JCAHO Pain Rating Standards

Resolution 302 asked Texas Medical Association (TMA) to: reject the subjective description of pain as being a "vital sign," and consider vital signs to be pulse, blood pressure, respiratory rate, and temperature; urge that the numerical recording of subjective pain not be used by any reviewing entity as a measurement of quality of any health care facility, whether that be a physician's office, outpatient surgery center, hospital, nursing home, or home nursing service; and forward the resolution to the American Medical Association (AMA) House of Delegates for adoption. Resolution 304 requested TMA to: work on a state level with other organizations, such as the Texas Hospital Association, to rescind in Texas the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) pain standard and any other required pain standard documentation; and submit a similar resolution to the AMA House of Delegates opposing the pain standard and directing AMA to work on a national level to withdraw the mandated JCAHO pain standard and any other mandated pain standard documentation in hospital records or physicians' offices.

The council reviewed the current scientific literature on pain assessment, pain rating scales, and pain rating standards, as well as a historical view of the current and evolving field of pain medicine. This report is a summary of that research.

Pain Assessment and Management
The "modern" field of pain medicine is very new, having developed only in the past two to three decades.  Prior to this time, treatments for pain were limited and standardized tools for pain assessment were non-existent.1  In the midst of this rapid progress, it is now well-recognized that historically pain was both significantly under-treated and under-recognized.2,3  The World Health Organization's (WHO) creation of a "stepladder" of pain treatment in 1986 was revolutionary,4 and originated in part from an idea that many parties were introducing, namely that of "cancer pain of increasing severity must be aggressively treated."1 This is but one of many of the early examples of the principle of grading pain or evaluating its severity. 

On this foundation, the medical community sought to improve the care of patients by ensuring their pain was recognized and treated, the two elements so long absent in American health care.  Part of this effort included development by the American Pain Society (APS) in 1995 of an awareness campaign entitled "pain as the 5th vital sign."  This effort, which might best be described as a professional and public health awareness effort, is summarized by then-President of the APS, James Campbell, MD:

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. ⁵

This effort then grew into the standards, which JCAHO established in 1991.

Key aspects of the JCAHO standards, and clarification of their intent, include :

• Patients have the right to appropriate assessment and management of pain (RI.1.2.9)
• Pain is assessed in all patients (PE.1.4)
  • this assessment and a measure of pain intensity and quality…are recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the organization.
• The organization collects data to monitor its performance. (PI.3.1) 6

Current scientific literature includes a large number of references covering a wide range of components/issues related to the multiple aspects of pain assessment and management. The continuing problems nationally with the under-diagnosis of pain and the under-treatment of pain are well documented. The lack of a uniform standard of care is obvious in the review of the literature. There is support for a numerical rating system for pain assessment, which, while not perfect, does appear to bring more benefits than other rating systems or not having a rating system in place. The literature also confirms the advantages of a multi-modal approach to pain management.

Of note, the TMA Committee on Cancer, in its efforts to develop a TMA in-depth policy recommendation on diagnosing and treating cancer pain, has requested collaboration with the Council on Scientific Affairs to broaden the project to cover more than just cancer pain patients. That collaboration is currently underway.

Summary and Conclusions
With strong support in the current scientific literature, the under-diagnosis and under-treatment of pain are continuing problems in medicine needing attention. Assessment and management of pain are vital components of a system to address the problems. Contributing to the difficulties is the lack of a uniform standard for treating pain or even shared goals about management. Numerical rating systems in that assessment and measurement have documented benefits outweighing the risks/concerns.

JCAHO standards require a pain assessment but do not dictate the method of assessment, how to handle the response, or the monitoring. These are entirely within the control of the organization. JCAHO does not require clinical decisions to be solely based on rating scales such as numerical scales.

Recommendation 1:  That the Texas Medical Association use its communication resources, i.e., The Knowledge Center, Web site, etc., to educate physicians to direct any complaints specific to the pain assessment process to the medical staff office in the particular hospital or organization.

Recommendation 2 :  That the Committee on Cancer and the Council on Scientific Affairs expedite, for submission to the House of Delegates at TexMed 2008, the development of the association policy recommendation on the management of pain.

Relevant AMA Policy

H-120.960 Protection for Physicians Who Prescribe Pain Medication . Our AMA supports the following: (1) the position that physicians who appropriately prescribe and/or administer controlled substances to relieve intractable pain should not be subject to the burdens of excessive regulatory scrutiny, inappropriate disciplinary action, or criminal prosecution. It is the policy of the AMA that state medical societies and boards of medicine develop or adopt mutually acceptable guidelines protecting physicians who appropriately prescribe and/or administer controlled substances to relieve intractable pain before seeking the implementation of legislation to provide that protection; (2) education of medical students and physicians to recognize addictive disorders in patients, minimize diversion of opioid preparations, and appropriately treat or refer patients with such disorders; and (3) the prevention and treatment of pain disorders through aggressive and appropriate means, including the continued education of doctors in the use of opioid preparations. Our AMA opposes harassment of physicians by agents of the Drug Enforcement Administration in response to the appropriate prescribing of controlled substances for pain management. (BOT Rep. 1, I-97; Reaffirm: Res. 237, A-99; Appended: Res. 506, A-01; Appended: Sub. Res. 213, A-03)

