Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
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A: EXAMPLES OF CLINICAL PRACTICE GUIDELINES AND RELATED MATERIALS
A: EXAMPLES OF CLINICAL PRACTICE GUIDELINES AND RELATED MATERIALS
Pages 243-345
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From page 243... ...
Apart from the sponsoring agency or organization, guidelines can vary (as noted in Chapter 1) in at least five key ways: · Clinical orientation whether the chief focus is a clinical condition, a technology (broadly defined)
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From page 244... ...
Detecting or tracking deteriorating metabolic acidosis Guidelines for Care of Clinical Conditions 11. Using oral contraceptives to prevent pregnancy and manage fertility 12.
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From page 245... ...
Shortened free-text versions of guidelines documents can be tailored for specific uses by specific types of practitioners. For instance, guidelines for the diagnosis and management of acute myocardial infarction might well be rendered into several different versions and formats depending on whether the target audience was to be emergency room physicians needing quick reference or cardiac specialists managing a patient over several weeks.
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From page 246... ...
One reason for translating free text into other formats is that some guidelines identify dozens, if not hundreds, of specific criteria for care; even creative free-text presentations may not allow practical, quick access to this volume of information. Instead, the free text may be reconfigured (or, less often, the initial guidelines may be drafted)
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From page 247... ...
The Health Standards and Quality Bureau of the Health Care Financing Administration (HCFA) is developing quality-of-care and appropriateness algorithms for collecting and analyzing clinical data in its Uniform Clinical Data Set (UCDS; Krakauer, 1990; Krakauer and Bailey, 1991~.
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From page 248... ...
begin with a clinical condition or patient symptom and lead the reader through a series of branching, dichotomous choices based on the patient's risk status, medical history, or clinical findings. They also include action steps such as testing, treating, or scheduling further examinations.
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From page 249... ...
The initial clinical state box should describe the clinical problem to be addressed. Clinical state boxes in the body of the algorithm are used to clarify the status of the patient or diagnosis along the path of the algorithm (i.e., to describe a subset of patients with a particular clinical condition)
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From page 250... ...
, "yes" arrows should point to the right, and "no" arrows should point down. NUMBERING SCHEME Clinical state boxes, decision boxes, and action boxes should be numbered sequentially from left to right and from top to bottom.
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From page 251... ...
Use of the Arden Syntax allows easy transfer of understandable contraindication alerts, management suggestions, data interpretations, treatment protocols, and similar aids from one computer system to another. Example 10, on detecting deteriorating metabolic acidosis, and Example 11, on the use of oral contraceptives, illustrate specific computer-based formats.
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From page 252... ...
It is one of 169 guidelines for specific preventive interventions, each of which may include recommendations for preventive care by age group (e.g., in favor of vision screening for children of younger ages and possibly for the elderly but not for adolescents and adults)
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From page 253... ...
become more common with age,'° and therefore the prevalence of visual impairment is highest in those over age 65. Preliminary statistics from recent surveys suggest that nearly 13% of Americans age 65 and older have some form of visual impairment, and almost 8% of this age group suffer from severe impairment: blindness in both eyes or inability to read newsprint even with glasses.,' Vision disorders in the elderly may be associated with injuries due to falls and motor vehicle accidents, diminished productivity, and loss of indepen dence.~2 Many older adults are unaware of changes in their visual acuity, and up to 25% of them may be using an incorrect lens prescription.
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From page 254... ...
Effectiveness of Early Detection There is convincing evidence that early detection and treatment of vision disorders in infants and young children improve the prognosis for normal eye development.2' A prospective study has demonstrated that preschool children who receive visual acuity screening have significantly less visual impairment than controls when reexamined 6-12 months later.25 Detection and treatment of strabismus and amblyopia by age 1-2 can increase the likelihood of developing normal or near-normal binocular vision and may improve fine motor skills.24 Interventions for amblyopia and strabismus are significantly less effective if started after age 5, and such a delay increases the risk of irreversible amblyopia, ocular misalignment, and other visual deficits.' 3 It is widely held that clinical screening tests can detect
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From page 255... ...
