Preparing patients for surgery
Chronic pain patients
Patients on maintenance with methadone/buprenorphine
Patients with history of substance abuse
Patients with established biopsychosocial risk factors
Genetic risk factors for postoperative pain and treatment selection
Patients at risk for chronification of acute pain
Patients at risk for severe morbidity/mortality from pain treatment
Patients undergoing surgeries associated with adverse acute pain outcomes
Optimizing intraoperative management
Perioperative regional anesthetics with appropriate temporal profiles
(Procedure-specific) multimodal analgesics
Optimal intraoperative maintenance of anesthesia
Immediate PACU care
Postoperative care
Daily rounds
Medication and intervention management
Coordination with functional recovery (e.g. PT, OT)
Transitional care
Transition to home-based analgesic regimen
Provision of ambulatory regional anesthetics
Need for f/u with chronic pain team
Ideally, the APS’s initial encounters with a particular patient begin well before the onset of injury. This rubric is idealized in the model of scheduled, elective surgical procedures that permit considerable lead time to optimize a patient prior to surgery. Such optimization commonly begins with offering education on available pain management options and managing subsequent patient expectations of such options [29–32]. Such discussions should involve trained individuals so that patients are not given unrealistic expectations pertaining to analgesic options [33]. Many an acute pain physician has encountered patients who have come to believe that their services would lead to a completely pain-free recovery from even major surgical procedures. Such belief patterns, once erroneously instilled, may inevitably lead to patient dissatisfaction, regardless of the physician’s assessment of the success of an analgesic intervention [34, 35]. Preoperative optimization may often extend to prescribing specific multimodal analgesics and coordinating the availability of certain perioperative interventions, consultants, and expertise [36, 37]. One exciting possibility of such a screening process involves identifying patients with high degrees of pain catastrophizing, which is strongly associated with adverse acute pain outcomes, who may be amenable to brief cognitive-behavioral therapy interventions [38–40]. This coordination itself may require further consultation with the patient’s primary care team in the case of patients suffering from chronic pain and/or substance abuse. This is especially true for those patients who have been prescribed methadone or buprenorphine within the outpatient environment, especially given that the optimal method of managing these patients is currently under debate [41–45]. While discussions in these circumstances traditionally revolve around transitioning to the acute pain setting, the preoperative time frame is optimal for also discussing a transition from the acute inpatient setting back into the outpatient primary care environment.
The preoperative setting is also a common point of consultation where astute primary surgical services can identify patients for whom surgical concern of the pathophysiologic sequelae of pain, rather than pain itself, is the primary concern. Examples include vascular surgery patients suffering from limb ischemia, facilitation of limb reattachment surgery, and patients at increased risk for postoperative cardiac or pulmonary complications [46, 47]. Coming full circle, there has also been a resurgence of interest in optimizing postoperative pain management in patients undergoing minimally invasive surgeries whereby the minimal invasiveness was initially championed as a way to decrease postoperative pain. For instance, despite laparoscopic colorectal surgeries offering substantially less postoperative nociception, recent data still suggests a role for the APS to further reduce the time to return of bowel function through epidural analgesia, opioid minimization, and aggressive multimodal analgesia [48, 49]. Perhaps somewhat counterintuitively, APS’s have also been regularly consulted for thoracic endovascular aortic repair for patients with an elevated risk for postoperative spinal cord ischemia [50]. Here, the APS may be asked to facilitate intrathecal drain placement and management of naloxone infusions while still optimizing patient analgesia.
Given the propensity of surgical patients to comprise the majority of the patients on an APS census, it is our firm belief that an APS must maintain a very significant presence within the intraoperative environment. Aside from offering concrete recommendations and even direct patient care, a regular intraoperative presence offers a plethora of opportunities for informal conversations, education, and feedback on matters pertaining to the APS with the surgical team. Given equipoise in other factors, there are many circumstances whereby a certain approach to anesthesia may offer an improved postoperative pain outcome [51]. Indeed, even within the realm of general anesthetics, there is mounting evidence that certain maintenance agents and adjuncts may lead to substantial improvements in postoperative pain management [24]. For instance, data from retrospective cohort studies suggest that a propofol-based maintenance strategy may be associated with less postoperative pain and opioid consumption compared with maintenance conducted with inhalational agents [52, 53]. An intraoperative presence also helps with the process of translating clinical science into clinical practice by virtue of understanding the practical concerns, limitations, and opportunities that exist on the front line of this incredibly dynamic time period.
