International Journal of Anesthesiology & Pain Medicine

Keywords

Pain; Measurement; Jimma hospital

Introduction

Assessment of pain include about issues of temporal pattern, location, description, intensity, aggravating and relieving factors, previous treatment and effect [1]. Interventions for pain must be tailored to each individual with the goal of preempting chronic pain and relieving breakthrough pain [2].

A hospital-based cross-sectional study to assess drug related problems(DRP) conducted at JUSH from February 2011 to March 2011 at medical ward showed that out of 257 study participants, 189 (73.5%) had DRPs. From the six classes of DRPs studied, 103 (32.6%) cases related to untreated indication or need additional drug therapy, and 49 (15.5%) cases related to high medication dosage. Unnecessary drug therapy in 49 (15.5%) cases, low medication dosage in 44 (13.9%) cases, and ineffective drug therapy in 42 (13.3%) cases were the other classes of problems identified. Noncompliance in 31 (9.8%) cases was the least prevalent DRP. The study concluded that drug-related problems were common among medical ward patients. Also, indicationrelated problems, untreated indication and unnecessary drug therapy were the most common types of DRPs among patients of medical ward [3].

A prospective cross sectional study conducted among 252 postoperative patients during February 13 to April 30, 2012, at surgical ward of JUSH showed that incidence of postoperative pain was 91.4%, and remained high over 3 measurements, 80.1% of the patients were undertreated, 50% of the patients were adequately satisfied with their pain management. As needed (prn), solo analgesic, null analgesic, and intramuscular orders were noted for 31.3%, 89.29%, 9.7% and 20.1% of the prescription orders respectively. Diclofenac and tramadol were the top prescribed medications, and only 57% of their dose was administered. It was concluded “Despite patients’ paradoxical high satisfaction with pain management, the majority of patients were inadequately and inappropriately treated. Thus, further research is needed to determine how best to break down current barriers to effective pain management” [4].

A VISITING LECTURER PROGRAMME with key aims to develop and introduce a guideline for the management of pain was carried out from August-October 2012. Specific guidelines for pain management were designed for JUSH and introduced to all surgical wards, ICU and to the nursing staff, interns and residents running these areas. This was preceded by a number of teaching sessions involving over 150 staff on issues surrounding pain management and its importance. This teaching received feedback from trainees, such as: the need for further training and education in pain management, that the guideline will require follow -up training, and the need for updates for staff that have already been trained by successive visiting lecturer [5].

A record-review of 302 patient cards to assess the quality use analgesics in dental out patient in Jimma University Specialized Hospital, conducted from 22/01/2013-27/01/2013 showed that the most commonly prescribed non-opioid analgesic was diclofenac (43%) followed by paracetamol (36%) and concluded that the prescription analysis demonstrated that pain was neglected and the analgesics available are irrationally used [6].

In A cross-sectional survey was conducted among 2013 graduating-class students of medical and paramedical students of Jimma University concluded “Unacceptable level of knowledge deficits and poor attitudes were distinguished in this study which augments the universal concern of inadequate knowledge and attitudes regarding pain management. The study also recommended that the situation demands various educational and quality improvement initiatives in pain management [7-9].

Materials and Methods

A cross-sectional study to assess pain management practice among patients admitted to medical ward of JUSH was conducted from Aug 1, 2014-Sep 30, 2014. Situated at 350 km to the southwest of Addis Ababa, and is the only referral hospital for South Western Ethiopia. With a catchment population of approximately 15 million people, it provides services for approximately 90,000 patients every year. JUSH has 450 beds [7]. Medical ward has 81 beds (medical A, B and C have 32, 40 and 9 beds respectively).

All patients admitted to the ward during the study period were considered for study and, among them, 161 patients who full filled the inclusion criteria were selected as study subjects. The technique was interview of patients and observation (measurement of vital sign, pain assessment and chart review). Independent assessment of pain at set times was conducted using standard tool for assessment of clinical practice of pain management, pain (onset, type, intensity, worst), pain aggravating conditions, non-pharmacological management of pain. Finally review of patient chart was done. The quantitative variables were age (measured to nearest year), temperature, respiratory rate, pulse rate (measured in in number per minute). The qualitative variables were sex, literacy, chief compliant, pain, pain aggravating conditions, non-pharmacological management of pain and analgesics (type, dose, pattern and route).

Inclusion criteria

Patients who are conscious, able to communicate and willing to participate in the study.

Exclusion criteria

Readmissions, transfer and referral outside Jimma zone.