Recommendations of Others The American Academy of Ophthalmology recommends an ophthalmological examination of newborns who are premature or at risk for eye disease; an examination of fixation preference and ocular alignment by age 6 months; an examination of visual acuity, ocular alignment, and ocular disease at age 3-4; annual screening of schoolchildren for visual acuity and ocular alignment; occasional examinations from puberty to age 40; and an examination for presbyopia at age 40 and every two to five years thereafter.' The American Academy of Pediatrics recommends external examination and tests of following ability and the papillary light reflex in the newborn Period and once during the first six months.5 Testing of visual acuity, ocular alignment, and ocular disease is recommended by the Academy at ages 4, 5-6, and at less frequent intervals thereafter.S The Canadian Task Force recommends an eye examination and cover test at ages 1 week, 2 months, and, along with a vision chart test, at age 2-3 years and 5-6 years. Testing at age 10-11 is considered discretionary, and no adult screening is recommended.28 The American Optometric Association recommends screening schoolchildren every three years and annual eye examinations in adults after age 35.29 Screening guidelines have also been issued by other organizations, such as the National Society to Prevent Blindness, the National Association of Vision Program Consultants, Volunteers for Vision, and the American Public Health Association.28 Vision screening of preschool and school children is also required by law in some states and in a number of Federal programs.222 Discussion Although it is established that early detection of strabismus and amblyopia is most beneficial for children under age 3, a practical and effective screening test is not yet available for this age group.
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From page 256... ...
is more effective than visual acuity testing (e.g., Snellen optotype cards) in detecting these conditions.
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From page 257... ...
Visual acuity of the preschool child: a review. Am J Optom Physiol Opt 1986; 63:319 - 45.
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From page 258... ...
SCREENING PATIENT & PARENT Height and weight COUNSELING Blood pressure Diet and Exercise Eye exam for amblyopia Sweets and between-meal snacks and strabismus' iron-enriched foods, sodium Urinalysis for bacteriuria Caloric balance I~//GH-R/SK GROUPS Selection of exercise program Erythrocyte protopor phyrin2 (HR1) Injury Prevention Tuberculin skin test (PPD)
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From page 259... ...
EXAMPLES AND RELATED MATERIALS 259 Table 2. Ages 2-6 High-Risk Categories HR1 Children who live in or frequently visit housing built before 1950 that is dilapidated or undergoing renovation; who come in contact with other children with known lead toxicity; who live near lead processing plants or whose parents or household members work in a lead-related occupation; or who live near busy highways or hazardous waste sites.
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From page 260... ...
. c .ltlon Low Free text; summary tables; maps (excerpts included)
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From page 261... ...
Both yellow fever vaccine and OPV can be given to pregnant women at substantial risk of exposure to natural infection. When a vaccine is to be given during pregnancy, waiting until the second or third trimester is a reasonable precaution to minimize any concern over teratogenicity.
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From page 262... ...
Mumps Rubella Yellow fever Live-attenuated Contraindicated except if exposure is unavoidable. Poliomyelitis Trivalent live- Persons at substantial risk of attenuated (OPV)
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From page 263... ...
EXAMPLES AND RELATED MATERIALS YELLOW FEVER ENDEMIC ZONES IN THE AMERICAS ~ 80 70 60 ; ~ ~ 263 50 40 -- - - 10 : - 30 ~ Yellow Fever Endemic Zone Zone d'Endemicite Amarile : 80 ,, ,,,,, c~> ~ - - - - 1 0 Ail -- -- -- -- -- -- - 15 / 20 me, -- ~5, 40 -- -- -- 401 NOTE: Although the "yellow fever endemic zones" are no longer included in the International Health Regulations, a number of countries (most of them being not bound by the Regulations or bound with reservations) consider these zones as infected areas and require an International Certificate of Vaccination against Yellow Fever from travelers arriving from those areas.
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From page 264... ...
It was produced by the American College of Surgeons' Committee on Trauma. The excerpt deals with field triage (essentially the decision of whether to move an injured patient to a trauma center or to evaluate and manage the patient at a local hospital)
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From page 265... ...
