A small scale exploration of potential benefits of routine rounds by a Chronic Pain Nurse Specialist on orthopaedic wards

Article Outline

• Summary
• Introduction
• Methods
• Results
  • Pain assessment
  • Treatments
• Discussion
• Conclusion
• Recommendations
• References
• Copyright

Summary 

This study is a small-scale audit to evaluate the effectiveness of regular ward rounds by a Chronic Pain Nurse Specialist (CPNS) on orthopaedic wards in a UK District General Hospital. Objectives were to assess existing practice in relation to pain management, identify the impact of regular ward rounds by the CPNS and identify key improvements for patient care.

A retrospective audit of current practice was undertaken using patients’ medical records. This was followed by the CPNS commencing bi-weekly ward rounds and then a further audit. Participants were those admitted to orthopaedic wards with non-malignant musculoskeletal pain for which surgery was not appropriate. The length of hospital stay of these patients was significantly reduced (p=0.0001). The largest sub-group of patients admitted had chronic back pain, and a greater number of patients received pain management interventions. The introduction of ward rounds by the CPNS appeared to have an effect on the length of stay of this sub-group and on pain management.

Keywords: Chronic pain, Musculoskeletal pain, Orthopaedic nursing, Audit, Nursing ward rounds, Chronic Pain Nurse Specialist

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Introduction 

Chronic pain is a world wide problem and it is estimated that 7% of the United Kingdom’s population have pain every day (European Federation IASP Chapter (EFIC), 2003). The EFIC (2003) statistics demonstrate the negative impact of chronic pain, but it remains one of the most under recognised and under treated medical problems of the twentieth century. It is suggested that patients who suffer chronic pain make great demands on resources and time available in the Health Service (Clinical Standards Advisory Group (CSAG), 2000). Even so it has been identified that pain management services are poorly resourced and variable in what they can offer (Allcock, 2005).

It was identified on reviewing orthopaedic services in the study hospital that there were a number of patients being admitted to orthopaedic wards suffering from musculo-skeletal pain for which surgery was not appropriate. Very few of this patient group were referred to the Pain Management Service (PMS) during their stay. This was highlighted as a problem, and it was thought that intervention by the PMS could have an influence on the patients’ comfort and well being, and potentially reduce their length of stay in hospital. It was decided that a way to overcome the problem of lack of referrals would be to introduce regular ward rounds by a member of the PMS. It was agreed that the CPNS would commence bi-weekly ward rounds on the orthopaedic wards identifying patients who required pain management. To evaluate the effect this would have for patients, a retrospective audit was first required. The CPNS undertook this on past patients’ medical records who fulfilled the criteria. The aim was to evaluate the impact upon pain management of regular rounds by the CPNS on orthopaedic wards. Specific objectives were to

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Methods 

Any patient over the age of 18 years admitted to orthopaedic services with musculo-skeletal pain that did not require surgery, excluding head injuries, were included.

A retrospective audit was first carried out using patients’ medical records that had been admitted with musculo-skeletal pain for which surgery was not appropriate. This was carried out on medical notes of patients who had been admitted in the six-months period prior to the CPNS commencing ward rounds. This was undertaken with the consensus of the clinicians. A standard against which to measure the effectiveness of the CPNS intervention was therefore established.

A second audit was undertaken over a six-month period following the introduction of CPNS bi-weekly ward rounds. Information was collected from in-patients medical records who fulfilled the same criteria as in the first audit, and the patient was then assessed by the CPNS who advised on pain management. The items of data that were collected can be seen in Table 1.

Table 1. Data collection form

ID=identification BD=twice daily PRN=as required.

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Results 

The cohort from the first audit consisted of 17 female and 14 male with an average age of 47 years, in audit two there were 11 females and 15 males with an average age of 42 years. Reasons for admission in the two audits are shown in Table 2 and sources of referral for admission are shown in Table 3.

Table 2. Reason for admission

Reason for admission	Audit one (n=31)	Audit two (n=26)
Low back pain	21	15
Neck pain	4	1
Knee pain	2	6
Hip pain	1	4
Spinal swelling	1	0
Fall (fractured femur no surgery)	2	0

Table 3. Source of admission

In both audits there was one patient whose length of stay was 4 hours, which is shown in the data as one day stays. It can be seen from the data (Table 4) that 35% (n=11) of patients in the first audit had a stay of seven days or more, in audit two there are no patients staying more than six days. In audit two 58% (n=15) only stayed one day compared to 11% (n=4) in audit one. When statistical analysis was carried out using an unpaired t-test, this showed a p value of <0.0001 with a mean value of five days in audit one and two days in audit two, showing significance.

Table 4. Length of stay

Pain assessment 

While all of these patients were admitted with pain, documentation of pain assessment was very poor. In audit one 29% (9) of the 31 patients had pain assessment recorded on admission, and 55% (17) patients had pain assessment recorded on the ward. None of these were recorded regularly.

In audit two 42% (11) of the 26 patients had their pain assessed on admission, 65% (17) had pain assessment recorded on the ward, 6 of these were performed on a regular basis and were on patients with a short length of stay, not exceeding two days.

