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Guideline Summary
Guideline Title
Pain management guideline.
Bibliographic Source(s)
Health Care Association of New Jersey (HCANJ). Pain management guideline. Hamilton (NJ): Health Care Association of New Jersey (HCANJ); 2006 Jul 18. 23 p. [19 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Pain management guidelines. Hamilton (NJ): Health Care Association of New Jersey (HCANJ); 2005 Jan. 18 p.

The guideline was reaffirmed for currency by the developer in 2011.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)

Pain

Guideline Category
Evaluation
Management
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Nursing
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
  • To establish common definitions for terms used in pain management
  • To promote the health, safety and welfare of residents in nursing facilities, assisted living, residential health care facilities, and adult health services, by establishing guidelines for the assessment, monitoring, and management of pain
  • To provide professional staff with standards of practice that will assist them in the effective assessment, monitoring, and management of the resident's pain
  • To educate the resident, family, and staff
  • To limit liability of health care providers
  • To comply with State of New Jersey's Pain Management regulations
Target Population

Adult patients/residents in nursing facilities, assisted living, residential health care facilities, or adult day health service facilities located in New Jersey

Interventions and Practices Considered

Evaluation

  1. Pain screen (upon admission)
  2. Use of pain rating scale (Wong-Backer, Numerical, or FLACC [face, legs, activity, cry, consolability] scale)
  3. Pain assessment

Management

  1. Formulation and implementation of a specific pain treatment plan
  2. Rehabilitation treatment modalities
    • Physical therapy (PT)
      • Therapeutic exercises
      • Manual therapy
      • Modalities
    • Occupational therapy (OT) (interventions for pain reduction)
    • Illustrated home exercise program upon discharge (both physical and occupational therapy components)
  1. Pharmacological interventions
    • Non-opioid analgesics
    • Opioid analgesics
    • Other classes of drugs
  2. Alternative interventions
  3. Documentation of pain assessment findings, treatment findings, and resident response
  4. Education and continuous training
    • Facility staff training
    • Patient/resident/family education
Major Outcomes Considered
  • Pain severity, character, frequency, pattern, location, duration
  • Interventions to promote comfort
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

2006 Guideline

Not stated

2011 Currency Review

The Best Practice Committee of the Health Care Association of New Jersey (HCANJ) searched Pub-Med.gov; The Cochrane Collaboration (Cochrane.org and Cochrane Reviews); and AHRQ's guidelines.gov (National Guideline Clearinghouse) Web site. The time frame for literature searches was from mid 2006 through mid 2011 (5 years). Search criteria limits included past 5 years, English language, and adults 18 years and older. Search terms used included the following: pain management, pain management in nursing facilities, pain management in assisted living, and pain management at end of life.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The development process includes a review of practice guidelines completed by others, literature review, expert opinions, and consensus. The guidelines are consistent with these principles:

  • Relative simplicity
  • Ease of implementation
  • Evidence-based criteria
  • Inclusion of suggested, appropriate forms
  • Applicable to various long term care settings
  • Consistent with statutory and regulatory requirements
  • Utilization of minimum data set (MDS) (resident assessment instrument [RAI]) terminology, definitions and data collection

2011 Currency Review

The Best Practice Committee of the Health Care Association of New Jersey (HCANJ) reviewed published articles from mid-2006 through mid-2009 along with the current Pain Management Guidelines and determined that they are still considered current best practice and meet the regulatory requirements.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Definitions