EXAMPLES AND RELATED MATERIALS 265 SOURCE: American College of Surgeons, Committee on Trauma. Resources for Optimal Care of the Injured Patient.
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From page 266... ...
Trauma patients who, because of injury severity, require care at Level ~ or Level II trauma centers, constitute a fraction of all patients hospitalized each year for trauma. In 1983, approximately 3.75 million patients were h`'spitalized for injury.
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From page 267... ...
impact · Pedestrian thrown or run over · Motorcycle crash - 20 mph or with separation of rider and bike | Take to trauma center | l _ · Age c 5 or - 55 years · Known cardiac disease; respiratory disease; or psychotics taking medication · Diabetics taking insulin; cirrhosis; malignancy; obesity or coagulopathy Contact medical control and consider transport to trauma center WHEN IN DOUBT TAKE TO A TRAUMA CENTER l Re-evaluate with medical control l
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From page 268... ...
mspi~t<>ry ~_~ patients with an lSS of greater than 15 far Junta center care. Patients ~s~ Ada Ma firm ^~[ is (often best evaluated in a trauma center
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From page 269... ...
Conversely, patients win<' are in need of trauma center care but fail to gain timely access to such care are referred to as under-triaged. Together, over-triaged and under-triaged patients combine to form a misclassification rate for any triage decision scheme or rule.
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From page 270... ...
The excerpt given here is for the assessment of chest pain in the diagnosis of (possible) ischemic heart disease (see the guideline's "Appendix A
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From page 271... ...
271 ~ Z I ~ ~ e ~ S fir ~ ~ a' a)
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From page 272... ...
272 ._ C O 3 Z ._ In _ :E ~ 3 o c' .= O at' .
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From page 274... ...
274 C~ ._ _ ~C ._ ~m O 3 Z ~C ._ ~n _ o D cn o CO ._ a)
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From page 275... ...
Apart from its clinical significance, this guideline is of interest for formatting, as it makes use of free text, graphics, and tables. As is true of several other items in the appendix, it cites directly the literature on which its conclusions and recommendations are based.
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From page 276... ...
The frequency of an increased ESR in the cancer-free reference subjects shows the lack of specificity of an increased ESR in sick people. The shortcomings of studies of the ESR affect only the interpretation of an abnormal ESR.
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From page 277... ...
EXAMPLES AND RELATED MATERIALS A 1.0 FPR = .05 ~, ~' in' // ~ "' B 1.0 ~ .8 _ .6 _ .4 _ .' _ ,,' Pretest Probability .8 1.0 ~/ ,' ~ ,' '/ ~ wl-0= .2 .4 .6 Pretest Probability .8 1.0 FIGURE 1. Relation between pretest probability of disease and post-test probability.
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From page 278... ...
However, when the pretest probability of disease is low, the post-test probability will be low unless the ESR is markedly elevated. The probability of some form of serious disease is probably relatively high when the ESR exceeds 50 mm/in, because a markedly increased ESR seldom occurs in healthy people.
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From page 280... ...
are not tied directly to that literature. Like Example 3, on triage of injured patients, and Example 5, on the use of erythrocyte sedimentation rates, this guideline implicitly considers the cost-effectiveness of resource use.
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From page 281... ...
Note that the first indication for carotid endarterectomy is for a patient with a single episode of carotid TIA or amaurosis fugax whose surgical risk is low and whose angiogram demonstrates an occlusion of the ipsilateral artery and less than 50 percent stenosis of the opposite artery. This indication received a rating of 1 (extremely inappropriate)
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From page 282... ...
l | 9 = extremely appropriate l +___ _________ ________ ____ __+ I Carotid TIA and/or Amaurosis Fugax -- Single episode APPROPRIATENESS OF OPERATING I PS I LATERALLY IF ANGIOGRAPHY SHOWS: Ipsi: Degree of stenosis of ipsilateral artery Contra: Degree of stenosis of contralateral artery APPENDIX A Low E levated Surgical Risk Surgical Risk Surgical Risk 1.
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From page 283... ...
