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Safely treating postsurgical pain continues to be a challenge, despite more than a decade of focus on its appropriate management. Overuse of opioids and undertreatment of pain continues, as does insufficient monitoring of patients at risk for opioid and pain-related complications. It is clear that relying only on numeric subjective pain scores is inadequate when treating pain. Appropriate bedside evaluation should also include measures of respiration and sedation. Furthermore, assessment of risk should be done with initial pain assessment and continued throughout the pain management course. The recently developed Michigan Opioid Safety Score integrates health risks and objective measures of respiratory rate and sedation, while encouraging the use of multimodal analgesia for all patients.
“EXCUSES FOR INADEQUATE pain control appear to have run their course and will no longer be accepted because poor pain control is unethical, clinically unsound, and economically wasteful.”
Thus starts an article in the Journal of the American Medical Association (JAMA) describing The Joint Commission's (TJC) efforts to treat pain as the fifth vital sign.
The “fifth vital sign” model came initially from Veterans Administration policies and American Pain Society discussions, both of which outline ongoing problems with pain control including education, standardization, and safety.
Unfortunately, the catch-phrase led the health care team to treat pain as a static number, resulting in patient harm. Vila et al found that when pain was treated based purely on a numeric scale (as the “fifth vital sign”), the incidence of adverse events related to opioids increased by greater than 100%.
The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Is patient safety compromised by treatment based solely on numerical pain ratings?.
More recently, Lucas et al examined data of the American College of Surgeons Committee on Trauma and found that the incidence of inpatient death related to opioid overuse similarly increased significantly following implementation of “fifth vital sign” recommendations.
The Anesthesia Patient Safety Foundation convened a workshop in 2006 to examine the causes of increased morbidity and mortality from opiates as reported in the literature.
The dangers of postoperative opioids were summarized and published in a newsletter format. A repeat workshop in 2011 resulted in a white paper entitled “No Patients Shall be Harmed by Opioid-Induced Respiratory Depression.”
Nevertheless, during the decade following the initial “fifth vital sign” proclamation, no significant organized changes were made to improve pain care while reducing adverse events.The phrase “pain as the 5th vital sign” was initially promoted by the American Pain Society to elevate awareness of pain treatment among health care professionals. The phrase “pain as the 5th vital sign” was initially promoted by the American Pain Society to elevate awareness of pain treatment among health care professionals. Vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated.—James Campbell, MD, in his Presidential Address to the American Pain Society on November 11, 1996
In August of 2012, TJC released the Sentinel Event Alert entitled “Safe Use of Opioids in Hospitals.”
In the alert, TJC outlined the increasing incidence of opioid-related adverse events, as well as the continuing problems with inadequate management of pain. The Alert delineated risk factors for adverse events (based on internal data) and made solid recommendations for education and training, appropriate patient monitoring, effective tools and processes, and the appropriate use of safer technologies. By describing means to reduce complications and improve pain management, the Alert outlines the basics for development of an evidence-based roadmap for improving patient satisfaction and reducing cost.
In conjunction with the Michigan Hospital and Healthcare Association and Michigan Society of Anesthesiologists, the authors created a patient safety tool designed to maximize the use of multimodal analgesia, identify patients at risk for opioid-related harm, and move beyond a simple numeric rating scale for pain assessment.
Assessment Tools
It is generally accepted that recognition and assessment be the initial steps used to treat pain. Subjective measures such as numeric pain rating scales as well as objective measures of sedation, breathing, and health risk have all been described independently as means of improving safety.
Numeric rating scales for pain intensity have been the standard for nursing assessment for over a decade, with numerical, graphical, and pediatric modifications being commonly used world-wide. Unfortunately, patients' subjective reports of pain may trump objective nursing observations of patient response to opioids. For example, in the Vila study mentioned previously, 15 of 16 patients who experienced opioid-related adverse events were described as sedated or confused immediately before receiving further opioid therapy that led to the adverse event.
The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Is patient safety compromised by treatment based solely on numerical pain ratings?.
American Society of PeriAnesthesia Nurses' (ASPAN) Practice Recommendation (PR ) Strategic Work Team The ASPAN prevention of unwanted sedation in the adult patient evidence-based practice recommendation.
Although each has been used successfully during the treatment of patients receiving opioid medications, their use has not been tied to continuation or discontinuation of treatment at the point of care.
Respiratory depression is usually described in terms of decreased respiratory rate (<10 breaths/minute). Although respiratory depression is less common than sedation, it is the most serious of opioid-related complications and associated with significant mortality. In 2011, the American Society for Pain Management Nursing released guidelines on monitoring for opioid-induced sedation and respiratory depression, with suggestions that serial sedation and respiratory assessments be done to evaluate patient responsiveness during opioid therapy by any route of administration.
Most recently, the American Society of PeriAnesthesia Nurses published practice recommendations calling for the assessment of sedation in the postanesthesia care unit (PACU).
