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BY: JUDY CASSIDY

Ms. Cassidy, former editor of Health Progress, is a St. Louis-based freelance writer and communications consultant.

Despite the affirmation that pain can be assessed, communicated, and controlled with relatively simple means, pain continues to be an overlooked and neglected institutional problem nationwide," says Karen Knox, pain management advanced practice nurse, St. John Hospital and Medical Center, Detroit. Experts in pain management interviewed for this article agree with Knox. One noted that although knowledge about pain control has been growing for the past two decades, it is only in the past few years that healthcare providers have begun to give adequate attention to pain relief.

Confusion and ignorance among healthcare providers about pain management have been major causes of inadequate treatment of pain. "Efforts to make pain relief a clinical reality need to begin at the bedside," Knox says. Healthcare professionals should be aware that all chronically ill persons experience pain, according to Sr. Alice O'Shaughnessy, CIJ, MD, medical director at Mercy Hospice, Uniondale, NY. Because physicians and nurses cannot measure pain objectively, she says, they must use the only method that makes it possible to find out if patients are suffering: ask them. "It is necessary to reevaluate patients every time the professional sees them," says Sr. O'Shaughnessy.

Innovative efforts are improving the situation, however. At the national level, as part of a project to make pain assessment and treatment an integral part of the U.S. healthcare system, the University of Wisconsin—Madison Medical School is working with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to revise JCAHO standards, intent statements, scoring guidelines, and survey process questions so that they include assessment and treatment of pain in all patient populations. And in June 1999 the federal Health Care Financing Administration ruled that the 1990 Patient Self Determination Act may be interpreted to require California Medicare and Medicaid providers to inform patients of their right under state law to request (or reject) pain treatment. The Pain Relief Promotion Act of 1999, which would aid health professionals in improving care for people in pain at the end of life, passed the U.S House of Representatives in October and is now in the Senate.

At the regional and local levels, many Catholic providers are in the forefront in treatment of pain. They see alleviating pain as part of their mission and values that call them to carry out the healing ministry of Jesus and to recognize the dignity of all persons. They believe that the recent demands for physician-assisted suicide are primarily motivated by fear of a painful, undignified death — fears that can be mitigated by a caring response from the healthcare system, which assures patients they will not be abandoned to suffer needlessly when they are critically or chronically ill.

In spite of Catholic healthcare's widespread initiatives to treat pain effectively, more than 4,000 caregivers participated in two March 1999 audioconferences on pain sponsored by the Catholic Health Association. Many requested further information from Ron Hamel, PhD, CHA senior associate for ethics, who conducted the conferences. In response, Health Progress asked CHA members to submit their "best practices" for assessing and relieving pain to help their colleagues develop pain management programs. The replies, summarized below, describe many approaches at varying stages of development. Those who wrote to Health Progress were passionate about helping patients and eager to share their experiences and knowledge; a contact person is given for each institution. Several respondents suggested additional resources, which are listed below.

St. Mary's Hospital
Madison, WI

Two years ago St. Mary's formed a Pain Steering Committee that included physicians, nurses, pharmacologists, and occupational and physical therapists. The group worked with a yearlong, national collaborative of 40 healthcare organizations, including the University of Wisconsin Medical Center, Madison, and learned much from the other participants.

In addition to providing seminars and printed materials for patients, the hospital recently hung a pain scale in each patient room. One side is a traditional scale for rating pain; the other — primarily for children and people with dementia — shows six faces with different expressions to indicate pain intensity. The scale is attached to the wall with Velcro strips so that nurses may move it closer to the patient's bed when necessary. A smaller hand-held scale is available for places such as the emergency room that lack wall space. Laminated pamphlets with algorithms for pain assessment, acute pain management, and cancer pain management were placed in all patients' rooms and distributed to staff.

Nurses throughout the hospital graph pain in the patient record as a fifth vital sign. St. Mary's will be a trial site for testing protocols of the Joint Commission on Accreditation of Healthcare Organizations.

