation of practice standards in January 2003 at 1 suburban teaching hospital progressively increased compliance with those standards and decreased pain.

We retrospectively reviewed medical records each month during 2003, when pain standards were adopted with repeated, institution-wide, and nursing-unit-based interventions. Also, we reviewed discharges during 1 month in adjacent years.

We identified adult patients from 20 medical and surgical All-Payer Refined Disease Related Groupings (APRDRGs) in which opiate charges were most common in 2003. Among these, we considered patients actually receiving opiates and randomly chose equal numbers of matching subjects in each month of 2003. Matching was for APRDRG and complexity group. We also matched January 2003 discharges with those from January 2001, 2002, and 2004.

For each patient, we captured 3 variables measuring standards compliance: percentage pain observations reported numerically, number of observations, and median time to reassessment after opiates. We also captured 3 pain variables: median pain score, rate of improvement in pain score, and total opiates dispensed.

There were 360 qualifying discharges in 2003, and 75 in the other years. Numeric observations increased 15%, number of assessments 36%, and reassessment time decreased 60%. All changes were significant but occurred before standards implementation. Among pain measures, only rate of pain improvement changed, worsening slightly but significantly (-0.02 to -0.005 U/h), also before standards.

Implementation of pain practice standards affected neither practice nor pain.