development and introduction of a pain score documentation chart in the acute oncology setting

ORIGINAL ARTICLE

Development and introduction of a pain scoredocumentation chart in the acute oncology setting

Katherine CLARK,1,2 Judi GREAVES,1 Emily SUNG2 and Paul GLARE1,2

1Department of Palliative Care, Sydney Cancer Center, Royal Prince Alfred Hospital and 2Faculty of Medicine, University ofSydney, Sydney, Australia

Abstract

Background: Recommendations to improve cancer pain management include the introduction of routineand clearly visible documentation of pain scores. Whilst this practise has been adopted in many cancer andpalliative care units, longitudinal evidence to support the view that the practise has provided improvedanalgesic outcomes for patients is limited. The aims of this study were threefold; (i) to collaborativelydevelop a locally acceptable pain documentation chart; (ii) to test this chart by comparing patient-reportedand nurse-documented scores with pain scores collected by researchers using validated measures; and (iii) toexamine whether or not pain scores and analgesia scores longitudinally improved over the study period.

Methods: Using a multidisciplinary approach, a pain score documentation chart was developed for use onan acute hospital’s oncology ward. Prior to the chart’s introduction, the brief pain inventory (BPI) wasadministered to 45 in-patients. The patients were then asked to report on a regular basis their numeric painscores, which were documented on the chart. At the time of discharge or after 7 days, the BPI was repeated.The pain chart scores and the BPI item, ‘average pain experienced in the preceding 24 h’ were correlated.

Results: The initial chart scores significantly correlated with the first BPI score (P = 0.001), and a similarrelationship was found between scores collected at the end of the study period (P = 0.020). Analgesic scoresimproved, patients were satisfied with the approach taken to their analgesic management and the pain scoreswere charted with a similar frequency to vital signs (pulse, temperature, blood pressure).

Conclusions: Pain score charting is feasible and acceptable to patients and nursing staff in an acute hospital.Most importantly, this process has the potential to improve the analgesic outcomes of cancer patients.

Key words: analgesia, hospital, nurse, oncology service, pain measurement, pain.

INTRODUCTION

Despite the ready availability of guidelines to steer theprescription of analgesic medications, inadequate painrelief continues to be a problem for patients with cancerpain.1,2

There are multiple recommendations aimed atimproving this problem, which include the recommen-dation that regular and clearly visible documentation ofpain scores should be standard practise in the acutehospital setting. This is the concept that pain should beconsidered the fifth vital sign and thus pain scores aretreated in a similar fashion to other vital signs such asblood pressure, pulse and temperature. Recommenda-tions to support this have been incorporated into prac-tise guidelines and accepted as a quality assurancestandard in many cancer centres. Indeed, in the USA,this practise is required for the accreditation of a healthcare facility.3,4 Despite this, evidence to support the prac-tise is limited. This study aimed

Correspondence: Dr Katherine Clark, Department ofPalliative Care, Sydney Cancer Centre, Royal Prince AlfredHospital, Missenden Rd, Camperdown, Sydney, NSW 2050,Australia. Email: [email protected]

Accepted for publication 07 February 2007.

Asia–Pacific Journal of Clinical Oncology 2007; 3: 89–94 doi:10.1111/j.1743-7563.2007.00093.x

© 2007 The AuthorsJournal Compilation © Blackwell Publishing Asia Pty Ltd

• to collaborate with nurses on a cancer ward of anacute care teaching hospital to develop a locally accept-able pain score chart and to ascertain if it was possibleto introduce this chart into normal ward practise• to compare the pain scores collected and documentedby the nurses on the ward with pain scores collected byresearchers using a well-validated pain assessment toolto test the chart’s reliability• to examine whether or not pain scores and analgesiascores longitudinally improved over the study period.

METHODS

The study

In consultation with the nursing staff of a cancer ward,a simple chart was devised to record patient’s self-assessed numeric pain scores, based on a 10-pointnumerical recording system where 0 = no pain and10 = worst imaginable pain. When agreement over thechart’s appearance was reached, the study was com-menced (Fig. 1).

The study involved the recruitment of newly admittedcancer patients to the oncology ward. As far as possibleto consecutive cancer patients with pain, who wereadmitted to the ward, were identified to the researchersby the nursing staff. Within 24 h of their admission, ifthe patient was willing and able to participate, theresearchers administered the prestudy assessment of

pain. This involved the researchers administering thebrief pain inventory (BPI) and calculating the pain man-agement index (PMI). This pain chart was then filedwith the bedside notes. At the end of 7 days or at thetime of discharge from hospital, whichever occurredfirst, the researchers administered the post-study assess-ment of pain. This included the BPI, PMI and an assess-ment of the patient’s opinion of their hospitalized painmanagement.