2. Carotid TIAs and/or Amaurosis Fuga~c-Multiple Episodes, Never Tried on Medical Therapy: The patient's symptoms are consistent with hemispheric ischemia, the most recent TIA episode occurred within the past three months, the symptoms resolved within 24 hours of onset, and the symptoms are different from those grouped separately as "crescendo TIAs." The patient has never been placed on platelet inhibitors or anticoagulation for cerebrovascular symptoms in the past.
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From page 284... ...
Separate ratings were made for two subgroups: intra-abdominal or intra-thoracic excluding coronary artery bypass surgery, and coronary artery bypass surgery.
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From page 285... ...
16. Risk of stroke is either high or normal: High stroke risk is defined as a probability of greater than 100 per 1000 patients of developing an atherothrombotic brain infarction in eight years based on data from the Framingham Study, 18 year follow-up.5 Calculations of probability take into account a patient's age, sex, presence of left ventricular hypertrophy, whether the patient is diabetic, a smoker, and his or her diastolic blood pressure and cholesterol level.
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From page 286... ...
26d CL I N I CAL PRESENIAT 1 OM: P _ ~ ~ _S ~ Low APPROPR I ATENESS OF OPER^T I NG I PS I LATERA 1 f ANG I OgRAPHY SHOWS: Ip~l: -~ Or S~iS Or ipsl late~l arte~ Contre: Degree Or stenosis of cont~ late~ I arte~ Elevated Hlgh Su ro ~ ca I R ~ sk Su ro a CB I R 1 sk Su ra ~ ca 1 R ~ sk 1.
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From page 288... ...
Guidelines for the Early Management of Patients with Acute Myocardial Infarction. ACC/AHA Task Force Report.
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From page 289... ...
Percutaneous transluminal coronary angioplasty as the primary treatment strategy suffers from the need to have facilities and personnel for cardiac catheterization and a physician qualified to perform angioplasty available at all times. Because of this, intravenous thrombolysis has become established as the first line of therapy in acute myocardial infarction in suitable patients.
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From page 290... ...
Class IIb 1. Patients with known coronary anatomy in whom thrombolytic therapy is not contraindicated, but who develop symptoms and ECG evidence of acute infarction in hos
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From page 291... ...
2. Patients in whom thrombolytic therapy is not contraindicated who present within 4 h of onset of symptoms of acute infarction at a facility where rapid access to a catheterization laboratory with personnel experienced in performing expeditious angioplasty for acute myocardial infarction is available (completion within 1 h)
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From page 292... ...
It therefore appears that urgent angioplasty of infarct-related vessels with a residual stenosis after rt-PA therapy has no significant benefit, but does have a significant increase in risk. The failure of angioplasty immediately after thrombolysis may be related to an increased risk of hemorrhagic infarction when angioplasty is performed after administration of tissue plasminogen activator or to an increased risk of rethrombosis.
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From page 293... ...
of delayed angioplasty, patients were first randomized to receive tissue plasminogen activator or placebo and then after 48 to 72 h were rerandomized to undergo or not undergo angioplasty. At follow-up study before hospital discharge, patients undergoing angioplasty had a significant improvement in exercise ejection fraction but not rest left ventricular ejection fraction compared with those not undergoing angioplasty.
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From page 294... ...
Until further data are available from prospective controlled trials, a conservative approach after intravenous thrombolytic therapy seems indicated. This would reserve angiography and angioplasty for patients with postinfarction angina, severe left ventricular dysfunction or stress-induced myocardial ischemia detected before hospital discharge.
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From page 295... ...
For example: 1. Dilation in patients who are within the early hours of an evolving myocardial infarction and have <50% residual stenosis of the infarct-related artery after receiving a thrombolytic agent.
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From page 296... ...
In addition, it addresses an area of care about which, in the United States at least, malpractice concerns are great (see the discussions of malpractice and the anesthesia guidelines developed by the American Society for Anesthesiology in Chapters 2 and 5 and case study 4 of Chapter 3~. Malpractice is explicitly considered in Example 4 on evaluation of chest pain in the emergency room.