Treatments 

In audit one the treatment patients received during their stay were that on admission of the 31 patients 17 (55%) received analgesia, which consisted of a range from Morphine, Co-codamol, Non-Steroidal Anti Inflammatory Drug’s and Paracetamol alone or a combination of these. One was given an epidural. One was fitted with a TEN’s machine.

In audit two 21 of the 26 (81%) patients received analgesia on admission. Twenty-two (85%) patients received regular medication on the wards, which again consisted of a wide range of analgesia. Eight patients were fitted with TEN’s machines of which four (15%) found them helpful to some degree. One was given three acupuncture treatments, which reduced their pain score from severe to mild.

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Discussion 

Mintel (1997) suggests that chronic back pain is amongst the most prevalent health complaint and is associated with considerable socio-economic consequences. It is often best treated with a rehabilitative approach, but as McCaffery and Beebe (1994) observed, healthcare professionals prefer dealing with symptoms that can be detected and measured objectively. The more seriously we take the problem such as by admitting to hospital, the worse the problem becomes (Hadler, 1986). This suggests the quicker these patients are seen and discharged back into the community the more beneficial it is to the patient.

The findings show that in both audits the largest group of patients admitted had back pain (Table 2). However, the length of stay for these patients was reduced from one week or more in audit one, to only one patient staying six days, and with most patients only being admitted for one day. This audit shows that a greater input from the CPNS on orthopaedic wards has helped to implement effective pain management. One reason for this is the fact that the CPNS is more prevalent on the wards due to doing the ward round, and has established a better working relationship with the nursing staff. Because of this if a patient is admitted with a pain problem they contact the CPNS on their admission to the ward and a member of the pain team sees the patient as soon as possible. Some of the measures used by the CPNS are listening to the patients and discussing different treatment options, this allows the patient choice in their care. The types of treatments offered are transcutaneous electrical stimulation, acupuncture, education and analgesia advice. If patients require greater in-put then the CPNS will contact one of the Consultant Anaesthetists who work in pain management.

It is acknowledged that there are many factors that can influence the length of stay of patients, and that not all of the credit for the reduction in length of stay can be attributed to the in-put of the CPNS, but the fact that the Pain Team are having in-put in the patient care is an improvement in its self.

Recording of pain assessment continued to be poor, although there has been some improvements when comparing data from audit one to audit two, 29% (9) of patients had pain assessed on admission in audit one; and 42% (11) of patients in audit two.

Pain assessment on the ward had improved in audit two, 17 (65%) patients had pain assessment recorded although only 6 of these were recorded on a regular basis. But these 6 were of the short stay patients and those with longer stays did not fair as well. Paice et al. (2006) p2 suggests that

“Pain must be assessed regularly and appropriately in systematic ways and the assessment should be considered an essential part of management. Pain assessment should be comprehensive, reflecting the biopsychsocial nature of this phenomenon. Pain assessment serves as a guide to therapeutic intervention and its effects, not as an end in itself.”

In an effort to highlight the importance of pain management and therefore pain assessment and for staff to comply with continuing practical development and the knowledge and skills framework (Department of Health, 2004), a program of teaching, aimed at professional staff, on how to assess pain and the reasons why it is important to carry this out, has also been started during the time this audit was being conducted.

The PMS also offer regular study days on pain management and advanced pain management, together with teaching a session on the induction training for new staff, and teaching student nurses on a number of different aspects of pain management. Although it is acknowledged by clinical teams that this will help to improve pain assessment on the wards, there are often difficulties ensuring that staff are able to attend. Nursing practice should be guided by ongoing learning, critical appraisal and should be supported by the use of ethical principles. Nursing documentation of pain is poor but effective pain management rests on clearly documented assessments and evaluations (Paice et al., 2006).

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Conclusion 

This audit indicates that intervention on the orthopaedic wards by the CPNS does affect length of stay through pain management for patients with musculo-skeletal pain who do not receive surgery, thereby reducing costs for the Trust. However it also highlights the need for further work to be carried out on pain assessment.

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Recommendations 

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References 

1. Allcock N. Take a minute to get pain on the political agenda. British Pain Society Newsletter Summer. 2005;
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2. Clinical Standards Advisory Group, 2000. Back Pain London HMSO.
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3. Department of Health, 2004. The NHS Knowledge and Skills Framework and the Development Review Process. Department of Health Publications London.
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4. European Federation IASP Chapter 2003 <www.efic.oge/about_pain.htm> (accessed 14th February, 2005).
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5. Hadler, N.M., 1986. Regional back pain, New England journal of medicine 315: 1090–1092 in good prognosis for low back pain when left untampered. Spine 20 (4), pp. 473–477.
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6. McCaffery M, Beebe . Pain A Clinical Manual for Nursing Practice. London: Mosby; 1994;
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7. Mintel, 1997. Complimentary medicine. In: Market Intelligence Report. London.
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8. Paice, J., Abu-Saad, H.H., Coyle, N., Davis, G., Fothergill-Bourbonnais, F., Idvall, E., Johnston, C., Lai, Y., Onibokun, R., Quinn, R., Seers, K., Thomm, M., Walker, J., Watt-Watson, J., 2006. Outline Curriculum on Pain for Nursing, second ed. International Association for the study of pain.
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