Re: ACOG Antepartum Record - Pain Scale?
From: art fougner, md (evsono@pipeline.com)
Wed Nov 21 11:13:36 2007
"We have met the enemy. And they is us."
Walt Kelley
Art
At Wed, 21 Nov 2007, Lynn Montgomery wrote:
>
>I agree completely with Charlie. The hospital pain scale is one of the
>worst mandates to healthcare in my career. In our hospital, it has
>resulted in the following:
>
>1. Nurses no longer pay attention to vital signs; they simply ask
>the patient for their estimate of pain - even to the point of waking a
>sleeping patient to ask them how the rate their pain.
>
>2. When I get called for a patient "with uncontrolled pain", I
>always ask for their vital signs, reasoning that if the pulse and blood
>pressure aren't up, there is likely a disconnect between the patient and
>the evaluating nurse. Invariably, the nurse calling does not have the
>vitals available and has to go check - they haven't even evaluated the
>patient. After all, an over-medicated patient doesn't ring the nurse
>call button much!
>
>3. The pain scale has resulted in the hospital creating a "Pain
>Team" to specifically deal with patients who complain of "uncontrolled
>pain". Physicians who have grown weary of the numerous nursing calls
>for "uncontrolled pain", based on their pain scale assessment, can now
>just write an order for the Pain Team to be consulted "as needed". This
>results in significant additional costs to the patient, who typically
>just gets her analgesic changed to Dilaudid with Toradol.
>
>4. A postoperative patient in our hospital continued to complain
>of excruciating pain based on the pain scale and was repeatedly given
>narcotics without appropriate monitoring and was later found dead
>secondary to respiratory arrest.
>
>a. During a review of this case, a point was made regarding the
>contribution of the pain scale to this patient's demise, but despite
>this, the solution was not to re-address the scale, but rather to get
>more oximeters with louder alarms so that patients with respiratory
>depression secondary to analgesic therapy would be detected before they
>die...
>
>Lynn
>
>--
>Lynn D. Montgomery, M.D.
>
>Obstetrics & Gynecology, Maternal-Fetal Medicine
>
>The Birth Center/Rocky Mountain Women's Health
>
>1211 S. Reserve St.
>
>Missoula, Montana, 59801
>
>406-549-0978
>
>fax 406-549-0987
>
>e-mail: apgar10@thebirthcentermt.com
>
>________________________________
>
>________________________________
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
>________________________________
>Charlie Chambers
>________________________________
>Sent: Wednesday, November 21, 2007 10:25 AM
>To: Multiple recipients of list OB-GYN-L
>Subject: Re: ACOG Antepartum Record - Pain Scale?
>
>Pain is not a vital sign. It's a symptom. The key is what is the cause,
>not to go to endless lengths to document the symptom. No one ever died
>or suffered sequelae from pain alone. I have issues with our current
>society believing that everything should be painless. No, I don't think
>people should suffer needlessly, but the idea that we should be able to
>treat all pain till absent seems hopeless. Plus, it just contributes to
>all the oxycontin, methadone, etc addiction that exists.
>
>On Nov 21, 2007, at 8:34 AM, ainsron wrote:
>
>It also reflects the recommendation/requirement of the nursing and
>medical
>
>boards of California that pain be assessed on any patient whose vital
>signs
>
>are recorded:
>
>"It is now required that all health care staff record pain assessment
>each
>
>time that vital signs are recorded for each patient. If the institution
>is
>
>using the zero to ten pain assessment scale, a recording of pain 2/10,
>
>fulfills the requirements of this law. The Board reminds RNs that pain
>
>assessment is based on patient self-report and that patient's can be
>asleep
>
>and still experience significant pain; appropriate charting would be to
>
>write "asleep" for the pain rating. Registered nurses will continue to
>be
>
>required to monitor all five vital signs and take appropriate action
>based
>
>on deviations from normal. In other words, a competent registered nurse
>
>intervenes when the patient's pain is not being managed according to the
>
>agreed upon comfort level."
>
>Ronald E. Ainsworth, MD, FACOG
>
>-----Original Message-----
>
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
>ainsron
>
>Sent: Wednesday, November 21, 2007 8:26 AM
>
>To: Multiple recipients of list OB-GYN-L
>
>Subject: Re: ACOG Antepartum Record - Pain Scale?
>
>It probably reflects JCAHO's position that pain is the "fifth vital
>sign."
>
>Ronald E. Ainsworth, MD, FACOG
>
>-----Original Message-----
>
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Don
>Miller
>
>Sent: Wednesday, November 21, 2007 6:31 AM
>
>To: Multiple recipients of list OB-GYN-L
>
>Subject: ACOG Antepartum Record - Pain Scale?
>
>Just took a look at the latest ACOG Antepartum record and noticed that
>
>they slipped in a new column in the obstetric flowsheet for "Pain
>
>Scale". Considering that things that ACOG publishes tend to be held up
>
>as a standards of care (especially by lawyers), I'm wondering where this
>
>item came from.
>
>Where is the overwhelming evidence of benefit to the patient or a
>
>multitude of references to elevate such an item to suggest routine
>
>documentation at every prenatal visit? I've done a cursory look through
>
>PubMed and the ACOG website and haven't found anything.
>
>If there is such data, could someone please illuminate me as to the
>
>value of this new column and the proper response to patients who
>
>repeatedly say they have pain? What are the next diagnostic steps to
>
>defend oneself when a patient reports and you document continual pain?
>
>OR, is this designed to be defensive legal strategy to counteract
>
>patients with bad outcomes who said they were always in pain and there
>
>was no documentation of such (or the absence of pain)?
>
>My worst fear is that this was a pet project or self-serving agenda
>
>lobbied by someone on the committee that creates the form and is not
>
>evidence-based and adds one more task, one more question.. This is in
>
>the face of real evidence that suggests that urine dipstick testing for
>
>sugar and protein provides no benefit and probably should be dropped
>
>from routine prenatal care and from all prenatal forms.
>
>So, what's the story?
>
>--
>
>Donald W. Miller, Jr., MD, FACOG
>
>eNATAL, LLC
>
>http://www.eNATAL.com
>
>************************************************************************
>****
>
>Charlie Chambers
>
>Hood River, OR
>
>cchamber@alumni.rice.edu
>
>"Almost anything you do will seem insignificant but it is very important
>
>that you do it....You must be the change you wish to see in the world"
>
> -- Mahatma Ghandi.
>
>************************************************************************
>*******
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