Intraoperative involvement offers a number of opportunities to improve postoperative pain management. For instance, the APS may help select a more optimal regional anesthetic strategy (catheter vs. single shot) to better account for the anticipated temporal trajectory of postoperative pain resolution, or directly administer multimodal analgesics in the perioperative setting [54, 55]. For patients in whom the anticipated surgical plan has morphed into one with an anticipated worse postoperative pain outcome, intraoperative involvement may permit intraoperative placement or early postoperative placement of regional anesthetics and/or multimodal analgesics, although data suggest that pre-incisional timing remains optimal [56]. Intraoperative involvement should also extend to a robust presence within the recovery room, as this highly dynamic time period offers a unique opportunity to rapidly select and titrate optimal analgesic therapies, detect potential safety issues, and set the tone for successful and safe analgesia over the next several postoperative days [57–59].
Perhaps the most historically common practice arena for the APS has been in the postoperative care of surgical patients. Many APSs perform daily rounds on patients, assessing a patient’s pain and pain impact on functioning, and offering recommendations for improving and/or transitioning analgesics to the next phase of recovery. Generally, APS practices fall into one of two camps. In the first, the APS assumes full responsibility and control over all analgesics, and will be the only team of physicians who modify the analgesic regimen of a patient. Such patterns may be limited to those patients receiving neuraxial opioids, or may extend to all patients in whom the APS has been consulted [60, 61]. The second camp is a consultative practice whereby recommendations are made, but the final responsibility and coordination are maintained by the primary service. Even in this camp, it is often the standard that modifications to regional anesthetics still fall under the purview of the APS.
Regardless of the practice model applied in the postoperative setting, certain facets remain common. Close coordination is necessary to avoid duplicative, or countermanding, strategies and orders that could rapidly lead to patient harm. To this end, social network analyses of even small APSs suggest a very large network of communications stemming from this need for close coordination [62]. Next, communications among physicians, although necessary, is not sufficient to ensure optimal application of chosen analgesic strategies. Rather, these efforts must include coordination with nurses, therapists, pharmacists, and other consulting teams to ensure that the analgesic strategy is not interfering with other facets of the patient’s recovery.
One of the more overlooked aspects to modern APS practice involves the transition of patients to their post-admission destination and recovery. The import of this transition has received renewed focus given evidence reported by Chapman, Althus, and others that demonstrates that a significant portion of surgical patients will have a neutral, or even positive, pain trajectory slope over the first several days after surgery [54, 63, 64]. Many consultations to the APS for patients who have already received surgery focus on transitioning patients from an effective inpatient, IV-based analgesic regimen to a PO-based regimen that a patient may use at home. The APS encounters similar issues with patients whose pain has been well controlled with a regional anesthetic, but must transition to an environment where such a technique is not feasible. It is not unsurprising that many APSs thus conduct regular outreach to local rehabilitation centers, hospices, and even assisted living facilities to improve the likelihood that a patient’s perineural catheter infusions may follow them beyond the hospital setting [65, 66]. One intriguing option is the use of an APS to triage and refer select patient populations for early, aggressive interventional procedures in the chronic pain clinic for pain in the midst of transitioning from acute to chronic.
18.2 Team Composition
Every individual in a team should play a contributory role toward optimizing patient comfort during his/her progress through the healthcare system [67]. The group of individuals on the APS includes physicians, nurses both in the procedural care area and in the units/wards, and consultant staff (e.g., surgical team, physical therapy/occupational therapy, psychiatry, palliative care medicine, pharmacy, social work).
The large number of social connections results in complexity in communication [62]. Yet, solid communication is key for the team to function optimally. This communication can take place in the form of written frameworks or protocols set in place to minimize variability of patient care, in addition to verbal communication (both through group discussions or direct communication with the team members).
