Chapter 10: Pain Medicine 2026

 Professor Roger Knagg, Ms Felicia Cox 

Why do this Quality improvement project?

This Quality Improvement (QI) project focuses on pain assessment and documentation in an inpatient setting.  By systematically evaluating and improving these processes, healthcare providers can better identify, manage, and alleviate pain, leading to increased patient satisfaction and potentially reduced healthcare costs. 

Background

Effective pain management is essential for patient recovery and well-being. Inadequate pain management can lead to various complications, including increased risk of infection, delayed healing, and prolonged hospital stay. Patients who experience effective pain relief are more likely to be satisfied with their care. ¹
It is increasingly recognised that pain assessment tools based on assessing function should be used to guide analgesic management rather than relying on unidimensional pain assessment tools. ² Consensus recommendations on managing perioperative pain in all parts of the surgical journey are available. ³
Scoring and documenting pain in the inpatient setting underlies many quality assurance methods; improving these aspects is important to facilitate improvement efforts across inpatient pain management.  Creating a baseline for measuring improvement in inpatient pain services, facilitate analgesia for patients, and efficiency savings for staff.  In addition, improvements in documentation can potentially mitigate expensive legal cases for hospitals. 

Best practice

Protocols should be version-controlled, evidence-based and specific to techniques used in the trust.  There should be an appropriate local agreement for recording the directions of the anaesthetist alongside contingency recommendations for actions.  
Pain assessment tools should be appropriate to patient culture, language and development and consider cognitive and emotional influences. 
A robust process should exist and be used to report and investigate pain-related adverse events.
Effective and safe acute (inpatient) pain services will be able to demonstrate compliance with recognised national standards for governance, clinical practice, and quality assurance.^3,4 These standards require the presence of clear local protocols for defined clinical scenarios, including:
•    type and frequency of observations and pain assessment
•    appropriate maintenance and testing of equipment
•    easy access to a clear, concise operating manual for each piece of equipment that is used (e.g. patient-controlled analgesia or epidural infusion pumps).
•    completion of documentation regarding observations and pain management
•    competency of staff
•    provision of accessible patient information of sufficient standard
•    evidence of reporting, analysing and preventing adverse incidents aligning with local organisation policies

Service features are detailed in the Faculty of Pain Medicine’s Core Standards for Medicine Services and incorporate good medical practice. ⁴

Suggested data to collect 

Preoperative phase indicators (if appropriate)
1.    The proportion of patients for whom a perioperative acute pain management plan is created at the preoperative assessment clinic.
2.    The proportion of patients whose perioperative acute pain management plan is documented in an accessible manner in the clinical notes.
3.    Proportion of patients receiving patient information in line with locally agreed standards

Inpatient acute pain management 
1.    Proportion of relevant patients (i.e. post nerve or neuraxial block), with recorded instructions on anaesthetic plan and contingency recommendations 
2.    Proportion of patients meeting local standards for the assessment of their pain  
3.    Proportion of patients meeting local standards for the prescription and administration of appropriate analgesia, based on relevant national guidance where available
4.    Proportion of patients with recognised adverse effects to analgesic medicines, e.g., nausea and vomiting 
5.    The proportion of patients meeting local standards for the type and frequency of pain-related observations. Pain assessment tools should be appropriate to the patient's culture, language and development and consider cognitive and emotional influences. This may be combined with other observation parameters to reduce duplication, but the directions must be explicit. 
6.    Incidence of equipment-related issues, including lack of access to patient-controlled analgesia or epidural infusion pumps
7.    Incidence of pain-related adverse events.

QI methodology and worked example

• Investigate pain documentation in the organisation

Establish a log of all areas of documentation for all aspects of pain in your organisation.

Pain assessment and treatment: include electronic prescribing systems, paper-based drug charts or post-intervention order sheets 
Pain information: patient information sheets and pain-related content on the organisation’s website. 
There should be a process of who is responsible for keeping this information up to date.

• Preoperative phase

Identify all stakeholders and develop a stakeholder matrix of influence and interest.  Utilise this matrix to create a wide range of potential improvement ideas.

A process map can be utilised to investigate the process by which a pain management plan is instigated (i.e. by whom and when) and then implemented. This requires liaising with stakeholders to map the existing pathway to identify the problems and then creating a measurement plan and balancing measures.

• Inpatient acute pain management

As with the preoperative phase, a process mapping approach would be suggested for the perioperative phase, mapping out how, when and by whom recordings should be made and what recordings should be made, for each pain relief modality, especially those with higher risks of adverse effects such as opioids.

The modality addressed could be prioritised using an impact/effort matrix. The process map can be used to identify and prioritise challenges in the existing pathway.

Using the prioritisation exercise the stakeholders can then decide on an aim, create a driver diagram and test ideas using plan–do–study–act methodology. 

Worked example using a Plan-Do-Study-Act cycle
Before starting a PDSA cycle, identify what you are trying to accomplish, what changes need to be made, and how you will know if things have improved after these changes have been made.  It is important to identify stakeholders and process map your selected intervention.  One example would be the introduction of a functional pain assessment score for a specific cohort of patients. 
It could be considered that assessment and documentation of pain intensity is often conducted using dimensional pain intensity scores, but moving to a functional pain assessment could help improve management and consistency in monitoring the effects of analgesics.  Measuring uptake of usage over time would reveal if the implementation strategies have been effective. A variety of interventions could be considered, including education sessions, peer-led training, advertising across trust communications, or integration into an electronic system such as an EPR.  This could be tested in a small cohort of patients prior to scaling up.  

• Plan: The introduction of a functional pain assessment score for a specific cohort of patients  
• Do: A mandatory training session is held for all relevant staff on the use of a functional pain assessment score.  This is supplemented by further peer-led training, communications, and written instructions on use.
• Study: After each month, data should be reviewed on the proportion of patients now having a functional pain assessment in addition to a unidimensional pain intensity score recorded.  Enablers and barriers to change should be reviewed, with further interventions planned to overcome barriers to implementation
• Act: The change can formally be adopted into the Trust policy and scaled up. Serial sampling of the usage of functional pain assessments in small groups of patients is undertaken to ensure the change is sustained. The group moves to repeat PDSA cycling, looking at the other changes that could be implemented.

References

1. Schug SA, Palmer GM, Scott DA, Alcock M, Halliwell R, Mott JF; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 5th ed. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine; 2020 (https://www.anzca.edu.au/safety-and-advocacy/advocacy/college-publicati…).

2. Baamer RM, Iqbal A, Lobo DN, Knaggs RD, Levy NA, Toh LS. Utility of unidimensional and functional pain assessment tools in adult postoperative patients: a systematic review. Br J Anaesth 2022; 128: 874–888.

3. El-Boghdadly K, Levy NA, Fawcett WJ, Knaggs RD, Laycock H, Baird E, et al. Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society. Anaesthesia. 2024 Nov;7 9(11):1 220-1236.

4. Faculty of Pain Medicine. Core Standards for Pain Management Services in the UK. 2021 (https://fpm.ac.uk/standards-guidelines/core-standards)