Ethical approval

Approval was obtained from the hospital’s ethics com-mittee. The participants signed a written consent formindicating their willingness to participate and allowingthe data collected from them to be included in theanalysis.

Participants

Inclusion criteria included cancer patients with painadmitted to the oncology ward who were older than17 years, and were willing and able to sign the consentform and to participate in the completion of the painscores, both the research-administered and the nursingstaff-administered chart (Fig. 1).

Clinical and demographic information were recorded,including age, cancer diagnosis, performance statusmeasured by the Eastern Cooperative Oncology Group

Figure 1 Pain documentation chart.

Instructions:1. In order to better assess and manage cancer pain, every four hours whilst patients are awake, the patient’s opinion of their pain

rating should be documented by shading the appropriate box. The patient is questioned about where, on a scale of 0 to 10 where they rate their pain, where 0=no pain and 10=worse pain imaginable.

2. Next, an assessment of whether or not the patient finds this level of pain/discomfort tolerable or intolerable. This is recorded by documenting Y(yes) or N(no) in the box.

Date

Pain Rating:

Time 06 10 14 18 22 06 10 14 18 22 06 10 14 18 22 06 10 14 18 22 06 10 14 18 22 06 10 14 18 22 06 10 14 18 22

01niap tsroW98ereveS765etaredoM432dliM10niapoN

Is this level of pain tolerable? (Y or N)

Does this pain require an intervention? (Y or N)

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Asia–Pac J Clin Oncol 2007; 3: 89–94

score (ECOG score),5 sites of pain, reason for admissionand cancer treatment during this admission.

Study measures

Pain score documentation chartThis was a collaborative, locally designed chart for plot-ting the patient’s self-reported numerical pain scores ascollected by ward-based nursing staff. The nursing staffwere asked to record the pain scores four times daily andto question the patient about their current level of pain.

BPIThe BPI is a well-validate research tool to comprehen-sively measure the history, intensity and impact ofcancer pain.6 It was incorporated into the study toprovide a standard against which the researchers couldcompare the scores collected by the nurses.

PMIThe PMI is used to ascertain whether there is congru-ence between the patients reported pain scores (derivedfrom the BPI) and the strength of analgesia required.7 Tocalculate the PMI, numeric scores are assigned to thestrength of analgesia required (0 = nil up to 3 = opioids)and the severity of pain (0 = nil and 3 = worst imagin-able). The analgesic score is calculated by subtractingthe pain score from the score of the analgesia required.A score greater than 0 is considered indicative ofadequate analgesia. For this trial, the PMI was collectedto ascertain if these scores improved over the periodwhen the pain scores were documented.

Patient’s opinion of pain management(POPM)The POPM is a six-item score derived from the Ameri-can Pain Society Guidelines. It provides informationabout the satisfaction expressed by patients when con-sidering the approach to their pain management in theacute setting.8

Statistics

Analysis was descriptive and comparative. MicrosoftExcel was used for the analysis. Descriptive statisticswere used to summarise the demographics of the par-ticipants. The frequency that the pain chart was usedwas summarized by counting the number of plotsmarked per day. Patient’s opinions were described asproportions or statements. The association between theresearcher-collected BPI and the nurse-collected painscores was considered using Pearson’s correlation coef-

ficient. Changes in pain scores and analgesic scores werecalculated by paired-sample t-tests and considered sig-nificant if P = 0.05.

RESULTS

Demographics and clinical characteristics

of patients

There were 152 patients screened for inclusion. Ofthese, 63 (41%) consented, but only 45 of these com-pleted both sets of questionnaires (Fig. 2). The clinicalcharacteristics of all the consenting patients is summa-rized in Table 1. The majority of patients were admittedfor symptom control of advanced and metastatic cancer.Despite the metastatic nature of the majority of cancers,more than half the group had an ECOG performancestatus of better than 2, suggesting this group was stillmobile and largely self-caring. Approximately half thegroup were able to identify more than two sites of pain(Table 2).

Outcome measures

Use and acceptability of the chart to nursesand patientsThe nurses were asked to complete the pain scores fourtimes per day, as this interval was identified by thenursing staff as being the usual frequency for recordingother vital signs. However, when the charts werereviewed at the end of the study, it was found that 80%of the charts had one or more scores daily, with 68% ofthe charts having scores documented at least twice daily.To correlate this with other vital signs, a weeklong auditof the frequency with which vital signs are collected anddocumented on the involved ward revealed a similarpattern. From this we discerned that the nursesapproached pain documentation in a similar fashion tothe collection of other vital signs.

152 patients screened

89 not enrolled

• 28 no pain • 18 poor English • 16 declined • 14 too unwell • 8 missed • 5 cognitively impaired

45 completed 18 not completed

• 11 missed • 5 declined • 2 died

63 consented

Figure 2 Study schema.