18.2.1 Physicians
A physician comprehensively trained in Acute Pain Medicine should be the cornerstone in a functional APS and needs to be involved during the entire perioperative course, not just the intraoperative period. Preoperative education and optimization of patients is vital preparatory work to reduce delays and cancellations on the day of surgery. Patient optimization includes addressing issues such as anticoagulation, infection, and cardiovascular stability, allowing the physician to appropriately decide anesthetic and analgesic modalities that optimize benefit:risk ratios [13]. Preoperative planning also includes discussion with surgical colleagues on potential factors that may complicate care of the patient (planned postoperative anticoagulation, anticipated duration of hospital stay, extent of surgery) as well as resource management (nursing staff and equipment availability).
The physician’s role in the postoperative period cannot be emphasized enough. The placement of a regional anesthetic is but one aspect of postoperative multimodal pain management. The physician must continue his/her involvement in the postoperative period with the following goals:
To continually assess the efficacy of the regional analgesic catheter and determine and manage etiologies for breakthrough pain (e.g., compartment syndrome, inadequate coverage by the regional anesthetic catheter, pump malfunctions, catheter migration, unanticipated extensive surgery, failure to reinitiate home opioid regimen)
To optimize functional recovery of the patient (improve physical function, assist with sleep hygiene, minimize undesired side effects of medications)
To address postoperative issues with the surgical team (e.g., optimal timing of postoperative anticoagulation, discharge planning)
To detect and manage post-procedural complications (infection, nerve injury, bleeding, local anesthetic toxicity)
To transition patients to oral analgesics and plan for regional analgesic catheter discontinuation
18.2.2 Nursing Staff
Different subsets of nurses play crucial roles in the pain management team. These subsets include nurses assisting in the procedural area, dedicated acute pain nurses who assist physicians with post-procedural rounds, and the floor and unit nurses who receive and care for the patients in the post-procedural period. These dedicated nurses require specific skill sets in order to assist the physician in safe and effective delivery of analgesic modalities while minimizing variability in practice.
Dedicated nurses in the procedural area may allow for improved patient safety and efficiency when performing regional anesthetics, especially in the context of a dedicated block area to perform procedures in the preoperative setting. Dedicated nurses in these areas can be involved in formal time-out processes to ensure placement of a regional anesthetic in the correct location of surgery and to confirm indications and contraindications to procedures (e.g., potent anticoagulation). They need to have a basic understanding of hemodynamic monitoring, sedation, and airway management in order to aid the physician during placement of a nerve block. They must understand nerve stimulation and be able to recognize block-related events (e.g. local anesthetic systemic toxicity) and be familiar with equipment such as ultrasound machines.
In one practice model outside the procedural area the role of the APS nurse is multidimensional, and a complement to the pain physician on rounds. The nurse assists with consult triage to determine the needs of the primary service and as an educational liaison for patients and their families as well as other support staff caring for the patient to communicate with them about topics relevant to the patient’s pain management (such as avoiding potent anticoagulation in patients with neuraxial or deep blocks, optimizing multimodal analgesia, and anticipating motor and sensory changes with regional anesthesia). The nurse gathers focused patient information, including pertinent medical history, active medications, and a history of chronic opioid requirements. The nurse communicates with other medical staff (ward nurses, surgical teams) to fully appreciate the patient’s course and conditions, round-the-clock efficacy of regional analgesics, and the anticipated discharge time, enabling the APS team to make more informed decisions regarding pain management. The APS nurse also is responsible for data collection for quality improvement to substantiate future management decisions [13, 67, 68].
Ward and unit nurses should be considered part of the acute pain team and be encouraged to participate on rounds in order to communicate with the physician issues that need to be addressed (e.g., adequacy of pain management, poorly tolerated side effects of systemic drugs, concerns for infection, equipment issues). These nurses should have a fair understanding of pain assessment, multimodal analgesia, basic pharmacology, and concepts related to regional anesthesia (e.g., motor weakness in the distribution of the nerve blocked, avoidance of potent anticoagulants with neuraxial catheters, pump mechanics, recognition of local anesthetic toxicity, and dressing maintenance).
