Broadening the choices of pain assessment tools

Accreditation Monthly, August 9, 2005

Dear Colleague,

Recently while conducting a JCAHO Continuous Survey Readiness Assessment visit with a client hospital, I asked a nurse in the emergency department how he went about assessing pain in patients presenting in the ED. He pulled out a blank copy of the hospital's ED assessment form and pointed to the section designed to record data from the pain assessment. He then noted that it included two frequently used pain scales. First the numerical 0-10 pain rating scale, and second, the Wong-Baker FACES 0-10 pain rating scale.

Since I knew the ED at this hospital was a full-service ED serving patients of all ages and conditions, I asked the nurse whether these two scales worked or could be applied with validity for all populations of patients encountered in ED. He wasn't sure where I was headed with this question so I assisted him by asking more specifically, what if you have an adult patient who appears cognitively impaired or perhaps, based on the history, suffers from dementia.

"Oh," he replied, "I would simply hold up my Wong-Baker FACES scale and observe my patient. If he or she is frowning, I would score their pain higher, in the 7-8 range. On the other hand, if the patient seems happy, I'd score them lower, in the 2-3 range."

"Yikes!" I said to out loud to those in attendance. "We've got some work to do." First off, the Wong-Baker scale has been shown to be valid in patients ages 3 to 16, and second, it is designed to be used by showing the "faces" to the patient and asking them to describe the face that reflects how they feel. It is never to be used as this nurse had suggested. Thus we spent a few hours that afternoon in discussion with leadership to begin the redesign of their pain assessment tools to broaden the choices available and provide greater validity and reliability for each population of patient served.

One such tool, called Pain Assessment in Advanced Dementia (PAINAD) scale, is designed for adult patients with advanced dementia or cognitive impairment. While presently PAINAD is seldom used, I think it is likely that it will catch on quickly. I believe it is first attributed to researchers Warden and Volicer working at Bedford Veterans Affairs Hospital in 2001. It converts nicely to a 0-10 point rating scale to allow calibration to other pain rating scales and has been shown to be easy for staff to learn and use with high interrater reliability.

I found a great article describing this scale and its proper use written by Kathryn Agarwal, MD, Geriatric Fellow, Harvard Medical School and Faculty Scholar, Program in Palliative Care Education and Practice, Harvard Medical School. It may be accessed at the web site of the Massachusetts General Hospital's clinician-focused educational initiative called "MGH Cares about Pain Relief."

The PAINAD is an observational scale based on 5 items with a scale of 0-2 for each (totaling 0-10):

  1. BREATHING (independent of vocalizations) - normal (0) vs labored (1) vs noisy labored (2) or long periods of Cheyne-Stokes respirations.
  2. NEGATIVE VOCALIZATION - none (0) vs occasional moans or muttering (1) vs. repeated troubled calling out or loud moaning or crying (2).
  3. FACIAL EXPRESSION - smiling or inexpressive (0) vs sad, frown (1) vs facial grimacing (2).
  4. BODY LANGUAGE - relaxed (0) vs tense and pacing (1) vs rigid with fists clenched, or striking out (2).
  5. CONSOLABILITY - no need to console (0) vs distracted or reassured (1) vs unable to distract or console (2).

Staff needs valid tools to assess and rate pain across the full continuum of patients seen in their setting. Additional scales to research and perhaps make available to your staff depending on your patient populations include the NIPS scale for neonates, the CRIES scale for neonatal postoperative pain rating, and the FLACC scale for infants and pediatric patients ages 0-3.


John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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