Pain scores in the acute oncology setting 91



To ascertain whether or not the patients found theprocess arduous, the POPM was administered at the endof their hospital stay or after 7 days on the chart. Overthis period, 97% expressed satisfaction with theapproach to their pain control and felt that their reportsof pain had been taken seriously (Table 3).

Reliability of the locally developed chartThe first and last pain scores documented on the chartwere compared with the BPI item, ‘average pain score inthe previous 24 h’ collected at the beginning and end ofthe study. The first pain chart score correlated signifi-cantly with this BPI item (Pearson coefficient r = 0.47,P < 0.001). A similar correlation was found with thefinal pain chart score and the second collection of thisBPI item (Pearson coefficient r = 0.417, P = 0.020).

Changes in pain scores and analgesic scoresover the study periodThe mean scores of the pre- and post study BPI itemswere calculated and compared. All the scores improvedstatistically, apart from the item which measures the‘best pain score experienced in the previous 24 h’(Table 4). The pain scores from the pain documentationchart also improved. The first mean recorded score was3.15 (�0.77 95% confidence interval [CI]), whichimproved to a mean of 2.17 (�0.55 95% CI) (pairedt-test 2.27, P = 0.018). Finally, the PMI scores from thestart of the study improved to the end of the study. Themean prestudy PMI was 1.10 (�0.38 95% CI), whichimproved to 1.42 (�0.29 95% CI) (paired t-test 2.12,P = 0.040).

DISCUSSION

The aims of this study were threefold. The first aim wasto collaborate with nurses to develop a pain chart andintroduce the chart into clinical practise. Developing thechart was the initial step. This was done in as inclusivefashion as possible. A series of in-service workshopsregarding the assessment and management of cancerpain, including the rationale for documenting pain, wasundertaken. The nursing staff were then asked tocomment on the first draft of a very simple pain docu-mentation chart. Suggestions for modifications wereinvited and when general agreement was reached, thestudy was implemented. Although in many cancer andpalliative care units, pain is documented on similarcharts, we believed that developing a local chart was animportant part of the process, as this allowed the cancerward involved to develop a degree of ownership of theproject. This is likely to have contributed to the ongoingsuccess of pain documentation on this ward.

Table 1 Clinical details of consenting patients

Age (years) 55 (23–82)Gender 30 men

33 womenPerformance status (ECOG)

0 81 172 263 104 0Not recorded 2

Cancer diagnosisGI (upper and lower) 17Breast 8Lung 6Melanoma 6Head and neck 2Other 24

Cancer stageLocalized 15Metastatic 48

Sites of metastasesBone 6Lung 5Liver 5Other single sites 6More than one site 26

Reason for admissionSymptom control 35Chemotherapy 5Radiotherapy 4Combination therapy 13Other 6

Table 2 Mechanism of the predominant pain experiencedand the number of pains patients were able to describe

Presumed mechanism based on history of the worst painperceived by the patient (n)Visceral 38Bone 11Neuropathic 6Soft tissue 6Unable to describe 2

Number of pains patients were able to listOne 29Two 19More than two 15

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During the study, the charts were filled in with similarfrequency to the documentation of other vital signs,suggesting that the staff saw the process as similar. It wasnoted that patients who were more physically unstabletended to have their vital sign observations recordedmore frequently. It is possible that differences in thefrequency of pain documentation may reflect the percep-tions of nursing staff of the adequacy of pain control forindividual patients. It is notable that this process ofcharting pain has continued on the ward as part of anursing-driven quality assurance project separate fromthis investigation. In this quality assurance project, thenursing staff complete the pain charts on a strictly four-hourly basis to coincide with newly implemented painrounds. It is reasonable to conclude from this that thenursing staff perceive the practise as useful and notburdensome. Indeed, the staff report increased control

over their patients’ pain management and better com-munication with the medical staff.

Most patients reported high levels of satisfactionwith the approach taken to their analgesic manage-ment during this hospital stay. There have been sug-gestions that patients may under-report their pain inorder to be seen as ‘good patients’, in order not todistract their clinicians from the task of addressingtheir cancer treatment.9,10 From this study, we haveconcluded that, far than distracting clinicians, discuss-ing patients’ pain scores on a regular basis validatesthe importance that health professionals place on thepatient’s reports of pain and may help remove abarrier to pain reporting. Additionally, charting painreinforces the understanding that this is as importantas all the other measures that are collected during apatient’s admission.