18.2.3 Consult Services
The role of the pain team is to optimize the patient’s functional status and not just to reduce pain scores to a minimum. The pain team operates in a multidisciplinary milieu where consult services should be utilized to improve the patient’s overall perioperative outcome. This includes working in concert with physical and occupational therapy to enable successful rehabilitation for the patient (maximize regional anesthetic efficacy while minimizing motor weakness, optimize fluid status and local anesthetic infusions in patients receiving epidural catheters to reduce the incidence of orthostatic hypotension, etc.). Psychiatry should be consulted in patients with conditions such as depression or post-traumatic stress disorder that may hinder functional recovery. Pharmacy should be involved in processes to minimize medication errors (safe labeling of medications such as local anesthetics), to supply appropriate types and concentrations of medications, and to design underlying systems to minimize clinical errors (clarify necessity of potent anticoagulation prescriptions in patients with neuraxial or deep blocks) [13]. Services such as palliative care and social work can be consulted for further specialized care and to aid in a smooth transition from the inpatient to outpatient setting.
18.3 Daily Workflow
18.3.1 Environmental Assumptions
Here, we describe a typical day on a modern APS. Note that this “typical day” carries many assumptions. The day is modeled on an academic medical center in the United States. The APS is administered by the Department of Anesthesiology with additional resources from the hospital itself. It is staffed by attending anesthesiologists who supervise fellows, residents, and undergraduate trainees of all stripes. The APS here also offers side duties, including regional anesthesia, intraoperative, and recovery room anesthetic care, and pre-anesthetic evaluation. Attending anesthesiologists are also responsible for administrative, education, quality improvement, and research duties. While the APS may offer care across separate facilities, each facility is geographically co-located to be within walking distance. The typical patient census for this APS ranges from 20 to 50 patients and consists of a mix surgical patients, medical patients, and patients from special populations such as pediatrics, obstetrics, and palliative care.
18.3.1.1 Pre-rounds
We begin this walk through at 0600, whereby the in-house overnight resident for the APS provides sign out to the oncoming team. The oncoming team is split between those placing nerve blocks and consults for new patients (the block team) and those providing care for existing patients (the rounding team). The rounding team initially assists with care of patients presenting for nerve block until 0800 and then collects data on overnight pain evaluations, analgesic requirements, hemodynamic hepatorenal and coagulation status, progress with recovery, and disposition planning. There is typically then an hour of formal education for fellows, residents, and trainees.
18.3.1.2 Blocks
Nerve blocks are a key tool for a modern, effective APS. Here, we focus on organizational issues surrounding block placement. Patient candidacy for a nerve block is initially assessed the day before surgery. Note than with over 200 patients presenting for surgical procedures each day, an in-depth chart review and interview for all patients by the APS is not feasible, therefore a number of heuristics are involved. For high-volume, low-variance procedures such as total joint arthroplasty, blocks are placed according to established frameworks. A similar approach is followed for low-volume, high-variance services such as orthopedic oncology, where the majority of procedures are likely to benefit from a nerve block. However, in these populations, following a review of the medical record and imaging, there is a discussion with the surgical attending on the planned approach and anticipated recovery profile to better match block selection to each patient. For relatively rate, one-off combinations of patients/procedures that are highly likely to benefit from a nerve block, there is a lengthy discussion with the surgical team that includes an in-depth review of anticipated postoperative analgesia, anticoagulation, and functional recovery before the decision for nerve block placement.
18.3.1.3 Intraoperative Consults/Blocks
Occasionally, the surgical plan will need to be heavily modified intraoperatively due to unanticipated events. For example, this may include aborting a Whipple procedure due to advanced metastasis, or conversion from a mass excision to an amputation. Intraoperative changes may also be subtle, such as a requirement for substantially more anti-nociceptive agents than anticipated, or even the possibility of a failed preoperative nerve block. Regardless, it is not uncommon for the APS to be summoned to the operating room prior to emergence to either assist with planning of intraoperative multimodal analgesia, planning for or placing of postoperative regional anesthetics, or troubleshooting of existing nerve blocks. Even in the absence of changes to the surgical plan, intraoperative assessment of block performance by the APS block team serves as an internal quality control. Additionally, these encounters offer opportunities for informal consults, queries, and education. They can also demonstrate a commitment to follow-through and excellence, alleviating surgical fears of “fire and forget” nerve blocks that leave any adverse outcomes or block failures to the already busy surgical team to manage. Such intraoperative consultations point to the need for the APS to be both familiar with and accessible to the intraoperative environment to support the continuity of analgesic care.