Contact: Cynthia Leeder, Medical/Surgical Clinical Nurse Specialist, 608-251-6100

SSM St. Mary's Health Center
St. Louis

In 1997 SSM St. Mary's, a member of SSM Health Care, formed the SMHC Pain Management Team — which consisted of a physician, pharmacist, case manager, chaplain, and nurses — to improve pain management in the inpatient medical/oncology unit. Concentrating on the timeliness of pain assessments and outcomes, the team introduced processes and tools to assess pain, decrease waiting times for medications, and measure results. Efforts included standardizing the time frame for completing initial pain assessments, and asking patients whether they were in pain whenever vital signs were taken so that pain would be included as a fifth vital sign. Pain-rating scales and a "Stop Pain" logo in the shape of a stop sign were posted in patient rooms. An equianalgesic dosing chart was distributed to health professionals, and a pocket-size version is also available.

Outcomes are encouraging. The average time a patient waits for medication after the initial nursing assessment has been reduced from two hours to 20 minutes. Patient comments and satisfaction ratings indicate dramatic improvement in pain management. These pain management efforts are now practiced throughout the hospital.

Contact: Jean Brontoli, Clinical Director, Medical Oncology, 314-768-8645

St. John Hospital and Medical Center
Detroit

A Pain Management Steering Committee has conducted an inpatient satisfaction survey to provide baseline data, integrated the American Pain Society Quality Improvement Guidelines into clinical practice, identified pain resources available to clinicians, and made information accessible to clinicians where they write orders and prescriptions. Ongoing chart audits and patient satisfaction surveys are part of continuous quality improvement efforts in pain management.

In addition, St. John has a Pain Service — a team of physician specialists, nurses, therapists, psychologists, and others — who develop care plans for inpatients and outpatients; these are then carried out by the referring doctor with the patient.

St. John has created six resources for its staff, including a pain assessment tool, a brochure on surgical pain, a medication reference guide, and chart documentation forms, and it makes other resources available for use in daily practice (some are available through Mayday; see Box below). Some of the medical center's resources were customized from others available to the public.

St. John is a member of the Sisters of St. Joseph Health System, Ann Arbor, MI. Staff at the system's nursing homes use a pain management plan, a pain management procedure, and a referral policy. The long-term care facilities also have a pain management policy.

Contact: Karen Knox, Nurse Practitioner, Pain Management Department, 313-343-4813

St. Clare's Hospital
Denville, NJ

A multidisciplinary team met in February 1998 to develop a pain scale, pain treatment protocol, and patient education plan. Representatives of nursing, medicine, spiritual services, complementary medicine, pharmacy, performance improvement, administration, social services, and oncology made up the team. The following April the team assisted in a symposium for all hospital staff led by Kathleen Foley, MD, chief of Memorial—Sloan Kettering Cancer Center's pain service.

The team began its evaluation of the hospital's management of pain in two inpatient units that admitted cancer patients. It completed a chart audit to establish a baseline on which to measure improvement in how often pain assessments were included in patients' medical records. The team also adopted the zero-to-10 pain scale as an assessment tool. The team will conduct a second audit to evaluate the effectiveness of its efforts.

Staff participated in educational sessions that introduced the concept of pain as a fifth vital sign to be documented on the patient's vital sign graphic sheet. A poster in the physicians' lounge alerted doctors to the need for this new documentation. An educational session for physicians at the November medical grand rounds presented basic concepts in pain management, clinical applications, and future trends.

The physician team members developed a pain management algorithm and a formulary of pain medications, which were distributed to physicians and posted on the inpatient units. The hospital has also established a support group, conducted by a pain management physician, for inpatients and outpatients experiencing pain.

Contact: Nancy Librera, Director, Oncology Services, 973-625-6176

St. Charles Mercy Hospital
Oregon, OH

As part of its ongoing education efforts to improve patient access to pain management, St. Charles Mercy Hospital conducted four conferences for approximately 400 healthcare professionals in 1995. Most attendees were nurses; about 16 physicians attended the conferences.

Nurses now routinely assess patients' pain, and, according to anecdotal evidence, patients are experiencing improvement in their quality of life and decreased opiate use. As part of the pain management program, the hospital has a CARF (Rehabilitation Accreditation Commission)—accredited pain management program for both inpatients and outpatients with chronic pain.

