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American Pain Society Quality of Care Committee; Mitchell B. Max, MD; Marilee Donovan, PhD, RN; Christine A. Miaskowski, PhD, RN; Sandra E. Ward, PhD, RN; Debra Gordon, MSN; Marilyn Bookbinder, PhD, RN; Charles S. Cleeland, PhD; Nessa Coyle, RN, MS; Margaret Kiss, MS, RN; Howard T. Thaler, PhD; Nora Janjan, MD; M. D. Anderson; Sharon Weinstein, MD; M. D. Anderson; W. Thomas Edwards, PhD, MD

JAMA. 1995;274(23):1874-1880.

Abstract
Objective.
—To develop quality improvement (QI) guidelines and programs to improve treatment outcomes for patients with acute pain and cancer pain.

Participants.
—Twenty-four members of the American Pain Society (APS) participated in preparing the statement, including 15 nurses (oncology, general medical-surgical nursing, pediatrics, and QI research), seven physicians (clinical pharmacology, neurology, anesthesiology, radiation oncology, and physiatry), one psychologist, and one statistician. Participants were self-selected from the 3000 members of the APS, which supported the process and held annual open committee meetings and scientific symposia beginning in 1988.

Evidence.
—MEDLINE was searched (1980 to 1995) to identify all articles on pain assessment, treatment of acute pain or cancer pain, and QI or education related to pain.

Consensus Process.
—Following panel discussions, one member (M.B.M.) prepared successive drafts and circulated them to the panel and APS membership for comments. After publication of a prototype version in 1991,14 panelists carried out formal studies of implementation of the guidelines at three medical centers. This article was prepared based on this research, a new literature review, and suggestions from 50 pain clinicians and researchers.

Conclusions.
—Quality improvement programs to improve treatment of acute pain and cancer pain should include five key elements: (1) Assuring that a report of unrelieved pain raises a "red flag" that attracts clinicians' attention; (2) making information about analgesics convenient where orders are written; (3) promising patients responsive analgesic care and urging them to communicate pain; (4) implementing policies and safeguards for the use of modern analgesic technologies; and (5) coordinating and assessing implementation of these measures. Several short-term studies suggest that this QI approach may improve patient satisfaction and facilitate recognition of institutional obstacles to optimal pain treatment, but it is not a panacea for undertreated pain. By making the magnitude of the problem apparent and committing the institution to change, pain treatment QI programs can provide a foundation for a multifaceted approach that includes education of clinicians and patients, design of informational tools to minimize errors in prescribing, and improved coordination of the process of assessing and treating pain.

(JAMA. 1995;274:1874-1880)

Author Affiliations
Neurobiology and Anesthesiology Branch, National Institute of Dental Research, National Institutes of Health, Bethesda, Md; Department of Nursing, Kaiser Sunnyside Medical Center, Clackamas, Ore; Department of Physiological Nursing, University of California, San Francisco; School of Nursing, Pain Research Group, and Comprehensive Care Center, University of Wisconsin, Madison; Department of Nursing, University of Wisconsin, Madison; Department of Nursing, Memorial Sloan-Kettering Cancer Center, New York, NY; Department of Neurology, Pain Research Group, University of Wisconsin, Madison; Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York; Department of Nursing, Memorial Sloan-Kettering Cancer Center, New York; Department of Biostatistics and Epidemiology, Memorial Sloan-Kettering Cancer Center, New York; Department of Radiotherapy, University of Texas; Cancer Center, Houston; Department of Neuro-oncology University of Texas; Cancer Center, Houston; Department of Anesthesiology, Harborview Medical Center, University of Washington, Seattle.

Footnotes
A list of the members of the American Pain Society Quality of Care Committee appears at the end of this article.

Reprint requests to the American Pain Society, 4700 W Lake Ave, Glenview, IL 60025-1485.

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