18.3.1.4 Rounds
The APS rounds on each patient occur at least twice a day. The first set of rounds is teaching rounds, where a resident or fellow to the APS attending presents each patient. The APS attending sometimes directs that the fellow perfunctorily lead rounds, a transition generally occurring later in the academic year. The presentation will generally focus on the patient’s documented pain evaluations from the prior evening, including any salient details passed on from the night resident. The presentation will also cover the prescribed analgesics, as well as any hepatic, renal, hemodynamic, or coagulation issues that may impact any analgesic decisions. Updates to the surgical recovery plan and disposition goal are addressed during this pre-interview discussion as well. Once the established data have been reviewed, the APS then enters the patient room and interviews the patient. Aside from inquiries on the patient’s pain, recovery, and response to analgesics, the patient is also given a thorough neurovascular examination depending upon the type of regional anesthetic. This interview should move well beyond simple numeric rating scale (NRS)-based inquiries of the patient’s pain intensity at rest and with movement. Rather, any inquiries regarding the patient’s pain intensity are placed within the context of recovery goals. Has the patient been able to breathe deeply and cough? How was it getting out of bed? Did the patient have any difficulty ambulating, voiding, or moving the afflicted surgical areas? Were there any adverse events to the prescribed analgesics; if any analgesics were modified, how did the updated plan work? How well did the patient sleep, and how is pain influencing the patient’s mood?
Note that such a shift to assessment across patient-reported outcomes could theoretically consume an inordinate volume of time for each patient. Indeed, inefficient survey-based methodologies of established patient-reported outcome (PRO) reporting tools can require per-subject time allocation even when subjects are not recovering from surgery [69]. Thus, the patient interview necessitates mediation of tension between rapid, highly efficient assessments of patient well-being versus those questions likely to be of actual value from the patient’s perspective. Recent work on the use of computer-adaptive testing to rapidly sort through the myriad possible PRO items may offer an exciting opportunity to rapidly yet effectively assess PROs [70–72].
To add further context, any patient-controlled analgesic (PCA) devices are also queried to determine utilization rate. Note that the PCA in this instance serves as an important behavioral indicator of the patient’s response to pain. Given that the PCA is often applied as a means of achieving, rather than maintaining, a minimum effective analgesic concentration, the patient interview is an important opportunity to offer ongoing education on the role and purpose of the PCA device, although such education must also be directed toward members of the healthcare team charged with choosing among multiple available analgesic options in the face of an uncomfortable patient [73].
18.3.1.5 Post-anaesthesia Care Unit (PACU) Evaluations
While the rounding team is underway, the block team continues its work with patients presenting for surgery and offers intraoperative consultation. As patients present to the PACU for recovery from surgery, the APS block team will frequently walk through the PACU to preemptively identify patients with aberrant analgesic requirements and/or offer troubleshooting of nerve blocks. At our institution, all patients with nerve blocks must be seen by the APS prior to discharge from the PACU, whether for ambulatory surgery or inpatient recovery. Even for patients with adequate pain control, the APS may be consulted for patients experiencing difficulties with oxygenation or ventilation to help rearrange and optimize analgesics.
18.3.1.6 Post-block Rounds
Following formal rounds, a “to do” list of tangible activities is reviewed. Responsibilities are divvied among the team according to suitability, availability, and priority. A “list” of all patients on the service is maintained and updated to reflect the observations and treatment plans reviewed during rounds. Blocks placed by the block team during rounds are reviewed with the rounding team. The rounding team sees new consults. By evening, most of the task list is complete, and progress notes are completed. Each evening, there is a designated physician on the APS who provides in-house coverage for the APS. This individual rounds on all new and established patients in the late afternoon, and often again during the evening. This ensures that the APS is able to achieve multiple diagnose-treat-evaluate cycles throughout the day, “pressing” progress forward and ensuring that appropriate monitoring exists on patients beyond the presence of a physician’s order. Even patients for whom the team has difficulty achieving safe and effective analgesia, we firmly believe this multi-round approach sends the informal message that the APS has not forgotten about nor ignored them, but is continuing to press forward with new therapies. This multi-round approach is also critical for certain populations such as orthopedic trauma to prevent masking of complications and to offer increased numbers of neurovascular exams for at-risk patients.
