A Vital Sign with concerning unintended consequences

Great post over at Aggravated Surgery Doc about the on the Downside of the 5th Vital Sign on how the PC infiltration of pain management policy caused poor patient outcomes and placed patients at higher risk. He makes valid points that political pressure has lead to more aggressive use of IV narcotic pain management instead of IM or other management thus putting patients at risk.

“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”

“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“

In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.

The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.

I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.

“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.

I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.

If this practice has not hit your ER yet, consider yourself lucky for now.