NCCN Explores Pain Documentation in Cancer Patients

HOLLYWOOD, Florida— The first review of the pain assessment database established by the National Comprehensive Cancer Network (NCCN) has shown that pain is documented in the vast majority of cases.

"Pain is being screened in some way nearly all the time," Sharon M. Weinstein, MD, said at the NCCN’s Seventh Annual Conference. "In the majority of patients, over 60%, pain was documented in between 75% and 100% of encounters." Dr. Weinstein is director of pain medicine and palliative care, Huntsman Cancer Institute, University of Utah.

The results are based on 116 records (more than 1,000 documentation episodes) collected continuously for 3 months at five NCCN institutions. The study will be complete at 250 cases. Patients studied were those with breast cancer and metastatic bone disease.

With no uniform pain documentation protocol in place at the institutions, the investigators looked for verbal mentions of pain or pain intensity scores. About 60% of the pain mentions used the numeric rating (0 to 10). Nurses, according to the review, used the numeric system significantly more often than physicians when documenting pain.

Nurses were the mostly likely to document pain (nearly 50%), followed by nursing assistants (15%). Oncology fellows, members of the pain team, consultant MDs, and others each documented pain less than 5% of the time.

Documenting Pain Characteristics

The researchers also looked for documentation of certain pain characteristics: location, etiology, pathophysiology, or all three. About 70% of the pain mentions included location. Etiology was recorded in about 20% of the pain mentions, and pathophysiology in about 25%. All three characteristics were recorded in less than 20% of the pain mentions.

Nurses were least likely to mention pain by location, etiology, pathophysiology, or all three, whereas pain team members documented these characteristics most often.

The review showed that the location of the pain documentation varied, with about 50% of the documentation found in nursing records, vital signs sheets, or administration records. About 40% of the time, the mention of pain was found in progress notes.

The prominent role of nurses in the review calls for an emphasis on multidisciplinary communication, Dr. Weinstein said. "I think we’ve made great strides in acknowledging that symptom control, especially pain control, is a multidisciplinary effort. And it’s not enough to screen for pain, which nurses are doing very well. In order for pain to be attended to, there has to be communication within the interdisciplinary team," she said.

Documenting Interventions

While as many as 27% of the cohort had no documentation of a numerical pain intensity rating even once, of those who did, about half reported moderate to severe pain, Dr. Weinstein said. For these patients, about half did not have any interventions recorded. "The pain was mentioned, but there was no further discussion about how it was going to be treated," she said.

Of the 84 patients with a documented numeric rating pain score, 51 reported having pain, and 20 of these received a strong opioid. Of the 11 who reported pain at a level of 1 to 3, only one was documented as having received a strong opioid; 5 of the 12 who reported pain levels between 4 and 6 received a strong opioid; and 14 of the 28 reporting severe pain (7 to 10) received a strong opioid. The other patients received nothing, a nonopioid, or a weak opioid. In fact, three of the patients reporting severe pain had no documented treatment.

That many are not receiving opioid treatment for their pain could be a documentation error, Dr. Weinstein said. "Probably, that’s where documentation needs to be improved. If you’re going to prescribe opioids, you need to document when you use them," she said.

There are clear opportunities for improvement, Dr. Weinstein said. "We need to establish a uniform documentation of pain intensity scores in a place in the record that is easily located and reviewed," she said. "Numbers don’t tell the whole story, so we have to decide what to do after the numerical score is recorded and what should trigger further assessment. Recordings of interventions are fairly sporadic; if we’re going to evaluate outcomes, we’ll have to work on proper documentation first."

The information from this study will be used to develop pain documentation standards. Future expansion of the data will include clinical outcomes, such as pain intensity, pain relief, side effects, adverse events, functional improvement, and quality of life.

The take home messages for clinicians, Dr. Weinstein said, are: (1) Screening for pain is easy, especially with nurses assisting doctors; (2) most cancer patients will need some intervention, according to studies; and (3) available treatments are effective. "We need to deploy these treatments and document what we do—especially with the opioids," she said.