18.3.1.7 Ambulatory Catheter Care
Many patients receiving ambulatory surgery are candidates for ambulatory perineural catheters. This topic has been exceedingly well covered in reviews by Enneking and Ilfeld [66, 74]. Organizationally, the assessment for candidacy for ambulatory perineural catheters begins with the preoperative assessment. Postoperatively, patients are transitioned to an ambulatory perineural catheter infusion device on the day of discharge. Follow-up is conducted at least once via telephone, including a telephone discussion during the catheter removal process. The APS will contact the patient at least once per day via telephone, and the patient is instructed to contact the APS at least once per day via the telephone number provided, even if there are no appreciated issues, if they have not heard from the APS. Patients are also provided a very detailed set of instructions on maintenance and troubleshooting of perineural catheters, with explicit instructions to call the APS with any questions they may have.
18.4 Pain Evaluation
A cornerstone of APS rounds is the evaluation of pain, which is not an easy thing. In the late nineteenth century, psycho-physical analysis was an attempt to correlate a patient’s subjective expression of pain intensity with actual physical level of pain [70]. In a controlled laboratory setting, this may have been feasible, but it became less useful when used in the clinic. There were just too many confounding factors that influenced the subjective pain experience: the surgical experience, comorbid conditions, medications, and psychological stressors to name a few. Pain rating scales were developed out of the need for a simple and efficient method to evaluate pain intensity over time, as a way to gauge the efficacy of treatment [71]. In the setting of the increased recognition of pain in the backdrop of the congressional designation of the Decade of Pain or the Joint Commission’s mandate to consider pain as the “fifth vital sign,” accurate assessment of pain has therefore arisen as a key issue in acute pain medicine [75].
18.4.1 Pain Intensity Measurement Tools
Often, the assessment of pain will default to the question, “What is the best scale?” However, a comprehensive pain assessment should include a precise pain history, a measurement of intensity, measurement(s) of pain impact, and follow-up assessments for treatment response. Although the frequency of such assessments should be regular, assessments must be tailored to the patient’s pain intensity (more intense = more frequent) and treatment (follow-up assessments after intervention).
The initial evaluation should consist of a review of salient medical history along with medications currently being administered for pain and non-pain-related conditions. Investigation into pain characteristics should subsequently involve defining the location of the pain, exacerbation, alleviating factors, quality, etc., as is standard. Such an initial evaluation allows for the generation of differential mechanisms for a given patient’s pain such as nociceptive, neuropathic, or mixed etiology.
Numerous intensity scales have a long history of use and validation, including the Visual Analog Scale (0–100 mm), the NRS (0–10), and the Verbal Rating Scale (VRS; No Pain, Mild, Moderate, Severe, and Excruciating) [76]. Hewer and Keele developed one of the earliest versions of the VRS, a categorical scale of pain intensity where patients assign their pain to one of three categories: “0” being no pain, “1” is mild, “2” is moderate, and “3” is severe pain [74]. In the 1960s, Bond, Pilowsky, and Spear created the Visual Analog Scale (VAS), a 10-cm line (100-mm) on paper with “0 cm” being defined as “no pain” at one end, and “10 cm” being defined as “the pain is as much as I can bear.” The patient draws through the line to express the level of pain they are experiencing. Given that they can draw at any point along the line, linear data on the patient’s pain are obtained. As a result, in comparison to the categorical scales, the VAS is thought to be more sensitive at detecting a change in pain intensity with treatment (in persons capable of performing the task), and may reflect ratios of pain intensity [77]. Still, the major drawback is that written scales are an inefficient way to regularly assess pain.
Verbal assessment is more practical on APS rounds and with repeated, regular assessment by the bedside nurse. Although the VRS, VAS, and NRS are traditionally written scales, the NRS is more commonly applied verbally. To use the NRS, a patient is asked to rate the intensity of his/her pain on a scale from 0 to 10. At many institutions, including ours, the NRS pain scale is documented after recovery from surgery, on rounds, and before and after pain medications are given, to assess efficacy of treatments over time. While practical and efficient, the NRS may not be statistically sensitive enough for clinical research to detect treatment effects [78].