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From page 297... ...
in EFFEC TIVE CARE IN PREGNANCY AND CHILDBIRTH. 1 Introduction 2 Results of a trial of labour 3 Risks of caesarean section to the mother 3.1 Risks to the mother 3.2 Risks to the baby 4 Factors to consider in the decision about a trial of labour 4.1 More than one previous caesarean section 4.2 Reason for the primary caesarean section 4.3 Previous vaginal delivery 4.4 Type of previous incision in the uterus 4.5 Gestational age at previous caesarean section 4.6 Integrity of the scar 5 Care during a trial of labour 5.1 Use of oxytocics 5.2 Regional analgesia and anaesthesia 5.3 Manual exploration of the uterus 6 Rupture of the scarred uterus in pregnancy and labour 7 Gap between evidence and practice ~ Conclusions 1 Introduction Although in recent years the dogma of 'once a caesarean always a caesarean' has come under both professional and public scrutiny, in many countries the practice is still carried out, and remains a stated policy in many institutions.
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From page 298... ...
Thus, for the series for which total data are available, well over half of all women with a previous caesarean section gave birth vaginally. A large number of retrospective studies have also compared the effects of elective caesarean section versus trial of labour in women who have had one previous caesarean section.
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From page 299... ...
While it is not possible to quantitate exactly the extent of increased risk of death to the mother from elective caesarean section, the data available suggest that it is between two and four times that associated with vaginal delivery. Most forms of maternal morbidity are higher with caesarean section than with vaginal delivery.
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From page 300... ...
The technique of decision analysis has been used to determine the optimal delivery policy after previous caesarean section. The probabilities and utilities of a number of possible outcomes, including the need for hysterectomy, uterine rupture, iatrogenic 'prematurity', need for future repeat caesarean sections, prolonged hospitalization and recovery, additional cost, failed trial of labour, discomfort of labour, and inconvenience of awaiting labour can be put into a mathematical model comparing different policies.
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From page 301... ...
4.3 Previous vaginal delivery Mothers who have had a previous vaginal delivery in addition to their previous caesarean sections are more likely to deliver vaginally after trial of labour than mothers with no previous vaginal deliveries. This advantage is increased even further in those mothers whose previous vaginal delivery occurred after rather than before the primary caesarean section.
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From page 302... ...
It would seem reasonable that women who have had a hysterotomy, a vertical uterine incision, or an 'inverted T' incision should be treated in subsequent pregnancies in the same manner as women who have had a classical caesarean section, and that trial of labour, if permitted at all, should be carried out with great caution, and with acute awareness of the increased risks likely to exist. 4.5 Gestational age at previous caesarean section During the past decade improved neonatal care has increased the survival rate of preterm babies, and this in turn has led to a reduction in the stage of gestation at which obstetricians are prepared to perform caesarean sections for fetal indications.
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From page 303... ...
It is sensible, safe, and justified to use analgesia for the woman with a lower segment scar in the same manner as for the woman whose uterus is intact. 5.3 Manual exploration of the uterus In many reports of series of vaginal births after previous caesarean section, mention is made of the fact that the uterus was explored postpartum in all cases, in a search for uterine rupture or dehiscence without symptoms.
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From page 304... ...
Although often considered to be the most common cause of uterine rupture, previous caesarean section is involved in less than half the cases. Excluding symptomless wound breakdown, the rate of reported uterine rupture has ranged from 0.09 per cent to 0.22 per cent for women with a singleton vertex presentation who underwent a trial of labour after a previous transverse lower segment caesarean section.
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From page 305... ...
8 Conclusions A trial of labour after a previous caesarean section should be recommended for women who have had a previous lower segment transverse incision caesarean section, and have no other indication for caesarean section in the present pregnancy. The likelihood of vaginal birth is not significantly altered by the indication for the first caesarean section (including 'cephalopelvic disproportion' and 'failure to progress')
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From page 306... ...
This guideline is of interest for several reasons. First, its use was mandated by a state, a relatively unusual occurrence with guidelines (although see Example 4 on diagnosis of chest pain and its relationship to events in Massachusetts)
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From page 307... ...
307 A Patient's Guide to Blood Transfusions · ASK YOUR PHYSICIAN ABOUT NEW DEVELOPMENTS IN TRANSFUSION MEDICINE.
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From page 311... ...