  • Pain means an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
    1. Pain Classification
      • Somatic Pain: Result of activation of nociceptors (sensory receptors) sensitive to noxious stimuli in cutaneous or deep tissues. Experienced locally and described as constant, aching and gnawing. The most common type in cancer patients.
      • Visceral Pain: Mediated by nociceptors. Described as deep, aching and colicky. Is poorly localized and often is referred to cutaneous sites, which may be tender. In cancer patients, results from stretching of viscera by tumor growth.
    1. Chronic Pain Classification
      • Nociceptive pain: Visceral or somatic. Usually derived from stimulation of pain receptors. May arise from tissue inflammation, mechanical deformation, ongoing injury, or destruction. Responds well to common analgesic medications and nondrug strategies.
      • Neuropathic Pain: Involves the peripheral or central nervous system. Does not respond as predictably as nociceptive pain to conventional analgesics. May respond to adjuvant analgesic drugs.
      • Mixed or undetermined pathophysiology: Mixed or unknown mechanisms. Treatment is unpredictable; try various approaches.
      • Psychologically based pain syndromes: Traditional analgesia is not indicated.
  • Pain Management means the assessment of pain and, if appropriate, treatment in order to assure the needs of residents of health care facilities who experience problems with pain are met. Treatment of pain may include the use of medications or application of other modalities and medical devices, such as, but not limited to, heat or cold, massages, transcutaneous electrical nerve stimulation (TENS), acupuncture, and neurolytic techniques such as radiofrequency coagulation and cryotherapy.
  • Pain Rating Scale means a tool that is age cognitive and culturally specific to the resident population to which it is applied and which results in an assessment and measurement of the intensity of pain.
  • Pain Treatment plan means a plan, based on information gathered during a resident pain assessment that identifies the resident's needs and specifies appropriate interventions to alleviate pain to the extent feasible and medically appropriate.

Program Outline

  1. Pain Screen
    1. A Pain Screen, including a Pain Rating Scale, shall be conducted upon admission.
  1. Pain Rating Scale
    1. One of the 3 following Pain Rating Scales shall be used as appropriate for the individual resident:
      1. Wong-Baker Scale
      2. Numerical Scale
      3. FLACC (face, legs, activity, cry, consolability) Scale
    1. A Pain Rating Scale shall be completed and documented, at a minimum, in the following circumstances:
      1. As part of the Pain Screening upon admission
      2. Upon re-admission
      3. Upon day of planned discharge (send a copy with the resident)
      4. When warranted by changes in the resident's condition or treatment plan
      5. Self reporting of pain and/or evidence of behavioral cues indicative of the presence of pain
      6. To identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief or pain control
    1. If the resident is cognitively impaired or non-verbal, the facility shall utilize pain rating scales for the cognitively impaired and non-verbal resident. Additionally, the facility shall seek information from the resident's family, caregiver, or other representative, if available and known to the facility.
  1. Pain Assessment
    1. A complete Pain Assessment shall be done if the Pain Rating Scale score is above 0 in the circumstances listed above in II-B, no. 1-5.
    2. In nursing facilities, a complete Pain Assessment shall be completed at the time of the quarterly Minimum Data Set (MDS) if pain has been recorded.
    3. In assisted living facilities, the semi-annual wellness nursing assessment shall include a pain rating scale. If greater than 0, a Pain Assessment shall be completed.
    4. In residential health care and adult day health services, a Pain Assessment shall be completed when pain is reported, and should be completed at least annually thereafter.
  1. Tools
    1. Pain Screen
    2. Pain Rating Scale
    3. Pain Assessment
  1. Treatment Plan Development and Implementation
    1. Information collected from the Pain Assessment is to be used to formulate and implement a resident-specific Pain Treatment Plan within the facility, or the resident shall be referred for treatment or consultation.
    2. Rehabilitation Treatment Modalities (Physical Therapy [PT]/Occupational Therapy [OT]):
      1. PT Intervention: Therapeutic Exercise
        • Passive range of motion, active assistive range of motion, active range of motion, progressive resistive exercise, balance training, gait training, postural correction and reeducation, ergonomics
      1. PT Intervention: Manual Therapy
        • Mobilization and manipulation of the joints, craniosacral therapy, myofascial release, massage
      1. PT Intervention: Modalities
        • Electrical stimulation, transcutaneous electrical nerve stimulation (TENS), iontophoresis, ultrasound, diathermy, infrared, hydrotherapy (warm), fluid therapy, cold laser, hot packs, paraffin wax therapy, ice packs
      1. OT Intervention for Pain Reduction:
        • Activity of daily living, adaptive devices to simplify tasks, energy conservation techniques, therapeutic exercises, wheelchair measurement, wheelchair positioning devices, bed positioning devices, cushions for appropriate pressure relief, splinting for stretching tight joints/muscles, reduce pain and prevent pressure sore
      1. Both PT and OT upon discharge from the therapy program should provide:
        • Illustrated home exercise program, in-service to caregiver
    1. Pharmacological Intervention:
      1. Non-opioid analgesics, such as acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (cox-2) inhibitors and tramadol
        • Considered but not recommended: Indomethacin, Piroxicam, Tolmetin, Meclofenamate.
      1. Opioid analgesics (oxycodone; morphine, transdermal fentanyl; hydromorphone; methadone; combination opioid preparations, such as codeine, hydrocodone, oxycodone)
        • Considered but not recommended: Propoxyphene, Meperidine, Pentazocine, Butorphanol
      1. Other classes of drugs (corticosteroids, anticonvulsants, clonazepam, carbamazepine, anti-arrhythmics, topical local anesthetics, topical counter-irritants)
      2. Monitoring for safety and side effects of medications
      3. Principles of Pharmacological treatment of chronic pain:
        • Administer medication routinely, not as needed (PRN).
        • Use the least invasive route of administration first. The oral route is preferred.
        • Begin with a low dose. Titrate carefully until comfort is achieved.
        • Reassess and adjust dose frequently to optimize pain relief while monitoring and managing side effects.
        • Maximize therapeutic effect while minimizing medication side effects.
      1. General Treatment Principles:
        • Ask about pain regularly.
        • Believe the patient's and family's reports of pain and what relieves it.
        • Choose appropriate pain control options.
        • Deliver interventions in a timely, logical, and coordinated fashion.
        • Empower patients and their families.
    1. Alternative Interventions:
      1. Acupuncture, reflexology, aroma therapy, music therapy, dance therapy, yoga, hypnosis, relaxation and imagery, distraction and reframing, psychotherapy, peer support group, spiritual, chiropractic, magnet therapy, bio-feedback, meditation, relaxation techniques
    1. Pain Assessment findings shall be documented in the resident's medical record. This shall include, but not be limited to, the date, pain rating, treatment plan, and resident response.
  1. Education and Continuous Training
    1. The policy for each facility shall include the criteria found in subchapter 6, General Licensure Procedures and Enforcement of Licensure Rules, NJAC 8:43E 6.5 (a) 1-4, (b):

