Re: ACOG Antepartum Record - Pain Scale?
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Wed Nov 21 19:38:23 2007
Charlie and Lynn are on the mark. The pain scale is the latest thing
the nurses want to tell us about. It used to be that you could ask an L
and D nurse, who was using her good clinical sense and judgement, "Is
she hurting, etc." and get a realistic answer "She needs an epidural" or
"She's fine--not really in good labor yet." Now, you sometimes get a
number, not an answer.
Donald said:
Wow. That would make sense, and I can understand that such a
recommendation/requirement would be appropriate for inpatient care or
outpatients receiving pain meds for chronic conditions, but requiring
such documentation for the prenatal care of generally healthy and
unmedicated patients is both absurd and misguided.
So this was indeed a pet project, someone's agenda, a
politically-correct intrusion, and an unintended consequence of a broad
brush policy into the conduct of prenatal care that I wish ACOG would
have resisted.
--
Donald W. Miller
This was key:
but requiring such documentation for the prenatal care of generally
healthy and unmedicated patients is both absurd and misguided.
Garry
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.
>
>************************************************************************
>*******
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