Screen for worsening metabolic acidosis based on serum bicarbonate. In the annual ASTM Book of Standards, copyright ASTM, 1916 Race Street, Philadelphia, PA 19103, forthcoming 1992.
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From page 312... ...
When an MLM is shared, this part must be altered to match the institution's patient database. The last statement defines "bicarb_storage" as an event in which a serum bicarbonate is stored in the patient database.
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From page 313... ...
In this case the term "bicarb_storage" is used to specify that this MLM is evoked whenever a serum bicarbonate is stored. The serum bicarbonate is usually stored as part of a panel of tests that includes the sodium, chloride, and creatinine.
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From page 314... ...
/ /* Check for evidence of significant metabolic acidosis.
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From page 316... ...
/* send an alert warning new or worsening metabolic acidosis *
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From page 317... ...
Another reason for including this guideline was that it involves a technology (here, a pharmaceutical agent) that raises questions of whether and how to manage a clinical condition with long-term therapy that may have significant harmful side effects.
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From page 318... ...
IF "ESTROGEN USE" EXISTS OR "ORAL CONTRACEPTIVE USE" EXISTS THEN CONTINUE ELSE EXIT The use of oral contraceptives is associated with an increased risk of stroke, myocardial infarction, and thromboembolic phenomena. The risk is proportional to the patient's age and is amplified by cigarette smoking.
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From page 319... ...
R:2229 AND EXIT ELSE IF "MOST RECENT VISIT" WAS BEFORE 1/1 AND LAST "SMOKER 0-1" WAS NOT = 0 AND "AGE" IS GT 35 THEN If patient is a smoker, her CV mortality risk from "B/C pills" is 6X that of the mortality risk of patients on IUD's & 2X that of patients using traditional birth control and therefore alternative birth control method should be considered. R:2229 AND EXIT ELSE IF "DIAS BP SITTING LAST" WAS GT 100 THEN "oral contraceptives" may cause or aggravate hypertension (R:1168)
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From page 320... ...
In younger women, the most important adverse effect of birth control pills is venous thrombosis and pulmonary embolism. Some empirical data suggest that the risks of these complications are less with 50~g than with 80 leg doses of mestrinol.
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From page 321... ...
EXAMPLES AND RELATED MATERIALS Example 12 DECIDING ON TREATMENT FOR LOW BACK PAIN Clinical orientation: Clinical purpose: Complexity: Format: Intended users: 321 Clinical condition (symptom state) Management Low Decision path graphic Patients This simple guideline was designed specifically for patient use and is taken from a well-known book designed to help individuals decide whether to consult a physician, apply home treatment, or do nothing.
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From page 322... ...
322 APPENDIX A Low Back Pain Is pain associated with any of the following: a) abdominal pain b)
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From page 323... ...
Specific steps in the pathway such as drug therapy may then be covered by more detailed protocols. Like several of the items in the appendix dealing with the management of a patient with a specific clinical state, this guideline is explicitly sequential in its approach to care; intermediate evaluations of the patient's state are necessary before a patient "moves" to the next step in the process.
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From page 325... ...
325 ~ o _ ~Cal ~ ~ _3 EON E o,g°E23 i ._ ad, ID ~Q c ~ _ > Hi -he (D c ° e o ~-+ ~ o lU 0 ~ + Q a' Z ~ Qy - - 0 ·C-Z ; os '8 = ~ .
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From page 327... ...
327 e B" =~ e lllill 0 ~ ~ 0 ~ ~ C 0 0 0 _~ e ~ ~ = :1 0 o e O ~W =B = ~ ~ C :~# ~ o ~ a.
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From page 328... ...
. Like Example 11 on the use of oral contraceptives, this guideline addresses the treatment of an ongoing condition; for both the treatment is "suppressive." Like Examples 1, 7, and 8 it summarizes the current information about a clinical condition in an easily read, free-text version.
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From page 329... ...