The NRS has a long history, thereby establishing reliability and validity. Specifically, the NRS has acceptable discriminative capability, but also enough options to have the ability to detect change over time. However, while the NRS is an important tool, its unidimensional nature significantly limits the characterization of the multidimensional nature of pain. As an expansion of such unidimensional scales, numerous functional and multidimensional scales exist such as the Brief Pain Inventory or the McGill Pain Questionnaire [79, 80]. Such scales capture additional insights into pain interference, impact on sleep, and anxiety. However, in a clinical setting, such scales have a limited role secondary to lengthy time of administration, which is impractical on a daily basis. Thus, in an inpatient setting, the NRS remains the most consistently used measure for daily measures of pain.
18.4.2 Development of the Defense and Veterans Pain Rating Scale
Current pain assessment practices within inpatient settings, while commonly employed, have not been shown to improve pain outcomes or the safety of care [81]. Furthermore, in a survey of 77 Veterans Administration providers, little confidence was expressed regarding the accuracy of nurse-acquired pain ratings [82]. Such insights reinforce the concept that current pain assessment practices lack the ability to capture the multifaceted patient experience of pain.
Stemming from the limitations of unidimensional scales, a 22-member working group chartered by the US Army Surgeon General in 2008 developed a novel scale focused on capturing the biopsychosocial impact of pain [81]. This scale, the Defense and Veterans Pain Rating Scale (DVPRS), focuses on expanding the NRS by integrating visual variables (faces/colors) along with descriptive functional anchors assigned to pain intensity designations (Fig. 18.1a). In addition, four supplemental questions focused on sleep, anxiety, activity, and mood offer further multidimensional information regarding the impact of pain (Fig. 18.1b). Such a tool can be quickly administered at the bedside and on a daily basis. The goal of such a scale is to further standardize pain assessments, improve the ability to identify “at risk” patients, and provide a tool that is applicable in numerous environments. Although new within the landscape of pain assessments, the DVPRS scale has been found to have acceptable reliability and validity in a sample of 350 inpatient/outpatient active duty or retired military personnel [83].
Fig. 18.1
Defense and Veterans Pain Rating Scale
18.4.3 Pain Assessment in Special Populations (Neuropathic Pain, Elderly, Pediatrics, Non-verbal)
Pediatrics
An important limitation of the commonly used pain intensity scales designed for use in healthy adults is that they require patient insight and participation. In most cases, verbal and preverbal children are incapable of using these scales. In preverbal children, pain has to be expected in conditions that are assumed to be painful, prevented, and treated [83]. Multidimensional pain scales such as the Face, Legs, Activity, Cry, Consolability (FLACC) Pain Assessment Tool provide a standardized method for use by nurses and clinicians to assess pain in preverbal children in the clinic. FLACC correlates well with other pain assessment tools such as the Coloured Analogue Scale, the COMFORT scale, and the NRS in verbal children as well [84].
Elderly
There is wide recognition that pain is under-recognized and undertreated in the elderly population [85]. Various factors such as cognitive impairment, altered sensation, or atypical manifestations all contribute to the variability in accurate pain assessments within this population. For patients with cognitive impairment that is mild or even moderate, scales such as the NRS or the Faces Pain Scale have shown good reliability and can be utilized in the inpatient setting [86]. However, for nonverbal or severely cognitively impaired individuals, observational scales such as the Checklist of Nonverbal Pain Indicators or the Pain Assessment in Advanced Dementia scale can be used [87]. Such observational tools can serve as a platform for empiric analgesic interventions followed by reassessment of such behavioral manifestations of pain. Of note, these observational tools are not applicable to unresponsive or sedated patients.
Critically Ill
Pain in a critical care setting is often complicated by coexisting physiologic derangements, agitation, sedation, delirium, and a variety of comorbidities that cloud both the assessment of pain and response to treatment. Numerous series have shown that large percentages of ICU patients experience significant levels of pain, which highlights the need for accurate assessments of pain [88]. Similar to elderly patients, patients with minimal cognitive deficits are able to accurately report pain intensity with the NRS scale or other unidimensional tools [89]. However, for patients that are either sedated or nonverbal, the Behavioral Pain Scale or Critical Care Pain Observation Tool are two validated tools used within an intensive care environment [90]. Both tools rely on observational data from behaviors such facial expression, body tone, or ventilator compliance.
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