Contact: Sr. Dorothy Thum, RSM, Regional Vice President, Mission Services, Mercy Health Partners—Northern Region, Toledo, 419-251-0715

Bon Secours Richmond Health Care System
Richmond, VA

In 1994 the system, which comprises four hospitals, created the Bon Secours Richmond Pain Committee, which developed policies, procedures, educational workshops, and a self-study test for nurses. The system holds about three eight-hour workshops annually for physicians, nurses, and other staff. The pain committee meets monthly to plan educational events, write articles for in-house and community newsletters, and evaluate the management of pain in the system's facilities.

Nurses are required to ask patients every four hours if they are in pain and evaluate the patient on a zero-to-10 pain scale. In a pilot project, one system hospital will add the pain scale as a fifth vital sign to the graphic sheet for charting temperature, pulse, respiration, and blood pressure. Monthly satisfaction surveys ask patients about their pain management during hospitalization. On a yearly systemwide Pain-Free Day, booths in the hospital lobbies educate the staff and community about pain treatment.

Contact: Mary Ann Mugel, Administrative Coordinator, Oncology and Medical Nursing, 804-281-8282; Judy Davis, Cochair, Bon Secours Richmond Pain Committee, 804-281-8298

St. Vincent Mercy Medical Center
Toledo, OH

A full-scale initiative to improve patient access to treatment of pain symptoms includes patient satisfaction assessments; ongoing pain assessment; recognition and treatment of opioid side effects, including pain relief in clinical pathways; and regular education for patients and staff. The graduate medical curriculum for residents includes ethics and mentoring by chaplains. Pain control is part of nurses' orientation and continuing education, and lectures for physicians, interns, and others are regularly provided. St. Vincent Mercy is committed to eliminating meperidine (Demerol) and unnecessary use of intramuscular analgesia. The hospital promotes the use of intravenous patient-controlled analgesic (IVPCA) or epidural infusions as appropriate, as well as state-of-the-art invasive procedures for chronic pain relief. It adheres to the Agency for Health Care Policy and Research (AHCPR) guidelines and the State Medical Board of Ohio rules on intractable pain and its prescription drug checklist.

Contact: Kathy J. Orra, Program Manager, Pain Management, 419-251-3110

St. James Mercy Hospital
Hornell, NY

As a result of 1995 patient satisfaction surveys, St. James Mercy Hospital formed a performance improvement committee to address the treatment of pain. The committee then surveyed nurses, physicians, pharmacists, and patients. On the basis of the findings, the hospital:

• Offered educational sessions to physicians and nursing staff
• Purchased books and videos on pain management
• Developed a pain scale
• Revised policies and procedures on pain treatment
• Distributed a booklet on postoperative pain to all surgical patients before surgery
• Added pain assessment to the patient handbook

In 1998 a patient satisfaction survey showed that 10 percent of patients were not satisfied with their pain control. The committee made pain assessment a part of the initial nursing assessment and the fifth vital sign on the graphic record. The medical staff are now prescribing more appropriate pain medications. The use of patient-controlled analgesic (PCA) has increased, and epidural analgesics continue to be used.

Contact: Nancy Khork, Senior Vice President, Patient Care Services, 607-324-8880

Saint Joseph Hospital
Lexington, KY

Together, Saint Joseph Hospital and Hospice of the Bluegrass, which resides on one floor of Saint Joseph Hospital, established a pilot program for palliative care in mid-1998. The Palliative Care Team is at the heart of the two facilities' efforts to address end-of-life issues with terminally ill patients who are not in hospice. The team consists of a radiation oncologist, palliative care practitioner, social worker, chaplain, and palliative care nurse, who works with both the hospice and the hospital. The team:

• Provides for specialized medical management of pain and other symptoms. It calls on a variety of healthcare providers for psychological, social, and spiritual problems.
• Assists with discussions of advance directives, treatment at end of life, and ethical concerns.
• Helps create a "healing environment" for patients who choose to stay in the acute care setting.
• Coordinates family conferences when appropriate.
• Educates patients and family about end-of-life care.

Since the program began, the number of requests for palliative care at Saint Joseph Hospital has doubled to approximately six a month, depending on the hospital census.