The cruder tar extracts are messier to use but are generally considered to be much more effective than more refined products such as coal tar solution. Although there is little published evidence to support the use of any particular concentration, a common treatment regimen is to start with concentrations of 0 5-1 0% of crude coal tar in petroleum jelly and increase the concentration every few days to a maximum of 10%.
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From page 330... ...
Guidelines for the use of topical corticosteroids · There should be regular clinical review · No unsupervised repeat prescriptions should be made · No more than 100 g of a British National F~ormulary grade III (moderately potent) preparation should be applied each month · There should be periods each year when alternative treatment is employed · Use of British National Formulary grade I (very potent)
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From page 332... ...
~2 Dse of ~ideVaes 1o de~ve audi1 measues -o~, o~r, ~d ~ff~Z ~' (1) Is ~e diagnosis in clinical doubl?
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From page 333... ...
SOURCE: Harvard Community Health Plan, Cambridge, Massachusetts. Used with permission.
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From page 334... ...
It is understood that some patients will Nat fit the clinical conditions contctoplatcd by a guideline and that a guideline will rarely establish the only appropriate approach to a problan.
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From page 335... ...
E Patients who have failed single dose Rx should be considered to have upper tract infection and treated per pyelo protocol.
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From page 336... ...
In addition to the full guideline cited above, there are two "quick reference guides for clinicians"Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures and Acute Pain Management in Adults: Operative Procedures-and a patient's guide, Pain Control After Surgery, available in both English and Spanish. The guideline will also be incorporated into data bases at the National Library of Medicine and the National Technical Information Service and into the computer-based information systems.
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From page 337... ...
Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline.
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From page 338... ...
338 Reassess Unacceptable Side Effects or Inadequate Analgesia No r ~ ~ Change Drug, Interval, Dose, Route, Modality; Add Adjuvant; or Treat Side Effect APPENDIX A Pain Treatment Flow Chart: Postoperative Phase 1 1 Termination of Operative Anesthesia/Analgesia 1 ~ No Pain or Pain Sigr,ificant Pain Not Requiring Consistent With Intervention Surgical Trauma Initiate Postoperative Analgesia or Adjust Dose/lnterval of Preoperative Analgesic Assess: Did Intervention Produce Satisfactory Pain Relief? _ Yes Optimize Dose Interval 1 ~Satisfactory Response } Discharge Planning Significant Pain, Not Explained by Surgical Trauma 1 1 Surgical Evaluation r ~I Treat
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From page 339... ...
Pain control options include: · Cognitive-behavioral interventions such as relaxation, distraction, and imagery; these can be taught preoperatively and can reduce pain, anxiety, and the amount of drugs needed for pain control; · Systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids using the traditional "as needed" schedule or around-the-clock administration (American Pain Society, 1989~; · Patient controlled analgesia (PCA)
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From page 340... ...
340 APPENDIX A Examples of Pain Intensity and Pain Distress Scales Pain Intensity Scales Simple Descriptive Pain Intensity Scale* No Mild Moderate Severe Very Worst pain pain pain pain severe possible pain pain O - 10 Numeric Pain Intensity Scale*
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From page 341... ...
TO ensure that this process occurs effectively, formal means must be developed and used within each institution to assess pain management practices and to obtain patient feedback to gauge the adequacy of pain control. The institution's quality assurance procedures should be used periodically to assure that the following pain management practices are being carried out: · Patients are informed that effective pain relief is an important part of their treatment, that communication of unrelieved pain is essential, and that health professionals will respond quickly to their reports of pain.
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From page 342... ...
Local Anesthetics Epidural and intrathecal Ia, IV Limited indications. Expensive if infusion pumps employed.
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From page 343... ...
Note: References are available in the Guideline Report. Acute Pain Management: Operative or Medical Procedures and Trauma.
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From page 344... ...
and with each new report of pain. The degree of pain relief should be determined after each pain management intervention, once a sufficient time has elapsed for the treatment to reach peak effect.
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From page 345... ...
6. Specialized analgesic technologies, including systemic or intraspinal, continuous or intermittent opioid administration or patient controlled dosing, local anesthetic infusion, and inhalational analgesia (e.g., nitrous oxide)
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Key Terms
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