      "(a) Each facility shall develop, revise as necessary, and implement a written plan for the purpose of training and educating staff on pain management. The plan shall include mandatory educational programs that address at least the following:

      1. Orientation of new staff to the facility's policies and procedures on pain assessment and management
      2. Training of staff in pain assessment tools; behaviors potentially indicating pain; personal cultural, spiritual, and/or ethnic beliefs that may impact a patient's/resident's perception of pain; new equipment, and new technologies to assess and monitor a patient's/resident's pain status
      3. Incorporation of pain assessment, monitoring and management into the initial orientation, and ongoing education of all appropriate staff
      4. Patient/resident rights

      (b) Implementation of the plan shall include records of attendance for each program."

    1. Patient/Resident/Family Education
      1. Explain causes of the pain, assessment methods, treatment options and goals, use of analgesics, and self-help techniques.
      2. Regularly reinforce educational content.
      3. Provide specific education before special treatments and/or procedures.
  1. Continuous Quality Improvement

    The policy for each facility shall include the criteria found in subchapter 6, General Licensure Procedures and Enforcement of Licensure Rules, NJAC 8:43E 6.6:

    "The facility's continuous quality improvement program shall include a systematic review and evaluation of pain assessment, management, and documentation practices. The facility shall develop a plan by which to collect and analyze data in order to evaluate outcomes or performance. Data analysis shall focus on recommendations for implementing corrective actions and improving performance."

  1. Policy
    1. Each facility shall develop a policy to define the system for assessing and monitoring resident pain.
    2. The policy for each facility shall include the criteria found in subchapter 6, General Licensure Procedures and Enforcement of Licensure Rules, NJAC 8:43E 6.4(f) 1-7:

      "(f) The facility shall establish written policies and procedures governing the management of pain that are reviewed at least every three years and revised more frequently as needed. They shall include at least the following:

      1. A written procedure for systematically conducting periodic assessment of a patient's/resident's pain, as specified in (b) above. At a minimum the procedure must specify pain assessment upon admission, upon discharge, and when warranted by changes in a patient's/resident's condition and self reporting of pain
      2. Criteria for the assessment of pain, including, but not limited to: pain intensity or severity, pain character, pain frequency or pattern, or both; pain location, pain duration, precipitating factors, responses to treatment and the personal, cultural, spiritual, and/or ethnic beliefs that may impact an individual's perception of pain
      3. A written procedure for the monitoring of a patient's/resident's pain
      4. A written procedure to insure the consistency of pain rating scales across departments within the health care facility
      5. Requirements for documentation of a patient's/resident's pain status on the medical record
      6. A procedure for educating patients/residents and, if applicable, their families about pain management when identified as part of their treatment
      7. A written procedure for systematically coordinating and updating the pain treatment plan of a patient/resident in response to documented pain status."
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate evaluation, management, and monitoring of pain in residents in nursing facilities, assisted living, residential health care facilities, and adult day health services may help reduce the incidence and severity of pain and, in some cases, help minimize further health problems and enhance quality of life.
  • Use of the guideline may improve the efficiency and effectiveness of the pain management process and related documentation.
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This Best Practice Guideline is presented as a model only by way of illustration. It has not been reviewed by counsel. Before applying a particular form to a specific use by your organization, it should be reviewed by counsel knowledgeable concerning federal and state health care laws rules and regulations. It should not be used or relied upon in any way without consultation with and supervision by qualified physicians and other healthcare professionals who have full knowledge of each particular resident's case history and medical condition.
  • This Best Practice Guideline is offered to nursing facilities, assisted living, residential health care facilities, adult day health service providers, and professionals for informational and educational purposes only.
  • The Health Care Association of New Jersey, its heirs, executers, administrators, successors, and members hereby disclaim any and all liability for damage of whatever kind resulting from the use, negligent or otherwise, of all Best Practice Guidelines.
  • The guideline assumes that recovery/rehabilitation is the treatment or care plan goal. Sometimes, other goals may be appropriate. For example, for patients receiving palliative care, promotion of comfort (pain control) and dignity may take precedence over other guideline objectives. Guidelines may need modification to best address each patient and family's expectations and preferences.

Implementation of the Guideline

Description of Implementation Strategy

Suggested implementation strategies are discussed in the original guideline document sections titled "Education and Continuous Training," "Continuous Quality Improvement," and "Policy." Refer to the "Major Recommendations" field for more information on these topics. In addition, a number of Pain Management Tools are provided in the original guideline document.

Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Health Care Association of New Jersey (HCANJ). Pain management guideline. Hamilton (NJ): Health Care Association of New Jersey (HCANJ); 2006 Jul 18. 23 p. [19 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2005 Jan (revised 2006 Jul 18; reaffirmed 2011)
Guideline Developer(s)
Health Care Association of New Jersey - Nonprofit Organization
Source(s) of Funding

Health Care Association of New Jersey

Guideline Committee

Best Practice Committee

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Pain management guidelines. Hamilton (NJ): Health Care Association of New Jersey (HCANJ); 2005 Jan. 18 p.

The guideline was reaffirmed for currency by the developer in 2011.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Health Care Association of New Jersey Web site External Web Site Policy.

Print copies: Available from the Health Care Association of New Jersey, 4 AAA Drive, Suite 203, Hamilton, New Jersey 08691-1803

Availability of Companion Documents

The following implementation tools are available in the original guideline document:

  • Pain screen form
  • Pain rating scales
  • Pain assessment form
  • Pain management: rating/medication administration record
  • Pain management: rating/treatment administration record
  • Data collection for analysis, outcome evaluation, and performance improvement forms

Electronic copies: Available in Portable Document Format (PDF) from the Health Care Association of New Jersey Web site External Web Site Policy.

Print copies: Available from the Health Care Association of New Jersey, 4 AAA Drive, Suite 203, Hamilton, New Jersey 08691-1803

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on July 18, 2005. The information was verified by the guideline developer on July 20, 2005. This NGC summary was updated by ECRI on September 29, 2006. The updated information was verified by the guideline developer on October 3, 2006. This summary was updated by ECRI Institute on January 10, 2008, following the U.S. Food and Drug Administration advisory on Carbamazepine. This summary was updated by ECRI Institute on May 1, 2009 following the U.S. Food and Drug Administration advisory on antiepileptic drugs. This summary was updated by ECRI Institute on July 20, 2010 following the U.S. Food and Drug Administration advisory on Ultram (tramadol hydrochloride), Ultracet (tramadol hydrochloride/acetaminophen). The currency of the guideline was reaffirmed by the developer in 2011 and updated by ECRI Institute on December 5, 2011. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

Per the Health Care Association of New Jersey, this guideline is not copyright restricted.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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