Contacts: Terence Gutgsell, Medical Director, Hospice of the Bluegrass, 606-276-5344; Kathryn Hansen-Kubley, Director, Saint Joseph Diagnostic Services, 606-278-3436; Billie May, Palliative Care Nurse, 606-278-3436; John Therkelson, Saint Joseph Chaplain, 606-278-3436

Providence Health System
Portland, OR

Providence is currently standardizing the system's approach to assessing and documenting patients' pain. A multidisciplinary committee developed a method for measuring pain assessment that could be implemented consistently at all the system's hospitals. With this method, nurses, who are trained to collect information in a standardized way, assess the pain of all adult inpatients before they are discharged from the hospital. The goal is to ensure that no patient goes home suffering unmanaged pain.

The information, which the nurses record in the patients' charts, will provide a database that Providence will use to evaluate the effectiveness of pain treatment throughout the health system.

Contact: C. Ken House, Senior Research Analyst, Center for Outcomes Research and Education, 503-216-7152

Mount Carmel Health System
Columbus, OH

Mount Carmel Health System has several activities to raise staff awareness of the need to control patients' pain. At its two hospitals, nursing staff, pharmacists, respiratory therapists, social workers, discharge planners, and residents have completed the Pain Assessment Attitude and Knowledge Survey.

In December 1998 pain management was incorporated as a fifth vital sign in the patients' medical record.

Contact: Bonnie Moses, Coordinator of Clinical Evaluation, Mount Carmel East Hospital, Columbus, OH, 614-234-6000

Bon Secours Health System, Inc.
Marriottsville, MD

The system is incorporating pain management into a comprehensive effort to improve care of the dying. A systemwide BSHSI Care of the Dying Quality Plan has recently been put in place. One of the plan's 10 elements is "Pain Management," and it calls for a multidisciplinary palliative care team in each local system, as well as processes to allow patients to describe their pain. Other elements also support good pain treatment. For example, "Integration of Hospice Philosophy" asks each facility to demonstrate the use of palliative care and to make palliative care consultation services available to patients, families, and caregivers.

Beginning in fall 1999, each of the system's facilities will provide an extensive training and education program (based on Education for Physicians in End-of-Life Care, a program of the American Medical Association) for physicians and other clinical staff.

Contact: Thom Morris, Director, Continual Development, 410-422-3209

St. Mary Medical Center
Langhorne, PA

In August 1998 St. Mary Medical Center opened a pain center through which a multidisciplinary team offers services to patients and staff. The team offers a program to physicians on the ethical concerns of using complementary therapies in pain management, and it is training nurse managers to be supportive care liaisons. These nurses receive special training in pain management and palliative care and then train their staffs. The team assists staff with nursing assessment, care planning, and care management; pharmacotherapy; anesthesia; psychosocial care (e.g., assistance in obtaining resources, counseling); spiritual intervention (e.g., prayer, relaxation techniques); physical therapy; psychological services; complementary therapies (e.g., therapeutic touch, massage); support groups; and education.

The team meets biweekly to discuss the care of inpatients and outpatients and has created pain management standards and policies. Pain will be included as a fifth vital sign in the patient record.

Contact: Christine Coletta, Supportive Care Coordinator, St. Mary Medical Center Supportive Care Program, 215-891-6602

All Saints Healthcare System
Racine, WI

All Saints Healthcare System has concentrated on helping staff see pain management as a patient right. It designated treatment of pain as a "domain of care," a system term for an element of holistic care that is the responsibility of all healthcare providers and that is essential to the delivery of consistently high-quality care.

In 1996 the system recognized adequate pain treatment as an ethical issue and created a subcommittee of the existing ethics committee to foster improvements in pain management. The subcommittee's members were representatives from the ethics committee, nursing, pharmacy, pastoral care, hospice, cancer center services, quality management, geriatric services, psychology, anesthesiology, psychiatry, and neurosurgery. The team developed a policy on pain management and added information on patient satisfaction with their pain treatment to the system's database. As a result, patient handbooks and signs posted throughout the system state, "The patient has a right to pain management as an integral part of his/her care."