Table 3 Patient’s satisfaction with health professionals’ response to pain control (%)

Very satisfied Satisfied Uncertain Dissatisfied Very dissatisfied

Patient’s satisfaction with the approach taken tomanage their pain during this hospital admission

60 33 4 3 0

Patient’s satisfaction with the way their nurses anddoctors responded to their complaints of pain

65 25 5 5 0

Table 4 Improvement in BPI scores on admission and discharge from the study

BPI itemMean pre-study score

(95% CI)Mean post-study score

(95% CI)Mean improvement in

score (95% CI)Paired T-test

(P-value)

Worst pain scores 6.80(�0.83)

4.47(�0.90)

2.33(�1.27)

3.70(0.001)

Best pain scores 4.11(�0.60)

2.69(�0.60)

0.55(�0.65)

1.67(0.101)

Average pain scores 4.11(�0.66)

2.69(�0.61)

1.42(�0.79)

3.61(0.001)

Pain interfering with activity 5.64(�1.11)

3.44(�1.04)

2.20(�1.12)

3.95(0.000)

Pain interfering with mood 5.09(�1.09)

3.00(�0.97)

2.09(�1.03)

4.08(0.000)

Pain interfering with walking 4.73(�1.21)

3.07(�1.03)

1.66(�1.23)

2.71(0.010)

Pain interfering with work 5.42(�1.23).

3.51(�1.15)

1.90(�1.19)

3.23(0.002)

Pain interfering with relationships 3.53(�1.21)

1.55(�0.82)

1.98(�1.17)

3.43(0.001)

Pain interfering with sleep 5.00(�1.10)

3.31(�1.04)

1.69(�1.24)

2.75(0.009)

Pain interfering with enjoyment of life 5.71(�1.10)

3.58(�1.16)

2.13(�1.01)

4.24(0.000)

The values tabled are means (95% CI). CI, confidence interval.

Pain scores in the acute oncology setting 93



The next aim was to compare the pain scores collectedand documented by the nurses on the ward with scorescollected by researchers using a well-validated painassessment tool. The pain chart scores correlated wellthe BPI scores, supporting the role of this chart as asimple pain assessment tool.

The final aim was to examine whether or not painscores and analgesia scores longitudinally improvedover the study period. When all the scores were com-pared, they had significantly improved, although itremains difficult to attribute this solely to the pain scoredocumentation. Other aspects during the planning andimplementation of the study included the developmentof the chart and in-service sessions for nurses and juniormedical officers regarding the assessment and manage-ment of cancer pain, which may have raised awarenessof the problem of cancer pain. Furthermore, some of thepatients had anti-cancer treatments and all the patientswill have received daily reviews by their medical teamswhilst hospitalized.

In conclusion, this study’s main strength is that itconfirms that introducing pain charting into a busy hos-pital ward is possible and suggests the process of paincharting is acceptable to nursing staff and patients. Thequestion of whether or not pain documentationimproves analgesic management remains unclear, but itseems highly likely that the practise may have a role inthe multiple interventions necessary for these patients. Arandomised, controlled trial would provide the mostuseful information.

ACKNOWLEDGMENTS

This study was made possible by the Pzifer Neuro-Sciences Awards Scheme. It would not have been pos-sible without the participation of the nursing staff of

the oncology in-patient unit of Royal Prince AlfredHospital.

REFERENCES

1 Cleeland CS, Conin R, Hatfield AK et al. Pain and itstreatment in outpatients with cancer. N Engl J Med 1994;330: 592–6.

2 Weiss SC, Emanuel LL, Fairclough DL, Emanuel EJ. Under-standing the experience of pain in terminally ill patients.Lancet 2001; 357: 1311–15.

3 Gordon DB, Dahl J, Miaskowski C et al. American PainSociety recommendations for improving the quality ofacute and cancer pain management. Arch Intern Med2005; 165: 1574–80.

4 Cohen MZ, Easley MK, Ellis C et al. Cancer pain manage-ment and the JCAHO’s pain standards. J Pain SymptomManage 2003; 25: 519–27.

5 Oken MM, Creech RH, Tormey DC et al. Toxicity andresponse criteria of the Eastern Cooperative OncologyGroup. Am J Clin Oncol 1982; 5: 649–55.

6 Carceni A, Cherny N, Fainsinger R et al. Pain measurementtools and methods in clinical research in palliative care:recommendations of an expert working group of the Euro-pean Association of Palliative Care. J Pain SymptomManage 2002; 23: 239–55.

7 Ward SE, Donovan H, Owen B et al. An individualisedintervention to overcome patient-related barriers to painmanagement in women with gynecologic cancers. Res NursHealth 2000; 23: 393–405.

8 Calvin A, Becker H, Beiring P et al. Measuring patientopinion of pain management. J Pain Symptom Manage1999; 18: 17–26.

9 Ward S, Goldberg N, Miller-McCauley V et al. Patient–related barriers to management of cancer pain. Pain 1993;52: 319–24.

10 Potter VT, Wiseman CE, Dunn SM, Boyle FM. Patientbarriers to optimal cancer pain control. Psychooncology2003; 12: 153–60.

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development and introduction of a pain score documentation chart in the acute oncology setting

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