Morrison R Sean, Meier Diane E, Fischberg Daniel, Moore Carlton, Degenholtz Howard, Litke Ann, Maroney-Galin Catherine, Siu Albert L
Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY 10029, USA.
Arch Intern Med. 2006 May 8;166(9):1033-9. doi: 10.1001/archinte.166.9.1033.
Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management.
This controlled clinical trial (April 1, 2002, to February 28, 2003) involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing.
Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; P<.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; P<.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; P<.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores.
A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.
疼痛是一个主要的质量问题。本研究的目的是评估一系列干预措施在疼痛管理方面的有效性。
这项对照临床试验（2002年4月1日至2003年2月28日）涉及将3项干预措施分两个阶段逐步实施到2组匹配的医院科室。研究地点是一家拥有1171张床位的医院。共对3964名成年人进行了研究。干预措施包括教育、使用1项或4项（强化）疼痛量表进行标准化疼痛评估、向护理人员审核并反馈疼痛评分以及计算机化决策支持系统。主要结局指标为疼痛评估、严重程度及镇痛药处方。
使用强化疼痛量表的科室疼痛评估率显著高于使用1项疼痛量表的科室（64%对32%；P<0.001），与未使用审核及反馈的科室相比，审核并反馈疼痛结果与疼痛评估率的提高相关（85%对64%；P<0.001），仅在与未进行审核及反馈的科室相比时，增加计算机化决策支持系统才与疼痛评估的显著增加相关（79%对64%；P<0.001）。与1项量表相比，强化疼痛量表与中度或重度疼痛患者使用世界卫生组织第2或3级镇痛药的处方显著增加相关（83%对66%；P = 0.01）。这些干预措施并未改善疼痛评分。
结合审核及反馈或计算机化决策支持系统的具有临床意义的疼痛评估工具可将疼痛记录改善至80%以上。强化疼痛量表与镇痛药处方的改善相关。未来的干预措施应针对改变医生与阿片类镇痛药滴定相关的行为。