Equianalgesic charts on pain have been given to nurses in the hospital and ambulatory care sites and have been posted in physician dictation areas. A newly developed pamphlet is given to surgical patients as part of their preoperative education. The system's Cancer Center has included questions on pain in their assessment and reassessment forms, and a section on cancer pain management is also included in the handbook for all center patients.

Cardiac and cardiac rehabilitation units are now using pain scales to assess patients' needs for pain control. The system provided an "Ethics Day" program on pain management for staff and community.

The system's future efforts will include additional educational sessions for all departments and development of a palliative care model.

Contact: Deborah Pape, Director of Pain Management Services, 414-636-4501

Provena Health
Frankfort, IL

In response to the CHA audioconferences mentioned in this article's introduction, Provena Health established a committee of physicians, nurses, pharmacists, social workers, theologians, and representatives of acute, long-term care, and ambulatory care facilities. Their first action was to adopt two best practices: Institutions would make pain a fifth vital sign and would use a scale of zero to 10 to measure patients' pain levels. Provena McAuley Manor, a long-term care facility, is planning to provide to its residents more alternative therapies, such as art, music, and massage.

Contact: Sr. Sharon Kerrigan, RSM, Director of Mission Integration, 815-937-2034

Diocesan Health Facilities
Fall River, MA

This diocesan-sponsored system of five skilled nursing facilities uses a multidisciplinary pain treatment program that has been accredited by the American Academy of Pain Management. The program includes a unique tool for evaluating pain in cognitively impaired residents by noting nonverbal indications of pain such as sleeping and eating habits and facial expressions.

Contact: Kim Rivard, Community Relations, 508-679-8154

St. Paul Home
Kaukanna, WI

In 1996 this long-term care facility adopted a pain management policy and procedure in which charge nurses assess pain with a tool that notes pain location, level, and type; treatments; and patients' method of expressing pain. In a pain journal, nurses record medication orders, changes in pain, and many other factors. They monitor residents' comfort and update physicians. All staff observe residents for the presence of pain and report pain promptly to the charge nurse.

Contact: Sr. Patricia Sevcik, OSF, Director of Pastoral Care, 920-766-6020

Kenmore Mercy Hospital
Kenmore, NY

Since 1996, when it initiated its Epidural Pain Management Program for nursing and anesthesiology staff, Kenmore Mercy has developed means to improve pain treatment. A Pain Management Committee, which included members from the departments of nursing, pharmacy, spiritual care, case management, and various medical specialties, developed a philosophy of pain management and surveyed patients. Subsequently the hospital developed a policy and procedure for pain management, education programs for nurses, and a flow sheet to track patients' pain.

Physicians on the committee will conduct an educational program for the hospital medical staff, and the hospital collects data on the effects of pharmacologic agents and patient length of stay.

Nurses from Kenmore Mercy are meeting with nurses from other Eastern Mercy Health System hospitals to expand pain management efforts. The hospitals will adopt standards for pain management. All nursing orientation programs now include a class on pain assessment and management, and the group has developed patient education materials.

Contact: Sharon Greathouse, Perioperative Staff Development, 716-447-6100

Center for Health Policy and Ethics
Creighton University, Omaha

In 1999 the center added an eight-session palliative care segment to a course for second-year medical students titled "Patient and Society." Among other topics, the course introduced the teachings of the Ethical and Religious Directives for Catholic Health Care Services on end-of-life issues.

The center devoted its 1999 Ethics Committee Workshop to suffering. More than 100 people attended, and several requested more information on the subject.

Contact: Ruth B. Purtilo, MD, Director and Dr. C. C. and Mabel L. Criss Professor, 402-280-2017

Diocese of Rockford
Rockford, IL

The diocese educates clergy, school principals, Illinois bishops, hospital presidents, and ethics committee chairpersons about the importance of alleviating pain through such activities as:

• Regularly referring to the Ethical and Religious Directives for Catholic Health Care Services in materials sent to clergy
• Carrying health and ethics news in the diocesan newspaper and Web site
• Parish workshops
• Parish nursing program

In the May 1999 issue of Ethics and Health Issues (the newsletter of the Office of the Diocesan Ethicist for Health Care Issues), Larry J. Frieders chronicled efforts by the Department of Veterans Affairs to reduce pain for its patients.

