Anthony D. Slonim, MD, MPH, FCCM Children's National Medical Center The George Washington University School of Medicine Washington, D.C., USA

Pain is a major problem among critically ill and injured patients in the intensive care unit (ICU). Pain from tissue damage related to acute disease, trauma or surgery might, in part, be related to the primary reason for ICU admission. In addition, discomfort is associated with changing the patient’s position, invasive procedures, the administration of therapies, and the psychological distress of critical illness.(1)

The ability to effectively manage the pain and suffering of critically ill patients is an important and fundamental principle for all members of the integrated critical care team. The knowledge to manage pain is gained as core content in critical care training programs, didactic sessions, and through guidelines published by the Society of Critical Care Medicine (SCCM).(1)

However, the literature would suggest that despite this training, ICU clinicians can still improve the ways in which they approach pain management, which is fundamental to providing high-quality critical care.(2-4)

Quality in Healthcare
Many decades have passed since “quality” first emerged in healthcare circles as a topic for discussion.(5-10) In the ensuing years, the meaning of the term “quality” has been modified considerably. However, Juran’s definition, which includes “meeting the needs of customers,” still has relevance in the modern era of healthcare.(9-10) Subsequently, American healthcare followed the lead of industry by focusing on quality assurance and quality management techniques to improve the delivery of healthcare.(10) In the 1980s, a shift from the more traditional “quality assurance” to “quality improvement” occurred. This was especially important for healthcare. “Quality assurance” focuses on production.(9-11) It is retrospective in nature and seeks to identify faults within the production process.(11) Importantly, it does not consider the patient or family in the healthcare experience.(11) As a result, transitioning quality assurance from industry to healthcare had its inherent challenges.

Over the past 20 years, increasing attention has been paid to the issues of quality improvement in healthcare. The Institute of Medicine (IOM) recently provided a report entitled
Crossing the Quality Chasm that focused on healthcare quality more broadly.(12) The document recommends “Six Aims for Improvement.” These “Aims” are intended to frame the fundamental changes that need to be incorporated to improve the healthcare services delivered to individuals and populations.(12) These Aims include: Safety, Effectiveness, Equity, Timeliness, Efficiency, and Patient-centeredness.

Patient-centeredness as an IOM Aim helps to characterize the interactions between practitioners and their patients and places the patient and family in a central role as the recipients of services during the episode of illness.(12) Healthcare personnel possess traits that comprise service quality including empathy, compassion and respect. Actions that demonstrate appropriate service quality include the provision of information, communication, education, attention to physical comfort, emotional support, and the involvement of family and friends in care.(12) The attention to both physical and emotional comfort is of considerable importance for the ICU patient and reflects one dimension of healthcare quality.

Beyond being a compassionate and empathetic intervention, managing acute pain in the critically ill patient has beneficial physiological and economic effects.(1) Adequate analgesia can promote good respiratory function and pulmonary toilet, modulate the stress response, and promote hemodynamic stability, thereby preventing complications and reducing the utilization of resources.(13) Patients treated appropriately for their pain can be mobilized quicker and discharged earlier than those who are not.(13) These considerations help to highlight how pain control impacts other domains of quality beyond patient-centeredness, including efficiency, timeliness and effectiveness.

Challenges to Pain Management
One major limitation in effectively managing pain in the critically ill is the inability to appropriately assess the quality and intensity of the pain. The PQRST of a pain history includes the Pain, Quality, Radiation, Severity, and Temporizing measures associated with pain and can be helpful in understanding a patient’s pain. These characteristics provide insight into the differential diagnosis and etiology of the pain.

Through an understanding of these characteristics of pain, the etiology may be determined. However, it is fully recognized that the ability to obtain such a thorough pain history in the critically ill patient is challenging and limited by numerous communication barriers. First, patients may not have an adequate understanding of the symptoms of discomfort and as a result may not be fully able to characterize their experiences.(3) Secondly, language
barriers and cultural issues in the communicative patient can affect the patient’s ability to provide this information to the caregiver. Finally, in the patient who is unable to effectively communicate either because of an altered level of consciousness or endotracheal tube, this detailed information can simply not be captured.

Pain Assessment
Indirect methods of assessing pain include the attention to sympathetic physical manifestations like tachycardia, diaphoresis, tachypnea, and facial expression. Behavioral changes such as posturing or protecting an area before examination may also be helpful. However, these are relatively nonspecific in the ICU patient who may have fever, anxiety or physiologic dysfunction that is unrelated to pain, yet manifests similar signs.(13) Furthermore, these indirect methods do not provide the practitioner with an opportunity to assess the intensity of the pain. Rather, they reflect an all-or-none phenomenon in which the patient is either in pain or not.

This scenario is not typically the case in the critically ill patient, who may have some degree of pain that varies in location and intensity throughout the course of the day. Furthermore, the intensity of pain is also difficult to ascertain in the critically ill patient. Scales that attempt to quantify the patient’s pain on a linear range of intensity, from least to most, or 1 to 10 in severity, are commonly used. Visual analogue scales or color ranges with a deepening intensity of color can also be helpful in representing a patient’s appreciation of pain and have been useful in pre-school children.(1) The “faces” scales provide a pictorial representation of different levels of pain and are also easily understood and communicated, even in the intubated patient.

Pain assessment needs to be performed regularly and consistently in the ICU setting. It is used to assess the initial onset and severity of pain as well as the response to interventions. If patients are unable to contribute to the providers’ understanding of their pain, alternative methods of gaining the information can be used. Surrogate decision makers are used often for end-of-life decisions when a patient is unable to communicate because of illness or disability. Perhaps surrogates may be able to assist ICU providers in establishing the severity of pain and the response to analgesia. Unfortunately, data demonstrate that surrogates are only moderately successful in estimating the presence of pain in their seriously ill loved ones and are only able to estimate the intensity of the pain approximately 50% of the time.(14)

Pain Management

Pain is a frequent and severe symptom in ICU patients, and controlling pain is important. However, many patients are dissatisfied with the pain control they receive.(2) Dramatic improvements in the methods of relieving pain have been achieved over the last 50 years. This includes the development of new and important analgesics such as synthetic narcotics, a full repertoire of adjuvant medications that act in conjunction with opioid and nonopioid analgesics, agents including nonsteroidal anti-inflammatory drugs, and an increased knowledge base of alternative medical options such as prayer, meditation, hypnosis, relaxation, and acupuncture. A framework for addressing the full range of potential opportunities in relieving pain should be considered.

Since effective medications and interventions to manage pain already exist, how then are providers to improve the pain control they provide for critically ill patients? Perhaps the answer lies in standardizing the care around pain control. Guidelines for the use of sedation and analgesia do exist,(1) however, adherence to guidelines, even when they are evidence-based and adapted to local practices, is generally poor.(4) Despite practice guidelines, there does seem to be considerable variability in the ways that providers address pain control.(15) In one academic inner city ICU, only one-third of patients received an analgesic medication order,(15) and only 50% of those receiving sedation received an accompanying analgesic.(15)

Pain control is important to critically ill patients and their families, and is a measure of the quality of care that is delivered in ICUs. For some patients, it is all that can be offered. If success in improving this important component of ICU care is to be realized, opportunities to improve its measurement, standardize its control, and link it to quality outcomes need to be achieved.