Data collectors

Nine data collectors who were known to take annual leave (two years) for the purpose of his study (because of duty Rota matched the beginning of data collection) were recruited. Also their linguistic proficiency and experience were considered.

Data collection

Began on August 1, 2014, 8:00 pm and ended Sep 30, 2014 5:00 pm

Each included patients was followed for 24 hrs from the time of admission. Information was collected from each patient at set times: at admission 4^th, 8^th, 12^th and 24^th hr from the time of their admission using the schedule:

At admission

Ensure fulfillment of inclusion criteria, time/date/month/YY/AM/ PM of admission, personal information, chief complaint, V/S, enquiry about pain that occurred before admission (experience, onset, type, intensity, duration, effect), and pain at admission.

At 4th hr

Time/date/month/YY/AM/PM, V/S, direct assessment of pain and pain aggravating conditions

At 8th hr

Time/date/month/YY/AM/PM, V/S, direct assessment of pain, and pain aggravating conditions

At 12th hr

Time/date/month/YY/AM/PM, V/S, direct assessment of pain, and pain aggravating conditions

At 24th hr

Time/date/month/YY/AM/PM, analgesic receipt, NP and

Chart Review

From each patient, a data collector ascertains receipt of analgesic (ordered, by patients request for prescription, or from outside sources) and the patient verify this by naming, identifying, or showing it. Data collector enquires about NP, reviews chart for written evidence about assessment of pain and management of pain.

Data Quality Control

Data collectors were freed from their regular work of assessment/management of patients. Training on objective, tools, measurement, patient inclusion, assessment of pain, ascertainment of analgesic, chart review and recoding were given. Similar thermometer and watch were used and supervision was conducted during data collection.

Data analysis

Results from patient interview, pain assessment and chart review was cleaned, coded and entered to computer using SPSS 20. Vital signs-temperature/RR/PR: measured and compared against standard normal for the same age and sex. Statistical summaries calculated for continuous variable intensity of pain categorized. Each patient was labeled as APMD, NAPMD, and IAPMD (defined below).

Ethical clearance was obtained from JUSH ethical committee of CPHMS and letter of cooperation was submitted for the hospital administration prior to data collection.

Operational Definition

Chief Compliant

Primal sign/symptom mentioned by patient, while at OPD, for which he/she sought the health care services. Patients with any two or more C/C are categorized “multiple”.

Before Admission

Refers to period of encompassing 24 hrs before the patient’s admission time.

At admission

Admission encompasses period 1 hour after admission time.

After admission

4^th hr from time of admission.

Onset

Period when the pain start. Pain aggravating condition

Conditions that made the pain worse.

Pain-in-Sequence

Sequence of various levels of severity of pain (the first/before admission based on patient’s memory, second/at admission and third/after admission based on here and now).

Temporal Pattern of Pain

Frequency of its occurrence and change in intensity.

Worst degree of pain felt

Memorable moment when peak intensity of pain felt from among periods before, at, or after admission. Different periods with similar intensity and/or absence of pain are categorized separately.

Effect of Pain

Patient’s memorable failure in psychological, physical, social function believed by patients to have happened due to pain before admission. Multiple effects of pain and absence of are categorized as “others”.

Regularly ordered analgesic

Written document about analgesic that is to be administered at fixed interval and specific dose/analgesic.

Irregularly ordered analgesic

Written document about analgesic without clear/absence of fixed interval of administration.

Condition of analgesic order

Ordered by HP, through self-request or other.

Received pain medication (RPM)

Analgesics at the patient’s disposal/administered or mentioned/ characterized (as assessed at 24^th hour).

Non pharmacological management of pain (NP)

If the patient gives affirmative response to questioning about whether the presence/action of caregivers effectively reduced their pain during any or whole of the previous 24 hrs, regardless of receipt of analgesic or not.

Documented/Not documented pain

Pain (or its absence) is mentioned/characterized /measured and documented on chart at 24^th hour after admission.

Assessment of pain & management documented APMD

If pain is assessed, managed and documented at 24^th hr after admission.

No Assessment of pain & management documented NAPMD

Neither assessed, managed and documented nor received analgesic at 24^th hr after admission.

Incomplete Assessment & management documented IAPMD

Partially assessed/managed or documented at 24^th hr after admission.

Pain Change

Degree of pain at 24^th hr after admission compared to the patient’s own degree of pain at 8^th hr.