In addition, Bp. Thomas G. Doran issued a Pastoral Statement on Euthanasia and Physician-Assisted Suicide in 1996. In recent months the Catholic Conference of Illinois and the Illinois Catholic Health Association have been planning to work together on legislating pain management components for medical education and other pain issues.

Contact: Rev. Timothy L. Doherty, Diocesan Ethicist for Health Care Issues, 815-963-4007

Mercy Hospital of Buffalo
Buffalo, NY

The Interdisciplinary Pain Management Committee at Mercy Hospital has focused on acute surgical pain, but it plans to address chronic and other types of pain in the future. Since the committee formed in 1998, it has written and distributed to staff an ethics statement on pain ("Philosophy of Pain Management") and a Pain Management Competency (a checklist that tracks pain assessment and interventions) for nursing staff. Minutes of the committee's meetings are distributed to nurse managers for discussion at staff meetings, and nursing staff may use a response form to alert the committee to issues that need attention.

The committee has circulated a traveling poster board to the nursing units that shows all the information presented to preoperative patients. Now that all staff are aware of the education patients have received, they can deliver consistent messages to patients. The hospital provides staff with the Agency for Health Care Policy and Research clinical practice guidelines for acute surgical pain, and it gives patients the corresponding AHCPR patient guide to pain control.

The committee conducts a variety of other educational activities. It submits articles on pain treatment to the hospital's bimonthly newsletter. In 1998 physicians were offered a continuing medical education class on different types of pain that surgical patients experience and various treatments, including relaxation therapy.

The hospital has also revamped its preoperative holding room to create an atmosphere conducive to pain relief. The room is softly lit, and music (at the recommended 60 beats per minute) is played.

The committee's next step will be establishing clinical protocols. Recently the hospital started monitoring patient satisfaction with pain management as a quality indicator, but it hopes to receive a grant to help it more thoroughly evaluate outcomes of pain control efforts.

Contact: Shirley Heintz, Vice President of Patient Care Services, 716-826-7000

Providence Health System
Los Angeles

A Pain Resource Team at Providence St. Joseph Medical Center, Burbank, CA, helps nursing staff address pain management issues. Members take a 16-hour class (designed on the model of the City of Hope National Medical Center, Duarte, CA) and participate in monthly meetings, performance improvement activities, and continuing education classes.

Both of the system's hospitals — Providence Holy Cross Medical Center and St. Joseph — have Performance Improvement teams. Holy Cross is collecting data and analyzing pain assessment processes to ensure that pain is consistently assessed in all areas of the medical centers.

Physicians receive continuing medical education credits for numerous courses. Recent topics have included hospice care, the cultural impact on pain management, and innovative technologies.

Contact: Robin Gemmill, Clinical Nurse Specialist, Medical-Surgical and Geriatrics, 818-898-4334

Northridge Hospital Medical Center
Sherman Way Campus, Van Nuys, CA

A Pain Management Performance Improvement Team has concentrated on bringing the patient into the process of pain management. The team installed zero-to-10 pain scales in patient rooms, where nurses ask the patients to specify their level of pain and indicate a level where they would be comfortable. With that level as a goal, the patient is given medication and any appropriate nonmedical interventions. Pain is then reassessed and tracked on a pain flow sheet at regular intervals.

Next, patient-controlled analgesic (PCA) was made standard for all patients, and the hospital established a PCA pharmacy protocol by which pharmacists can work with patients to control pain. The hospital also established triggers for intervention, such as a pain level of five or higher on two consecutive checks.

To assess the success of these efforts, Sherman Way used flow-sheet data to compare patients' pain levels at admission, within 48 hours of admission, and at discharge. These data indicated a high degree of success in controlling pain. The hospital believes the results are far more reliable than those of internal patient satisfaction surveys.

Nurses receive training in the City of Hope Pain Resource Nurse Program. The hospital has disseminated Acute Pain Management Principles, and its administrative and patient care services manuals contain extensive information on pain management, including definitions, policies, and procedures.

