Roswell Park’s Fifth Vital Sign Program Boosts Pain Assessment

BUFFALO, NY—A pain intensity assessment program undertaken at Roswell Park Cancer Institute has been successful in increasing staff assessment of pain and in promoting optimal pain management. Reporting at a poster session at the Oncology Nursing Society’s 26th Annual Congress, Jacqueline L. Massey, RN, MS, assistant director of nursing, described the development of the Center’s comprehensive program, known as the Fifth Vital Sign.

The purpose of the Fifth Vital Sign program is to identify patients in pain; adopt an age-appropriate, uniform approach to pain assessment; establish pain management standards of care; educate patients about the need to communicate with staff about their unrelieved pain; enhance patient comfort and satisfaction; and reduce the incidence and severity of patients’ pain.

Ms. Massey said that the Fifth Vital Sign program applies to all Roswell Park staff members involved in direct patient care and is administered by the Department of Anesthesiology and the Department of Nursing. The program began in April 2000.

The effectiveness of the new pain assessment policy was evaluated with a Fifth Vital Sign survey, which was conducted in June 2000 and again in December 2000 and March 2001. Survey results showed sometimes dramatic increases in staff attention to pain assessment.

Sample questions and percentage of respondents currently implementing the policy are:

If pain is persistently 4 to 10 on the pain scale, is the pain service or an MD called? In June of 2000, 80% of staff members said yes; in December 2000, 83.3% said yes; in March 2001, 100% said yes.

Are pain scores charted every 4 hours for 24 hours for postoperative patients? In June 2000, 28.6% of the staff were meeting this objective. By December 2000, the percentage had risen to 87%, and by March 2001, to 89.5%.

Are pain scores charted every 8 hours on the TPR sheet? In June 2000, 25% were doing this; in December 2000, compliance was 75%; and the institution had achieved 100% compliance by March 2001.

Are pain scores documented every 4 hours if pain is rated as 7 or greater? In June 2000, 33.3% of staff members were doing this; in December 2000, the percentage was 94%; and in March 2001, 92.6% were meeting this objective.

The pain assessment tools used were (1) a numerical pain assessment ruler in which 0 means no pain, 1 to 3 represents mild pain, 4 to 6 denotes moderate pain, and 7 to 10 signifies severe pain; (2) the seven faces scale; or (3) verbal assessments from a patient.

The new policies and procedures give special consideration to assessing and managing pain in children, Ms. Massey said. Moreover, they recognize the hysical, cognitive/emotional, and behavioral aspects of pain in children and emphasize the importance of using age-appropriate approaches to assessment.

The Fifth Vital Sign program is now conducting chart reviews of pain management at discharge, she said. A discharge quality assurance policy statement is being developed to help guide practitioners in prescribing a pain management discharge plan.

The pending policy statement guidelines indicate that at discharge, a patient’s pain should be 4 out of 10 or less. If the pain is more severe, but the patient is otherwise able to be discharged, a pain service attending physician or designee will formulate a pain management discharge plan for the patient. The patient will be provided with follow-up appointments for reassessment and adjustment of the plan, all of which will be documented.

The interdisciplinary pain initiative task force meets monthly to monitor the implementation of the Fifth Vital Sign program and to ensure continued progress. The task force recognizes the need to measure outcomes, measure the knowledge and attitudes of staff, and identify barriers to pain management, Ms. Massey noted.

Based on the data gathered, improved procedures will be implemented and assessed when needed.