Eye on EBVM: pain management – know the score

Management of acute pain is a considerable issue when it comes to patient safety, and since September is Animal Pain Awareness Month, it seems an apt time to discuss pain management within vet practice.

The simplest definition of patient safety is “the prevention of errors and adverse effects” – both of which would include a patient suffering from preventable pain and the underdose or overdose of analgesia.

Effective pain management can be difficult – especially for patients that have evolved to hide their pain. The veterinary world is full of anecdotal stories of dogs that have walked home with a stick in their thorax or cats that are purring despite a fractured pelvis.

Cats regularly use purring as a self-soothing mechanism, much like a child sucking his or her thumb, and many breeds of dogs (we’re looking at you, Labrador retrievers) will eat a meal regardless of any discomfort or injury.

Pain score

So, how do we recognise and treat pain to maintain patient safety when patients are seemingly acting “normally”? This can be done by combining physiological and behavioural signs to create a pain score.

The American Animal Hospital Association Pain Management Guidelines state this score is the fourth vital sign (after temperature, pulse rate and respiration rate). Meanwhile, the UK Animal Welfare Act 2006 states that owners or temporary carers of animals are responsible for providing their five welfare needs, which include the protection from pain and suffering.

The supporting guidance for the codes of professional conduct for both veterinary surgeons and veterinary nurses confirm that an animal’s health and welfare should be our first priority, and sets out the requirements for pain management.

The Practice Standards Scheme (PSS) includes pain management within its core standards – which are relevant to all veterinary practices – with one module within the standards solely dedicated to the provision and management of analgesia for both inpatients and outpatients. This is applicable to small animal, equine and farm practices, emphasising the importance of appropriate pain management within all scenarios.

Three of the six PSS awards for large and small animals involve a large percentage of pain management – in particular, the recognition of pain by using evidence-based pain scoring tools.

Why use a scoring tool at all?

Using pain scoring tools can reduce the risk of subjectivity and bias, quantify the pain to allow more accurate monitoring, and allow the correct type and strength of analgesia to be prescribed.

Pain scoring tools should be peer-reviewed and chosen for the type of pain the patient is experiencing, as acute and chronic pain can cause differing signs. Within the hospital environment, acute pain will be the most common – and most predictable – to treat.

A variety of pain scoring tools can be used (Panel 1) – not only for dogs and cats, but for rabbits, rodents, ruminants and horses, too.

Guidelines

However, pain scoring the patient is only a part of effective pain management. Surgery, whether routine or not, is classed as acute pain and, when poorly managed, can increase complications, leading to physiological stress and a longer rehabilitation period. Many practices have standard analgesia and premedication guidelines, but is this enough for the patient’s needs?

The development of pain guidelines can provide information for the entire team about when and how to assess pain, and what to do if the patient requires intervention. Pain scoring should occur routinely; if surgery is scheduled then preoperative, intraoperative, immediately postoperative and home postoperative are ideal times to pain score.

The effect and duration of analgesia – especially opioids – can vary considerably from patient to patient, so pain assessment after analgesia will evaluate its effectiveness and reduce the risk of underdose or overdose. This will also allow assessment of the degree of sedation, ensuring the patient is not only pain free and comfortable, but ambulatory (if the condition allows).

Regular pain scoring will assist towards analgesia being tapered down for a less dysphoric effect – especially after high doses of opioids. If required, other techniques can be instigated to give a multimodal approach to pain relief.

Pain guidelines can work alongside a surgical or inpatient checklist. The PSS Pain Management Award module requires practices to have a designated person involved in the teaching and monitoring of pain relief guidelines to ensure training is delivered to all team members, and it increases the likelihood of them being followed.

Clinical audit can help measure whether the practice guidelines are being used methodically by the team (process audit), and can help measure whether the guideline is fit for purpose and has led to an improvement in pain management (outcome audit). If guidelines are developed with input from the team, it is more likely they will be on board with the changes.

Home care

Pain guidelines shouldn’t stop at the end of the patient’s stay in practice. One of the key moments to monitor pain is postoperatively at home. Written postoperative instructions should include a personal analgesia plan, which can be discussed with the owner, taking into account his or her abilities to administer medication at home. This can increase the owner’s understanding of the medication required, and improve compliance. Pain scoring sheets can be explained, or given to the owner, so he or she can assess pain in the home environment.

When developing pain guidelines, think of the following questions:

• Do you routinely use pain scoring in all the species you see?
• Does your practice individualise analgesia?
• Is your team confident in recognising pain?
• Do you find patients would benefit from rescue analgesia?
• Do patients return postoperatively in discomfort?

Using consistent pain scoring throughout the practice and then auditing its use is a great start for effective pain management. This can help identify any requirements for improvement and training in practice.

To get started with preparing guidelines and clinical auditing, visit www.rcvsknowledge.org/quality-improvement