Contact: Nari Singh, Pharmacy and Rehabilitation Manager, Northridge Hospital Medical Center, Sherman Way Campus, 818-908-8664

St. John's Regional Health Center
Springfield, MO

All nursing areas of the health center have adopted a standardized pain assessment tool, which is also used with patients before they enter the hospital so that caregivers and patients have a common language for discussing pain levels and plans for pain control. Nurses use clinical pathways and record pain as a vital sign in patients' records. Physician protocols are used for certain procedures to address postoperative surgical pain, and results are being tracked. In the past two years, St. John's has held two pain conferences for providers. The first focused on raising awareness of pain issues through presentations by national and local speakers; the second included patients and their physicians in a panel discussion.

About 18 months ago, St. John's established a multidisciplinary team for chronic pain, which provides a two-week educational program to help patients cope with pain. A program is currently being planned to help St. John's Health System's 200 primary care physicians evaluate patients' pain and refer them to appropriate sources of help, including the system's pain clinic.

Contact: Jay Guffey, Vice President, Perioperative Services, 417-885-2620

Looking to the Future
The programs described here are often similar. Nearly all depend on a multidisciplinary team to lead pain treatment efforts, which usually include various types of education for staff and patients, as well as tools such as pain scales for assessing pain. But the programs demonstrate a variety of creative approaches that uniquely address the needs of the patient population served and take advantage of staff expertise.

These creative responses are encouraging. Although they indicate a need for more data to document outcomes of pain management efforts, in many cases organizations are compiling this information and beginning to analyze it. Much still needs to be done to educate caregivers and the public and to refine interventions on the basis of data, but today more than ever before it seems likely that pain control will become an important activity for all healthcare organizations.

Common Pain Management Practices

• Establish pain as a "fifth vital sign" to be checked regularly
• Establish a multidisciplinary pain management team to develop policies, procedures, and educational programs
• Conduct patient satisfaction surveys
• Develop a pain scale to use with patients and/or other tools for assessing and tracking pain
• Use delivery technologies such as patient-controlled analgesic
• Introduce alternative therapies such as massage, therapeutic touch, art, and music

Resources on Pain Relief

• American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 4th ed., Glenview, IL, 1999.
• American Pain Society Quality of Care Committee, "Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain," JAMA, December 20, 1995, pp. 1874-1880.
• Genesys Convalescent Center, 8481 Holly Rd., Grand Blanc, MI 48439, 810-694-1711, "Pain Management Policy," "Pain Management Plan," "Pain Management Referrals," "Pain Management Procedure."
• Mayday Pain Resource Center, City of Hope National Medical Center, 1500 E. Duarte Rd., Duarte, CA 91010, 626-359-8111, ext. 3829. This clearinghouse collects and disseminates a wide variety of resources on pain management. An index of materials available for ordering is available on Mayday's Web site, or at the address above.
• Margo McCaffery and Chris Pasero, Pain: Clinical Manual, Mosby, St. Louis, 1999. Contains a format for a formulary analgesic reference guide (p. 737).
• Mercy Hospice, Uniondale, NY, "Principles Guiding the Treatment of Chronic Pain." Contact: Sr. Alice O'Shaughnessy, CIJ, MD, Medical Director, 516-952-1891.
• St. Joseph Healthcare, Albuquerque, NM, "Belief Statement and Patient Care Policy and Procedure." Contact: Sr. Mary Kennan Kudlacz, OP, Vice President, Mission Services, 505-727-7063.
• U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, "Management of Cancer Pain: Adults: Clinical Practice Guideline No. 9," and "Managing Cancer Pain: Patient Guide (Consumer Version, Clinical Practice Guideline No. 9)," March 1994.
• Villa Maria Rehabilitation Hospital and Nursing Center, North Miami, FL, "Pain Assessment Form." Contact: Sr. Jane Miller, SSJ, Mission Effectiveness Coordinator, 305-891-8850.
• World Health Organization, "Cancer Pain Relief", 2d ed., WHO Collaborating Center for Policy and Communications in Cancer Care, Madison, WI, 1996 (also available in Spanish and French).
• Worldwide Congress of Pain.