American Society of PeriAnesthesia Nurses' (ASPAN) Practice Recommendation (PR ) Strategic Work Team The ASPAN prevention of unwanted sedation in the adult patient evidence-based practice recommendation.
Patient health factors have also been described as an important variable in determining opioid-related risk, with TJC providing a list of patient types especially vulnerable to the respiratory depressant properties of these medications.
Not surprisingly, those with sleep apnea, obesity, or a snoring history are at risk while less obvious perioperative surgical factors, such as anesthetic time and site of incision, can also impact opioid-related morbidity.
The Michigan Opioid Safety Score (MOSS) was developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy (Figure 1). Scoring is based on a summation of risk data with objective bedside measures of over-sedation trumping a patient's subjective reports of pain.
Figure 1Michigan Opioid Safety Score (MOSS).
Source: Copyright 2015, Roy Soto. Used with permission. This figure is available in color online at www.jopan.org.
Patients are initially scored based on health risk. These include four risk categories or groups:
1.
Snoring/obesity/sleep apnea history.
2.
Site of surgery (abdominal/thoracic) and anesthesia time (if >3 hours within 24 hours of MOSS assessment).
3.
Concomitant sedative use (if within 2 hours of MOSS assessment).
4.
Advanced age as well as current smoking history.
Patients are assigned points based on risk group, with a maximum possible score of two. Some patient risks may change over time (depending on concomitant sedatives and time from anesthetic exposure), while others (eg, weight, age) will be static.
Respiratory Rate
A respiratory rate of ≥10 breaths/minute yields no points on the MOSS assessment, whereas a rate <10 breaths/minute generates two points.
STOP Modifier
Based on a modified POSS (sedation) score, patients receive a STOP modifier if they are excessively sedated, drift off to sleep during conversation, or are difficult to arouse. Note that no points are assigned for sedation per se, and assessments are made subjectively by nurses at the point of care, that is, when the patient (or family member/care provider) ask for pain medications.
Scoring
Risk factors plus respiratory rate generate a score of 0 to 4, with the STOP modifier overriding the numeric score (Figure 1).
MOSS Interpretation
•
Safe: Patients may receive continued opioid therapy.
•
Concern: Patients should be identified during nursing handovers as at-risk patients that may need to be monitored more closely on the clinical unit than those deemed safe.
•
Caution: Opioids should be decreased and levels of monitoring increased. This may necessitate transfer to an intensive care or step-down unit, or the need for continuous pulse oximetry, respiratory rate, or capnographic monitoring on the clinical unit.
•
STOP: Opioids should be discontinued immediately, primary care providers should be notified, and patients should be monitored/treated aggressively to prevent hypoventilation, hypercapnea, hypoxemia, apnea, and death.
Multimodal Analgesia
Each step in the MOSS interpretation table includes comments regarding multimodal analgesia. Nurses are encouraged to review patient order sets to ensure that patients never receive opioid-only pain treatment regimens and that patients ideally receive non-opioid analgesics, such as acetaminophen and a nonsteroidal anti-inflammatory drug, on a continuous basis when opioid orders are active.
Although initially developed as a patient safety tool, nurses in the authors' hospital system have reported a high level of satisfaction with its use based, in part, on pressures faced at the bedside when patients, family members, or health care providers request/demand opioids. As one orthopaedic nurse recently stated “This is great, and will give me documentation I can use when a doctor or patient tries to push me to give more opioid, even when I know it's not safe.” Whether this experience can be generalized beyond our hospital system remains to be seen, but any tools that encourage nursing empowerment should be actively promoted.
Recommendations
The MOSS tool was developed for use in patients receiving intravenous (IV) opioid therapy for the treatment of post-surgical pain while on the inpatient surgical ward. Nevertheless, this tool may prove to be beneficial to non-surgical patients as well, including those on high-dose oral opioids and sedatives. Frequency of assessment should be determined by patient opioid need (ie, when a patient asks for additional pain medication) and should be increased for those whose interpreted scores fall into the yellow (or certainly red) categories of risk (Concern, Caution, or STOP).
Although the tool was developed for use on the inpatient surgical ward, it may prove to be useful in PACU as well. Inherent to the tool's design is the employment of progressive monitoring as risk for over-sedation and respiratory depression increases. Although PACUs typically have higher nurse-to-patient ratios with advanced levels of monitoring, not all recovery units are staffed or equipped equally. For example, the PACU of a busy academic hospital is very different in this regard than a recovery area in a plastic surgeon's office, but patients in both settings may benefit from the tool's use. The tool would provide direction in opioid therapy, empowering nurses to apply an evidence-based approach to escalating or de-escalating opioids with sedation state and easily identifiable risk factors taken into consideration. Additionally, multimodal analgesia, which is recommended for all patients, would be more reliably employed, given the tool's suggestion to ensure its use at each assessment interpretation.
With over 50 million inpatient procedures performed annually in the United States alone, the MOSS tool offers the potential for significant patient safety improvements and increased nursing empowerment with regard to opioid administration.
The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: Is patient safety compromised by treatment based solely on numerical pain ratings?.
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