Assessment and management of pain in a resident medical clinic.

management of a patient’S pain iS an important goal in outpatient primary care offices. Increasingly, panels such as The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) include pain assessments as a marker for quality of care. A physician’s ability to recognize pain and document pain management plans has important implications for accreditation and reimbursement, as well as patient outcomes. The identification of pain, often referred to as the fifth vital sign, is now standardized by a visual analog scale. This score is documented upon each clinic encounter. The question arises as to whether the clinician is responding to this score and if there are variables that affect such acknowledgement, documentation, and management. In the resident-run Medical Primary Care Unit (MPCU) at Rhode Island Hospital, nurses address pain upon patient intake using the standardized pain scale and document it in on the patient encounter form. In November 2009, a change was implemented with the goal of improving both assessment and management of pain. This change entailed the nurse asking the patient to localize their pain, and documenting the location on the intake sheet with the hopes of facilitating the clinician’s acknowledgment of the pain. methodS In a quality improvement study, for which Rhode Island Hospital IRB approval was obtained, we reviewed the impact of the above intervention on physician’s ability to address and document pain management in continuity notes. Our primary outcome was the acknowledgment of the patient’s pain in the assessment and plan of the clinic encounter form in compliance with JCAHO guidelines. Specifically, we noted if “pain” was addressed in the assessment and plan or if the problem listed in the assessment and plan clearly linked the disease process to the pain (e.g. osteoarthritis causing knee pain). As a secondary analysis, we examined whether a variety of demographic data and patient factors (stated below) influenced whether or not pain was addressed in the assessment and plan. Primary and secondary outcomes were assessed using random chart review for a two year period between Sept 1, 2008 and Sept 1, 2010. This time period was then divided into the pre-intervention period (before November 2009) and postintervention. If there was an encounter between Sept 1, 2008 and November 2009 and a different encounter between Nov 2009 and Sept 2010, those visits were both included. Multiple encounters between either of the two specified periods resulted in one encounter being chosen at random. Exclusion criteria included patients on a pain contract or those without pain greater than four on a one-to-ten pain scale. A variety of demographic and patient characteristics were collected, including gender, age, ethnicity, race, spoken language, insurance status, history of alcohol or substance abuse and psychiatric disease, chief complaint of the patient encounter, number of problems addressed at each visit, and measurements of continuity. These characteristics were then analyzed to identify any possible confounders or associations (as a secondary outcome). The pre-intervention data was analyzed separately from the post-intervention data, thus precluding the need for each chart to have both a pre and post intervention encounter. For both primary and secondary analysis, chi-square analysis was used to determine the rate of effectiveness of the intervention in obtaining at least one of the two outcomes. Inter-rater variability was calculated using an ANOVA calculator.