Results

Study participants

From a total 195 admitted patients over 55 days, 161 (82.56%) patients who fulfilled he inclusion criteria were included in the study. The mean age (SD) was 49.89 (15.60) years. The age ranges 19&84 years. About 69 (42.8%) were females. The mean age (SD) of females and males was 42.99 (13.51) and 55.08 (15.10) years respectively. There was statistically significant difference in mean ages between females and males (t159 = -5.257, p=0.000). About 77 (47.82%) wee literate and there was statistically significant difference in mean ages between literates and illiterates (t₁₅₉=- 7.074, p=0.000). Based on combined sex-literacy, one way ANOVA was significant and only mean age difference between illiterate females and literate males was not significant on multiple comparisons, as shown in (Table 1 and Figure 1).

Table 1: Showing Summary Statistics of age by sex, and literacy status, JUSH 2014.

About 29(18.01%) were aged 65 or above years. The female to male ratio within age group decreased with age from 2.50 at age group 15-24.9 to 0.20 at age group 75-84.9. And proportion of literates within age group decreases with increasing age from 100% at age group 15-24.9 to 0% at 75.0-84.9 year. There was no literate female above 53 years of age, as shown in (Table 2).

Table 2: Showing frequency of cases by age-group, sex, and literacy status, JUSH 2014.

Chief complaint

The prevalence of patients with multiple, fever, cough and body swelling was 57 (35.4%), 27 (16.8%), 33 (20.5%), and 44 (27.3%) respectively. There was significant difference in mean age by chief complaint F_3,157=5.526, p=0.001. On multiple comparisons, the mean age of those with BSW was significantly greater than those with fever, and multiple complaints. Among multiple complaints 29 (50.88%) were females. Among females, with multiple complaints half of were clustered in age group 19-34.9 years. Also, 30 (68.18%) of BSW were males 22 (73.33%) were aged 65 years or more years, as shown in (Tables 3-4).

Table 3: Showing summary statistics of age by chief complaint, JUSH 2014.

Table 4: Showing frequency of cases by age group, chief complaint and sex, JUSH 2014.

Vital sign (Table 5) Occurrence of Pain Occurrence

Table 5: Showing the vital sign of patient, JUSH 2014.

About 147 (92.45) patients had experience of pain before admission. While 22 patients had severe pain before admission, only 4 at, and no patient with severe pain after admission (Tables 6-8).

Table 6: Showing summary statistics of age by period and degree of severity of pain, JUSH 2014.

Table 7: Showing summary statistics of type of pain before admission by age group, JUSH 2014.

Table 8: Showing frequency by age group, period, and degree of severity of pain, JUSH 2014.

Pain-triggering conditions during before admission

Pain triggering conditions during before admission as reported by patients were: physical activity 101(68.24%), and cough 3(2.03%), while 44(29.73%) were unknown.

Effect of the pain during before admission

The effect of the pain that occurred before admission was said to be on sleep, physical activity, mood, and other in 71(44.94), 43(27.21), 23(14.56), and 9(5.70) of all patients respectively, as shown in (Tables 9-15).

Table 9: Showing summary statistics by effect of the pain during before admission, JUSH 2014.

Table 10: Showing frequency of cases by effect of pain during before admission and severity, JUSH 2014.

Table 11: Showing frequency of cases by effect of pain during before admission, chief complaint and age group, JUSH 2014.

Table 12: Showing summary statistics of age by worst intensity felt, JUSH 2014.

Table 13: Showing frequency of cases by age group and duration of worst intensity of pain felt, JUSH 2014.

Table 14: Showing Comparison of Worst Degree of Pain Felt Using FPS vs. Patient Response, JUSH 2014.

Table 15: Showing Frequency of Worst Degree of Pain Felt Using FPS by Social variables JUSH, 2014.

Pain aggravating conditions at 8th hr

Also, (at 8^th hour after their admission) sites of IV line, IV medication, IM, LP, ID catheter were mentioned as their pain aggravating conditions (and here the pain is localized type), as shown in (Table 16).

Table 16: Showing the frequency of pain aggravating conditions, JUSH 2014.

Chart Evaluation at 24th Hr after Admission at 24^th hr (Tables 17-21).

Table 17: Showing frequency of charts’ documentation of pain assessment/ medication by receipt of pain medication, JUSH 2014.

Table 18: Showing summary statistics of age by receipt of medication and assessment/documentation of pain, JUSH 2014.

Table 19: Showing Comparison of Patient Assessment and Chart Findings, JUSH 2014.

Table 20: Showing Comparison of Information about Patient Management from Chart vs. from Patients, JUSH 2014.

Table 21: Showing Comparison of Information about Patient Management from Chart vs. from Patients, JUSH 2014.

Discussion

Over 55 days, at the assessment of pain using FPS showed all patients experienced pain during before and the first 24 hrs.