D-120.997 Opposition of Government Determination of Appropriate Medical Practice . Our AMA will: (1) continue to support the Pain Relief Promotion Act of 1999 and will work with interested state and national specialty societies to improve the bill's language, as necessary; and (2) work with interested state and national specialty societies to improve Titles I and II of the Pain Relief Promotion Act of 1999 by deletion of those provisions which establish federal protocols and/or regulations for pain management and palliative care (including the proposed amendment to Section 502a of the Controlled Substances Act regarding educational and training programs for local, state, and federal personnel; Section 201(a)(2) of the proposed Act regarding the collection and dissemination of protocols and evidence-based practices for palliative care; and any other such objectional provisions of the proposed Act. (Sub. Res. 215, I-99)

D-220.987 Pain Management Standards and Performance Measures. (1) Our AMA shall continue to work with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and encourage continued collaborative efforts between the JCAHO and relevant medical specialty organizations to clarify the JCAHO pain management standards and to identify and clarify sources of information that are contributing to misinterpretation of the standards. (2) Our AMA, with or without partnership with other Joint Commission on Accreditation of Healthcare Organizations (JCAHO) corporate members, shall appoint a committee or task force of regularly practicing health care professionals, including a multi-specialty panel of physicians, nurses and other mid-level practitioners, and administrators to objectively study and evaluate the efficacy to date of the new JCAHO Standard as it is currently being applied and identify who is responsible for its origins. This task force shall be urged to report back to the AMA Board of Trustees at an early date so that the Board can formulate recommendations to the Joint Commission. (3) The JCAHO should be encouraged to disseminate substantial additional clarification for the "examples of implementation" and eliminate them from the accreditation manuals and other publications. (CSA Rep. 4, A-02)

Footnotes

1. Burton AW, et al. "Pain Management: A Handbook for Texas Physicians."  May 2006.
2. Marks RM Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Int Med 1973; 78(2):173-81.
3. Donovan M, Dillon P, McGuire L.  Incidence and characteristics of pain in a sample of medical-surgical inpatients.  Pain 1987; 30(1):69-78.
4. WHO Stepladder.
5. James Campbell MD, Presidential Address of APS, 11/11/1995. "Pain as the 5th Vital Sign."
6. JCAHO Web site.

References

Wharton, N. (1996). Health and safety in outdoor activity centres. Journal of Adventure Education and Outdoor Leadership , 12(4), 8-9.

Turk DC, Dworkin RH. (2004). What should be the core outcomes in chronic pain clinical trials? Journal of Arthritis Research & Therapy , 6(4):151-4.

Gordon DB, Pellino TA, Miaskowski C, McNeill JA, Paice JA, Laferriere D, Bookbinder M . (2002). A 10-year review of quality improvement monitoring in pain management : recommendations for standardized outcome measures. Journal of Pain Management Nursing ; 3(4):116-30 .

Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. (2006). Measuring pain as the 5th vital sign does not improve quality of pain management. Journal of Internal Medicine ; 21(6):607.

Choi YS, Kim SH, Kim JS, Lee J, Kang JH, Kim SY, Kim SY, Kim CS, Song HS, Lim HY, Yim CY, Chung IJ, Cho GJ, Lee MA, Park J, Yeom CH . (2006). Change in patients' satisfaction with pain control after using the Korean cancer pain assessment tool in Korea . Journal of Pain and Symptom Management ; 31(6):553-62.

Morrison RS, Meier DE, Fischberg D, Moore C, Degenholtz H, Litke A, Maroney-Galin C, Siu AL. (2006). Improving the management of pain in hospitalized adults. Archives of Internal Medicine ; 166(9):1033-1039.

Pitetti R, Davis PJ, Redlinger R, White J, Wiener E, Calhoun KH. (2001). Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines . Archives of Pediatrics & Adolescent Medicine ; 160(2): 211-216.

Sloman R, Rosen G, Rom M, Shir Y. (2005). Nurses' assessment of pain in surgical patients. Journal of Advanced Nursing ; 52(2):125-132(8).

Hurwitz EL, Morgenstern H, Yu F. (2005). Satisfaction as a predictor of clinical outcomes among chiropractic and medical patients enrolled in the UCLA low back pain study . Spine: The International Journal for the Study of the Spine , 30(19):2121-2128.

Leddy KM, Wolosin RJ. (2005). Patient satisfaction with pain control during hospitalization . Joint Commission Journal on Quality and Patient Safety , 31(9):507-513(7).

Frasco PE, Sprung  J, Trentman TL.  (2005). The impact of the Joint Commission for Accreditation of Healthcare Organizations pain initiative on perioperative opiate consumption and recovery room length of stay. Journal of Anesthesia and Analgesia, 100:162-168.

Pautex S, Herrmann F, Le Lous P, Fabjan M, Michel JP, Gold G. (2005). Feasibility and reliability of four pain self-assessment scales and correlation with an observational rating scale in hospitalized elderly demented patients . The Journals of Gerontology Series A: Biological Sciences and Medical Sciences , 60:524-529.

Treadwell MJ, Franck LS, Vichinsky E.(2002). Using quality improvement strategies to enhance pediatric pain assessment. International Journal for Quality in Health Care , 14:39-47.

Due to the extensive amount of research available in the scientific literature, not all references are listed in this report. For a literature search on specific aspects of this topic, contact TMA Knowledge Center. E-mail the  TMA Knowledge Center or call (800) 880-7955.

TMA House of Delegates: TexMed 2007