Pain before admission was said to be triggered by physical activity 101 (68.24%), cough 3 (2.03%), while 44 (29.73%) could not remember/would not. Also, effect of pain was said to be on sleep/ inability to fall asleep, physical activity/inability to work, mood/ lowered state, and other/appetite, as recalled by 71 (44.94%), 43 (27.21%), 23 (14.56%) and 9 (5.70%) of patients. Thus we note physical activity as pain precipitating event or as restrictive condition/effect of pain. Similarly, cough as pain precipitating condition or chief complaint. Cough can also present as chief complaint without pain.

The worst degree of pain felt (from among before, at, after) by patients also agree with a highest degree of pain as indicated by FPS. However, patients had difficulty of choice for example when pain before and at admission were both moderate. The worst degree of pain felt depends on the current degree of pain which in turn may be the result of interventions.

Also, (at 8^th hr after their admission) sites of IV line, IV medication, IM, LP, ID catheter were mentioned as their pain aggravating conditions (and here the pain is localized type), even though these were actually the means of investigation or treatment (including pain) or follow up by the practicing physician. These actions must be in such a way to minimize the pain.

About 43 patients had their assessment/ management documented as well as the patients received analgesics implied their respective chart. The contents of the documents showed: absence of recording about of time of assessment, time of analgesic order, and schedule and route of analgesic administration, the expression of degree of pain being subjective without rating or scoring the degree of pain (not measured using FPS), and conditions under which the analgesics were ordered that is mostly irregular and upon patients request. Together, these point to unguided assessment and management of pain during the first 24 hours. This also made difficult to know whether the measure of severity of pain after admission was affected by drug or not.

In 100 charts, neither assessment/management documented nor the respective patients receive analgesics even though all had various degree of pain which show absence of intervention at least during the first 24 hrs. This shows unrecognized/ill recognized pain.

Twelve charts contained documentation of assessment and management. Yet the patients did not receive analgesic at 24th hour after admission. Six charts contained no documentation of assessment and management. Nevertheless, the patients had analgesics at their disposal. We learned that they requested prescription and procured them.

In all charts there was no mention about NP. In this study, the assessment of NP was solely based on the patient’s own belief (affirmation or rejection) of the idea about whether his/her caregiver/relatives’ presence and/or behavior effectively resulted in reduction of his/her pain during the previous 24 hrs. It must be clear that all patients had caregivers/relatives, all were asked the same question and disregarding whether the patient received analgesic or not. The challenge in this respect was the existence, definition ad meaning of NP, the role of caregivers in bringing the patients, as negotiators with health worker in securing prescription/analgesic/purchase analgesic.

Noting teaching of large number staff, and Specific guidelines for pain management were designed for JUSH and introduced to all surgical wards, ICU and to the nursing staff, interns and residents running these areas during 2012, the feedback given by trainees (4), and the state of practice of pain management at various sections (3,4,6) and teaching (7). We appreciate the efforts made by A VISITING LECTURER PROGRAMME (5) that it was timely. Thanks to all who contributed to this work. The authors failed to find any evidence as to whether there was subsequent change in management practice at surgical ward, and whether the experience was adopted and expanded to other areas like medical ward. Our study shows this was unlikely, but there is a lesson that must be learnt.

Conclusion

In medical ward, pain assessment and management lacked measurement using scale, sustained follow up and documentation

Majority of patients felt the worst degree of pain before and/or at admission.

While FPS were appropriate for illiterate, literate and result of worst degree of pain felt according to FPS agreed with worst degree of pain felt by patient like difficulty answering worst degree of pain felt in particular situations (for example, pain before, at and after admission were all moderate based on FPS) was observed.

Emergent pain due to procedures on sites of IV line /IM/ catheter / LP/ID constituted most emergent pain and affects nearly all patients.

Changes in pain severity where not tracked, emergent pains were undetected.

Majority of patients with pain were unmanaged and considerably proportion where treated with unguided management.

Recommendation

Introduction of standard assessment and management of guideline

Training of health workers based on guidelines

Implementation and subsequent evaluation of outcomes of pain management

Procedures on sites of IV line /IM/ catheter /LP/ID must be done optimally to minimize the consequent pain

Further research on format of tool

Strengths and weaknesses of the study

Health workers (data collectors were free from their routine work)

Information was gathered independently and from multiple sources

Assessment of NP is open for question

Assessment of pain without treating pain-ethical concern

Information on vital sign was not utilized-ethical concern

Acknowledgements

We like to thank CPHMS for supporting this research. We are also grateful to all patients who were willing to be included in this study.

Facial verbal and numeric pain rating scale

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